SCENARIO 1
Donald is a 60 year old male presenting with dyspnea (shortness of breath), chronic productive cough, wheezing, and fatigue. He smokes 1 pack of cigarettes per day for the last 40 years. Post-bronchodilator FEV1/FVC ratio < 0.70 confirms persistent airflow limitation. What treatment plan would you implement for this patient? What medication(s) would you prescribe? How would you monitor the effectiveness of this plan?
SCENARIO 2
Allen is a 49 year-year-old man seeking evaluation for “a burning sensation in my chest,” often after eating and worse at night. He has frequent feelings of bloating and occasional nausea. Allen consumes a diet high in fatty foods and caffeine. He drinks alcohol socially on weekends. PMH includes asthma, diabetes and hypertension. His current medications include prn albuterol, metformin 1000 mg po BID, nifedipine ER 60 mg po daily. How would you improve his drug therapy plan? What changes would you make? What is your working diagnosis and what medication would you prescribe? What information would you provide to the patient at his visit?
SCENARIO 3
Jessica is a 37-year-old female diagnosed with mild persistent asthma. During her visit today, she reports having to use her albuterol 4 days per week over the past month. Over the past week she has been using albuterol at least once per day. She reports being awakened by a cough five nights during the last month. Her current medications include: fluticasone HFA 44 mcg, two puffs BID, albuterol MDI two puffs Q 4–6 H PRN shortness of breath, Medrol Dosepak, metformin 500 mg PO BID, Inderal LA 160 mg po daily. How would you step up therapy for this patient? What medication changes would you make? How would you monitor the effectiveness of this plan? What patient teaching would you provide?
Explain the problem and discuss how you would address the problem.
When recommending medications, write out a complete prescription for each medication. What order would you send to a pharmacy?
Full Answer Section
Prescription:
- Fluticasone propionate/salmeterol (Advair) 250/50 mcg, 2 puffs twice daily
- Oxygen Therapy: If Donald's symptoms are severe or his oxygen saturation is low, he may require supplemental oxygen therapy.
- Pulmonary Rehabilitation: This program can help improve lung function, exercise tolerance, and quality of life.
Monitoring Effectiveness:
- Monitor lung function tests (FEV1) to assess the effectiveness of treatment.
- Monitor symptoms, such as dyspnea, cough, and sputum production.
- Assess patient satisfaction with treatment.
Scenario 2: Allen, a 49-year-old male with GERD
Problem: Allen presents with symptoms of gastroesophageal reflux disease (GERD), including heartburn, bloating, and nausea.
Drug Therapy Changes:
- Increase dose of proton pump inhibitor (PPI): Increase the dose of metformin to 1000 mg twice daily.
- Add a histamine H2 receptor antagonist (H2RA): Prescribe a H2RA, such as famotidine, to reduce acid production in the stomach.
Prescription:
- Famotidine 20 mg, 2 tablets twice daily
Working Diagnosis:
Gastroesophageal reflux disease (GERD)
Patient Information:
- Dietary changes: Advise Allen to avoid trigger foods, such as fatty foods, caffeine, and alcohol.
- Lifestyle modifications: Recommend that he lose weight if overweight, avoid lying down immediately after eating, and elevate the head of his bed.
- Medication adherence: Emphasize the importance of taking his medications as prescribed.
Scenario 3: Jessica, a 37-year-old female with asthma
Problem: Jessica's asthma is worsening, as evidenced by increased albuterol use and nocturnal awakenings.
Step-Up Therapy:
- Increase inhaled corticosteroid dose: Increase fluticasone HFA to 220 mcg, 2 puffs twice daily.
- Add a long-acting beta-agonist (LABA): Add salmeterol 50 mcg, 2 puffs twice daily.
- Consider additional therapies: If symptoms persist, other therapies such as leukotriene modifiers or mast cell stabilizers may be considered.
Monitoring Effectiveness:
- Monitor lung function tests (FEV1) to assess the effectiveness of treatment.
- Monitor symptoms, such as wheezing, cough, and shortness of breath.
- Assess patient satisfaction with treatment.
Patient Teaching:
- Proper inhaler technique
- Trigger avoidance
- Medication adherence
- When to seek emergency care