Reference no: EM133241271

Your patient is a 23-year-old female. She presents with coughing and wheezing which she stated started about three weeks ago. She is currently 25 weeks pregnant. Her last prenatal visit was one month ago in another state. She has an appointment with the prenatal care provider next week, however her respiratory symptoms brought her to your office today.

History - Chickenpox as a child. Asthma as a child, diagnosed at age 8 for which she used a SABA when needed. She has not had the need to use an inhaler since she was 19. She takes only her prenatal vitamin. No other acute or chronic problems. She advises you that she is up to date on all immunizations except she has not had a flu shot (it is October).
Social - Non-smoker, no drug use. She relocated to your state two weeks ago to get away from an abusive domestic situation. She has no support network in this area and has not yet found employment. She has no medical insurance.

HPA - Non-productive cough x 3 weeks. Wheezing audible from across the room. She states it is like this all day and wakes her from sleep every night. She reports that she is fatigued even in the morning. No other complaints.

PE/ROS - Pt appears disheveled but clean. Wheezing in all lung fields. T 98, P 82 regular, R 28 no stridor. FH 130 regular. The remainder of the exam is WNL.

02 98% and FEV 70%

Here is my problem, I chose asthma exacerbation as her diagnosis.  I then chose the GINA guidelines to follow for treatment. Treatment includes using track 1, step 4 of those guidelines. Step 4 calls for a medium dose maintenance inhaler and a low dose reliever inhaler. Because this patient is homelss, no job, no insurance, I opted to prescribe Spiriva 160/4.5 mcg 2 inhalations q12h for maintenance and Spiriva 160/4.5 mcg 1 inhalation prn sob/wheezing for reliever but with her being without a job she likely won't be able to afford 2 inhalers.  Please help, am I on the right track. What medications should be prescribed for this patient?