Asthma Clinical Case Review

"This is a 35 year old male with past medical history of asthma, atopic dermatitis, allergic rhinitis, gastroesophageal reflux, and food allergies presenting with severe asthma, not well controlled with controller therapy. In the past month, patient reported chest tightness, shortness of breath, and wheezed multiple times a day. He had one episode of nighttime awakening from his asthma in the past month.

Patient was taking albuterol nebulizer treatment or ipratropium-albuterol nebulizer treatment four to seven times a day. In addition, he was taking fluticasone-vilanterol, 225 micrograms per dose, inhalation one puff once a day, and tiotropium bromide, two puffs once a day. Patient reported adherence to controller medications. In the past year, patient took three courses of oral steroids for asthma exacerbation. In addition, he had five emergency room visits and one hospitalization for asthma exacerbation.

Patient has been diagnosed with asthma since childhood, which improved during puberty, but then reappeared four years ago. Patient reported three episodes of pneumonia over the past 10 years. He reported frequent sinus infections when he was in his twenties. Patient did not endorse recent international travel. He did not endorse any recent fevers, chills, weight loss, night sweats, abdominal pain, vomiting, or diarrhea. The patient reported that his eczema would flare when he had an asthma exacerbations, and his triggers for asthma included mold exposure, exercise, upper respiratory infection and humid weather.

Past medical history significant for gastroesophageal reflux, and history of gastric ulcer and Mallory-Weiss tear. In addition, has a history of atopic dermatitis, allergic rhinitis, shellfish allergy, and tree nut allergies. Social history is pertinent for being a former smoker. Patient quit smoking eight years ago. Smoked five to 10 cigarettes per day for about eight to 10 years prior to quitting. Currently, he works as an environmental engineer and groundskeeper and works outdoors.

His medication list, in addition to his control and therapies for asthma, he's also taking fluticasone nasal spray, two sprays daily in each nare, and omeprazole, 20 milligram capsule once a day."