13 May Marla May, a 30-year-old non-binary client (pronouns they/them; DOB: 3/5/1994), presents to the clinic complaining of frequent episodes of shortness of breath, cough, and chest tightness that occur most days of the week
CASE STUDY:
Marla May, a 30-year-old non-binary client (pronouns they/them; DOB: 3/5/1994), presents to the clinic complaining of frequent episodes of shortness of breath, cough, and chest tightness that occur most days of the week. They have been taking prescribed low-dose ICS-formoterol inhaler twice daily and as needed for symptom relief, currently adhering to step three therapy, according to the CPG. Marla asks the NP if there is a possibility for other medications for better symptom control. The NP’s physical assessment reveals bilateral expiratory wheezes on auscultation with no retractions present. The rest of the physical exam is unremarkable. The NP determines that Marla is correctly using the inhaler and spacer and is strictly adhering to their medication regimen. Based on current asthma CPGs, the NP decides to prescribe different asthma medication for Marla and considers what would be appropriate.
Past Medical History: Asthma
Allergies: None
Medications: budesonide 80mcg/formoterol 4.5 mcg (Symbicort) two puffs via inhalation BID
Social History: They quit smoking cigarettes five years ago and drink alcohol once per month.
Physical Exam:
• Height: 5 feet 10 inches
• Weight: 160 lbs
• Body Mass Index (BMI): 23
• Blood Pressure (BP): 119/73
• Heart Rate (HR): 83
• Respiratory Rate (RR): 22
• Oxygen Saturation (O2 Sat): 96% on RA
• Temperature (TEMP): 98.7 oral
Step 1: Assess the client’s case, the applicable clinical practice guideline (CPG), and the prescription writing activity for that client within the lesson.
Step 2: Answer the discussion prompts below with explanation and detail, providing complete references for all citations. Refer to the lesson for client information.
1. Application of Course Knowledge: Answer all questions/criteria with explanations and detail.
a. Describe your assigned client’s situation. Why are they presenting to the clinic? What medications are they currently taking?
b. Assess the applicable clinical practice guideline (CPG) for your assigned client linked on the same page in the lesson where the client case is located. What treatment is recommended by the CPG for your client’s situation?
c. Discuss your personal professional assessment of the client’s situation provided in the scenario. What pharmacological treatment is necessary and why?
d. Reflect on additional questions you have about your assigned client that may influence treatment. What else do you need to know? What follow-up assessments, labs, or conversations are required to ensure optimal health outcomes?
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