Rick’s examination is normal except for soft expiratory wheezes and a loose cough. He did have his albuterol inhaler with him, and when asked
Details: “I need a refill for my inhaler.”
History
Rick, age 25, is being seen in your clinic for the first time. He recently moved to the area and is
establishing with you as a primary provider. His chief complaint is that he needs a refill for his
asthma inhalers and is hoping that you “know more about asthma than the last provider” because
his asthma has “never” been under control in spite of trying many different inhalers. He has
never seen an asthma specialist and has never had a written asthma treatment plan.
Rick reports having asthma “all his life,” beginning in early childhood. As a child, he
remembers being hospitalized a couple of times for asthma. He reports the mainstay of his
treatment has been to use an albuterol inhaler the past few years. He remembers using oral
medicine before but cannot remember the name. He has no other health problems except that he
smokes one pack of cigarettes per day. Upon further exploration, he reports that he used the
different inhalers for only a short time, because “they did not work.”
Assessment
Rick’s examination is normal except for soft expiratory wheezes and a loose cough. He did have
his albuterol inhaler with him, and when asked to demonstrate the use of his inhaler, he
demonstrated poor technique.
1. What would be the initial management plan?
2. What management would occur at a follow-up visit for asthma?
3. What is the ongoing management plan for asthma?
Answer preview for Rick’s examination is normal except for soft expiratory wheezes and a loose cough. He did have his albuterol inhaler with him, and when asked
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