Pulmonary Disease Asthma Management: Review Questions Gary A. Salzman, MD Dr. Salzman is the Section Chief, Respiratory and Critical Care Medicine; Professor of Medicine; and Director, Pulmonary and Critical Care Medicine Training Program, University of Missouri-Kansas City School of Medicine, Kansas City, MO. He is also a member of the Hospital Physician Editorial Board. Choose the single best answer for each question.
	1. A 25-year-old woman visits her physician’s office, requesting refills of her albuterol inhaler. She has had asthma with daily symptoms for the past 10 years. She generally uses 2 puffs of her albuterol inhaler 4 times daily. She wakes up with asthma symptoms 1 to 2 nights a week; 2 puffs from her inhaler always brings complete relief of her wheezing and cough. Her peak expiratory flow (PEF) is 400 L/min, which is 100‰ of predicted. Besides refilling her prescription for the albuterol inhaler, which of the following is the best management option for this patient? Have her return for a visit in 3 months Start therapy with a combination of a long- acting ß-agonist and an inhaled corticosteroid Start therapy with an ipratropium bromide inhaler Start therapy with clarithromycin Click here to compare your answer. 2. A 28-year-old woman comes to her physician’s office with a 24-hour history of continuous wheezing and dry cough. She is taking 2 puffs from an over-the-counter epinephrine inhaler every 15 minutes, with only partial relief. She used up her prescriptions for albuterol and fluticasone metered-dose inhalers, and she is requesting refills. Examination shows pulsus paradoxus (decrease in systolic blood pressure of 20 mm Hg). She is using accessory muscles of respiration and is unable to lie flat because of dyspnea. PEF is 100 L/min (30‰ of predicted) before 3 aerosol treatments with albuterol and saline solution and 110 L/min (37‰ of predicted) after treatment. She reports feeling better after the treatments. Subsequent examination shows decreased breath sounds and no wheezes in the lung fields. Which of the following is the best management option for this patient? Admit the patient to the hospital with a diagnosis of status asthmaticus Refill her prescriptions and have her return to the office in 24 hours Refill her prescriptions, prescribe prednisone 40 mg daily for 7 days, and re-evaluate in 24 hours Refill her prescriptions, prescribe trimethoprim sulfate, and re-evaluate in 24 hours Click here to compare your answer.		3. A 22-year-old woman goes to her physician’s office because of a 24-hour history of wheezing, dry cough, and chest tightness. She takes 2 puffs from an albuterol inhaler every 2 hours, with only partial relief. She ran out of her fluticasone and salmeterol 2 weeks ago. There is no accessory muscle use, and she has pulsus paradoxus (decrease in systolic blood pressure of 5 mm Hg). She is afebrile, with a pulse of 90 bpm and respiratory rate of 20 breaths/min. PEF is 100 L/min (30‰ of predicted) before and 250 L/min (83‰ predicted) after an aerosol treatment with albuterol and saline solution. The patient reports feeling better after treatment, but bilateral expiratory wheezes are heard in both lung fields. Which of the following is the best management option for this patient? Admit the patient to the hospital Refill her prescriptions and start therapy with clarithromycin Refill her prescriptions, prescribe prednisone 15 mg daily for 4 weeks (then taper over 4 weeks), and schedule a follow-up appointment in 1 week Refill her prescriptions, prescribe prednisone 40 mg daily for 7 days, and schedule a follow-up appointment in 1 week Click here to compare your answer. 4. An 18-year-old man comes to his physician’s office for follow-up examination because of his asthma. His PEF is 400 L/min (80‰ of personal best). He currently takes fluticasone 110 µg 2 puffs twice daily and uses an albuterol inhaler 3 to 4 times daily. He is compliant with his medications, but he still wakes up at night 3 to 4 times a week with coughing that is relieved with his albuterol inhaler. Which of the following is the best management option for this patient? Add a long-acting ß-agonist such as salmeterol or formoterol to his fluticasone therapy Prescribe erythromycin 250 mg 4 times daily Prescribe prednisone 40 mg daily for 7 days Prescribe prednisone 40 mg daily for 7 days, then 30 mg daily for 7 days, then 20 mg daily for 7 days, and then 10 mg daily for 7 days Click here to compare your answer.
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