Assessment and Management Plan

The management plan is directed at improving asthma control through more effective use of medications and removal of environmental allergens. At present she is using high doses of inhaled bronchodilators, but is not using inhaled corticosteroids adequate ly. Several possible aggravating factors are present in the environment: a work place where she may be exposed to textile byproducts known to trigger asthma problems, and could explain why her asthma is worse at the end of the week; tobacco smoke at ho me; pets at home (dogs and cats).

Her medication regimen should include an inhaled corticosteroid (Beclomethasone), initially 4 puffs 4 times per day until symptoms are stabilized. Later she may lower her dose to a 3 times/day regimen. She will continue to use Ventolin (albuterol) on a prn basis, keeping a diary of how much medicine she is using. The medication regimen should be kept as simple as possible to reduce the cost of medications.

The patient is at high risk of diabetes in view of her Mexican-American origin, family history of diabetes in her mother, obesity and a borderline high blood glucose value.

Patient Counselling and Education

• 1) The concept of asthma as a chronic inflammatory problem which requires continuous anti-inflammatory medication, even during symptom-free periods.

  Need for anti-inflammatory medication. The anti-inflammatory medication in her case will be an inhaled corticosteroid (Beclomethasone). Because of her fear of "steroids," the following points will be emphasized: the need for regular use of anti-inflamm atory medications, the advantage of using inhaled vs. systemic steroids, and the difference between corticosteroids and anabolic steroids, the different actions of inhaled corticosteroids and inhaled bronchodilators and the need to use beclomethasone regu larly in order for it to be effective.

• 2) The use of metered dose inhalers (MDIs). She will be trained in the correct use of inhalers. A spacer will be used, since it facilitates the MDI technique.

• 3) Identification of environmental triggers. The patient will be trained to keep a diary and measure her peak flow rates twice a day in order to establish a pattern between her symptoms, flow rates and invironmental circumstances. Since the p atient completed three years of high school, her literacy level is not a serious barrier to learning to keep the diary.

• 4) The environmental changes that may be required to control her asthma. In the session with her husband, who smokes, the adverse effect of tobacco smoke on the children, as well as the patient, will be emphasized, since Latinos are very conce rned about their children's well-being. Written educational materials available in English and Spanish from the National Institutes of Health will be used to reinforce simple measures recommended for dust and mold control in the home.

  The pets situation will be addressed, particularly the fact that asthma is not improved by owning a chihuahua dog. The results of her allergy testing will be stressed to support the need to remove the pets from the home environment.

  She will be advised to wear a mask in her work environment.

• 5) Her risk of diabetes. The importance of weight control through proper dietary habits and exercise will be reviewed.

Case #1 - Contributed by Benjamin Interiano, M.D., Department of Medicine, Baylor College of Medicine

Review the physical exam and laboratory findings.