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•Itbansforeigncountriesfromreimportingprescriptiondrugsandthesale,trade,andpurchaseofany
drugsamples.
• It prohibits the resale of prescription drugs from hospitals, health care entities, and charitable
organizations.
•Thepractitionermustaskfordrugsamplesinwriting.
• It regulates thewholesale distributionofprescriptiondrugs through the requirement of licensing in
stateswherefacilitiesarelocated.
Becausethesesamplesarefreelyavailable,someassumethatallpractitionerscandistributethem,but
this is notthecase. Thepractitioner mustbe aware oftherules thatgovern requesting,receiving,and
distributingtheseagentsbecausetheregulationsvaryfromstatetostate.
Accepting drug samples requires specific procedures. The pharmaceutical representative’s Sample
RequestFormmustbesigned.Itincludesthename,strength,andquantityofthesample.Thesamplemust
thenberecordedontheRecordofReceiptofDrugSamplesheet.Thesamplesmustbestoredawayfrom
otherdruginventoriesandwhereunauthorizedaccessisnotallowedorinalockedcabinetorclosetina
public area. Samples are to be inspected monthly for expiration dates, proper labeling and storage,
presenceofintactpackagingandlabeling,andappropriatenessforthepractice.Ifasamplehasexpired,
disposaloccursinamannerthatpreventsaccesstothegeneralpublic;itisnotdisposedintothetrash.
Whendistributingsamples,eachmustbelabeledwiththepatient’sname,cleardirectionsforuse,and
cautions. All samples are to be dispensed free of charge, along with pertinent information. The
medicationisthendocumentedinthepatient’schartwithdose,quantity,anddirections.
ADVERSEDRUGEVENTS
Prescription and nonprescription drugs have become an increasing part of life in the United States.
Between 2013 and2016, 48.4% ofindividuals tookat leastoneprescriptiondruginthelast30 days
(CDC,FastStats,2018). Adverse drugevents(ADE)haveconsequentlybecomeanincreasingproblem
resulting in adverse events both in the inpatient and outpatient settings. Due to the magnitude of the
problem, the Home of the Office of Disease Prevention and Health Promotion (2014) has created a
National Action Plan for Adverse DrugEventPrevention (http://health.gov/hcq/ade.asp). Therefore, a
prudentprescribermustalwaysbeawareofanymedicationswhenapatientispresentingforhealthcare.
Chapter3reviewstheimpactofADEindepth.
LackofDrugKnowledge
Duetothesheernumberofprescriptiondrugs,prescribersmusthavecurrentknowledge.Prescriberscan
lack knowledge about indications and contraindications for drugs. They must understand the
pharmacodynamicsandpharmacokineticsofmedicationstoordermedicationsafely.
Dosingerrorscanoccur,especiallywhenprescribingforchildren.Theseerrorscanbeattributedtothe
limitedinclusionofpediatricpatientsindrugstudies(Meyersetal.,2020).
Lack of knowledge about drug–drug interactions can also cause errors. For example, many drugs
interferewithwarfarinandcauseincreasedbleedingiftakentogether.Theprescribermustbeawareof
thepotentialfordrug–druginteractions(seeChapter3formoreinformation).
LackofPatientInformation
A standard error in prescribing is the failure to obtainanadequate history from the patient. Often, a
satisfactory drug history is not obtained, and the provider does not specifically inquire about herbal
preparationsorOTCmedications.Asmentionedpreviously,patientsdonotthinkOTCmedicationsare
drugs and, therefore, do not include them on intake documents. Also, information on allergies to
medicines is not reviewed. In addition to allergies, it is imperative to ascertain the reaction to the
medication. While nausea is not considered an allergic reaction, the prescriber would not want to
prescribe the drug. An allergy history should be taken and documented at each visit before a new
medicationisprescribed.Additionally,askingmultipletimesaboutallergiesorreactionstodrugsduring
anofficevisitisasafetycross-checktoresponsibleprescribing.
PoorCommunication
Poor communication among health care providers, pharmacists, and patients can be a result of poor
handwriting,incorrectabbreviations,misplaceddecimals,andmisunderstandingofverbalprescriptions.
Thesepotentialerrorscanbemitigatedusingelectronichealthrecords(EHR);however,newerrorscan
occur if the practitioner does not click on the correct medication or enter the right directions.
Additionally, there are areas in the UnitedStates where providers still handwriteprescriptions. Poor
communicationalso resultswhentheprescriber fails todiscusspotentialside effectsor askaboutside
effectsatsubsequentvisits.
SPECIALPOPULATIONCONSIDERATIONS
Dosesforchildrenareusuallybasedontheweightinkilograms.Theprescriberhasa responsibilityto
calculateandwritethecorrectdoseratherthanrelyingoncalculationbythepharmacist.SeeChapter4
formoreinformationaboutpediatricdrugdosing.
Older patients may have some difficulty hearing or reading small print. Additionally, they may be
takingmultipleprescriptionmedicationsandOTCmedications.Theprescriberneedstobespecificabout
whenthepatientshouldtakeeachmedicationandifonedrugcannotbeadministeredwithothers.When
the practitioner prescribes for older adults, he or she must consider renal function because some
medicinescancausetoxicity,eveninsmalldoses,withdecreasedrenalfunction.Chapter5reviewsthe
considerationsnecessaryforgoodprescribinginolderadults.
PHARMACOGENOMICS
Recently, the role of pharmacogenomics in prescribing medication is gaining more importance. Many
differentgenesinfluencethewayapersonrespondstoadrug.Withoutknowingallthegenesinvolvedin
drugresponse,ithasnotbeenpossibletodevelopgeneticteststhatcouldpredictaperson’sresponsetoa
drug. Knowing that people’s genes show small variations in the DNA base makes genetic testing for
predictingdrugresponsepossible.Geneticfactorscanaccountfor20%to95%variabilityinthepatient’s
reactiontoadrug.Whenpharmacogenetictestingisavailable,itcanenableproviderstounderstandwhy
patientsreactdifferentlytovariousdrugsandtomakebetterdecisionsabouttherapy.Thisunderstanding
mayallowforhighlyindividualizedtherapeuticregimens.ThisconceptisdiscussedindetailinChapter
7.
STEPSOFTHEPRESCRIBINGPROCESS
Ateachvisit,theprescriberobtainsamedicationhistorywiththenameofthedrug,dosage,andfrequency
ofadministration.Additionally,theinformationonanyallergiesshouldalsobereviewedordocumented.
Itisalsohelpfulifthepatientbringshisorheractualdrugstothevisit.
Multiplesteps(Figure1.2)areinvolvedinprescribingdrugsandevaluatingtheireffectiveness.Again,
thefirststepisdetermininganaccuratediagnosisbasedonthepatient’shistory,physicalexamination,and
pertinenttestfindings.
Next,inselectingthebestagent,thepractitionerthoroughlyevaluatesthepatient’scondition,takinginto
considerationtheeffectthatvariousmedicationsmayhaveonthepatientandthedisorder,theexpected
outcomesoftherapy,andothervariables(Box1.3).Toprescribeanydrugtherapy,thepractitionermust
havesubstantialknowledgeandbackgroundinthepathophysiologyofthedisease,pharmacotherapeutics,
pharmacokinetics,pharmacodynamics,andanyinteractions(seeChapter2).
Thepractitionerneedstobeknowledgeableaboutthebestclassofdrugsforthediagnoseddisorderor
presenting problem, the recommended dosage, potential side effects, possible interactions with other
medications,andspecialprescribingconsiderations,suchasrequiredlaboratorytests,contraindications,
andpatientinstructions.
FIGURE1–2Processforprescribing.
Box1.3 VariablestoConsiderinPrescribingaMedication
•Age
•Sex
•Race
•Weight
•Culture
•Allergies
•Pharmacogenomics
•Otherdiseasesorconditions
•Othertherapies
•Prescriptionmedications
•Over-the-countermedicines
•Alternativetherapies
•Previoustherapies
•Effectiveness
•Adverseeffects
•Adherence
•Socioeconomicissues
•Insurancestatus
•Incomelevel
•Dailyschedule
•Livingenvironment
•Supportsystems
•Healthbeliefs
Next,thepractitioner sets goals fortherapy. Goalsneedtobe patientcentered andrealistic andthe
outcomesmeasurable.Evaluationofanytreatment,nonpharmacologicorpharmacologic,isbasedonthe
results.
SelectingtheMostAppropriateAgent
For most disease entities, there is a recommendation for firstline, second-line, and third-line therapy.
Therapiesareidentifiedbyevidence-basedresearch,whichshowsspecificagentstobemoreeffective
thanothers.Foreachrecommendedtreatmentline,theprescriberevaluatestheeffectivenessandpotential
sideeffects.Thepatientresponseandpreferencesdictatechangesinthedrugs.Formoreinformation,see
thechaptercasestudyoutliningtheprescribingprocess.Casestudiesthatemphasizetheseprocesseshave
beenprovidedthroughoutthetext.
ConsiderationofSpecialPopulations
Anotherstepinprescribingdrugsisconsideringspecificconcernsrelatedtospecialpopulations,suchas
children, pregnant or breast-feeding women,andolder adults. Cultural beliefs are also considered to
ensurethatthedrugregimenhonorsindividualandfamilycustomsandpreferences.
IdentifyingOutcomes
Expected outcomes can include improvement in clinical symptoms or pathologic signs or changes in
biochemistryasdeterminedbylaboratorytests.Toassesswhetherexpectedresultshavebeenachieved,
thepractitionerreviewsdatacollectedonsubsequentvisits,evaluatestheeffectivenessofdrugtherapy,
andinvestigatesanyadversereactions.
Thefrequencyoffollow-upvisitsisdeterminedbythediseaseandthepatient’sresponsetotreatment.
Whileoutcomesarebeingassessed,thepractitionereducatesthepatientabouttheresultsoftherapyas
well. Topics for discussion include drug benefits, side effects, dosage adjustments, and monitoring
parameters.
Anundesirableoutcomecanoccurwithanymedication.Practitionersneedtoadvisepatientsaboutthe
potentialsideeffectsandadvisethemtoreportissuesrelatedtothedrugs.Reactionsthatmaybeexpected
andmustbediscussedincludesideeffects,drugorfoodinteractions,andtoxicity.Ifapatientexperiences
aseriousadverse drugreaction,thepractitionerfiles areportwiththeFDA’sMedWatchprogramona
special form obtainable from MedWatch (5600 Fishers Lane, Rockville, Maryland 20852-9787) or
reportsitonline,athttps://www.accessdata.fda.gov/scripts/medwatch/(seeChapter3forasampleofthe
MedWatch form). Similarly, adverse reactions to vaccines are reported through the Vaccine Adverse
Event Reporting System (VAERS) online, at http://vaers.hhs.gov/esub/index-#Online, or by mail by
completingaVAERSformrequestedbycalling1-800-822-7967andmailingittoVAERS,P.O.Box1100,
Rockville,Maryland20849-1100.AdverseeventsarediscussedinChapter3.
WRITINGTHEPRESCRIPTION
Thepracticeofhandwritingprescriptionsisquicklybecominganexerciseofthepast;however,thereare
still rare instances where a practitioner needs to know the steps. A prescription is a form of
communicationbetweenthepractitionerandthepharmacist.Itisalsothebasisforwrittendirectionsto
patients, and it is a legal document.Each prescription should be distinctlywritten to avoid errors of
misinterpretationinfillingtheprescription.Althoughpotentiallyseriouserrors occurinfrequently, they
areavoidableandshouldnotoccuratall.
Anearlystepintheprescribingprocessinvolvesensuringthatfrequentandpotentiallysevereerrors
arenotmade.Thefirststepisafailuretoidentifyapatient’sallergies,particularlytoamedication.In
determiningadrugallergy,thepractitionershouldalsoinvestigatethekindofreactionexperiencedwith
themedicationtodifferentiatebetweenareal,life-threateningdrugallergyandlessacutedrugsensitivity.
Some cross-sensitivities between categories of medication classes must also be considered. Another
erroristhefailuretoinstructthepatienttostopapreviouslyprescribedmedicationthattreatsthesame
condition,suchasanincreaseindose,andthepatientdoesnotstoptheotherdrug.Drug–druginteractions
areessentialtoconsiderwhenprescribing.Therearenowprogramsthatcanperformmultiplechecksfor
interactions.OneoftheseisEpocratesformobiledevicesanddesktops.
Date,Name,Address,andDateofBirth
Therearestandardcomponentsofanyprescription.Oneisthedate,andanotheristhefullname,address,
anddateof birthofthepatient.Theperson’sname should be thepatient’s givenname(theoneonthe
medicalrecord)andnotanickname.Ifadifferentnameisusedeachtime,thepatientcouldhavemultiple
filesinpharmacyrecord-keepingsystems.Theaddressshouldbethecurrenthomeaddressofthepatient
andnotaworkaddressorapostofficebox.
Prescriber’sName,Address,andPhoneNumber
Statelaws mandateprescribingpads tocontainthename, address,andphonenumberoftheprescriber
and,if required bystate law or regulations,the collaboratingphysician. This information enables the
pharmacisttocontacttheprescriberifthereisaquestionabouttheprescription.
NameofDrug
Ofcourse,thenameofthedrugisanessentialpartoftheprescription.Ideally,thegenericname(withthe
tradeor brandnameinparentheses) needsto be used.Legiblywritingthedrugnameavoidserrors in
fillingtheprescriptioncorrectly. For instance,somedrugshave namesthatarecommonlyconfused or
misread,suchasNorvascandNavane,PrilosecandProzac,carboplatinandcisplatin,andLevoxineand
Lanoxin. Severe problems may result if the wrong drug is supplied erroneously. The diagnosis may
optionally be added to the prescription, which can help the pharmacist avoid misinterpreting the
prescribedmedication.
Dose,DosageRegimen,andRouteofAdministration
The drug dose is essential because many drugs are available in various strengths. Write the dose in
numerals.Ifthedoseisafractionof1,itiswrittenindecimalformwithaleadingzerototheleftofthe
decimalpoint(e.g.,0.75).However,awholenumbershouldnotbefollowedbyadecimalpointanda
trailingzero (“10.0” could be misreadas “100”).Thenumeric dose isfollowedbythecorrectmetric
specification,suchasmilligram(mg),gram(g),milliliter(mL),ormicrogram(mcg).Manypractitioners
spelloutmicrogramtoavoidconfusionwithmilligram.Somedrugsaremanufacturedinunitsthatshould
bespecified,andthetermunitshouldbe writtenout(“insulin10units,”not“10 U”). There aremany
combinationdrugs,anditisimportanttodesignatethestrengthofeachmedication.Anexampleoftwo
drugsinonetabletislosartan25 mg/hydrochlorothiazide12.5mg—this drugalso formulateddifferent
dosecombinationswithoutdosespecificityerrorsinprescribing.
Theprescriptionalsomentionshowfrequentlythedrugistobetaken.Adrugprescribedtobetakenas
neededistermedaprndrug.Forexample,dosagefrequencycanbewrittenas“prnevery4hours”(or
another appropriate interval) for the problem for which the drug is prescribed (e.g., “as needed for
nausea”). It is good practice to write out the number (10—ten), especially with CSs. Any special
instructions,suchas“aftermeals,”“atbedtime,”or“withfood,”alsoshouldbespecified.Ifthedoseis
onceaday,itisasaferpracticetowriteout“daily”thantowrite“O.D.”becausethiscanbeconfused
witheveryotherday.
The prescriptionalso includes the number of pills, vials, suppositories, or containers or amountin
millilitersorouncestobedispensed.Prescriptionreimbursementorhealthcareinsuranceprogramsoften
allowfor30-or90-daysuppliestobedispensedatatime;workingwiththepharmacistisimperativefor
optimalprescribingpractices.Theyarethe bestconnectionregardingthe rules ofvariousprescription
plans. The prescription indicates whether the medicine may be refilled and the number of refills
permitted.
Whenprescribinganewdrugforapatient,thepractitionermaywanttoconsiderprescribingjustafew
doses or a 7-day supply initially, but this could be problematic with insurance paying for additional
medicationsinthemonth.Inthatcase,anotheralternative,ifavailable,istoprovidesamples,ifallowed
bylaworregulations.Thispracticeenablestheprescribertodetermineifthepatientcantoleratethedrug
andifitiseffective.Whendecidingonthenumberofrefills,thepractitionermaydecidewhenthepatient
shouldreturnforafollow-upvisitandallowjustthenumberofrefillsthatthepatientshouldtakeuntilthe
nextvisittoensurethatthepatientreturnstotheoffice.Somedrugprescriptionscannotberefilled.Forall
Schedule2drugs,forexample,anewprescriptionmustbewritteneachtime.
AllowableSubstitutions
Therearemanygenericequivalentsforbrandnamedrugs.Indicationofwhetherasubstitutionisallowed
isapartoftheprescription.Generally,onprescriptionpads,thereisaspecificlinetosignforageneric
replacement.Asdiscussedearlier,agenericdrugsubstitutemusthavethesamechemicalcompositionand
dosageasthebrandnamedruginitiallyprescribed.Inmanystates,agenericdrugwillautomaticallybe
substitutedforabrandnamedrug.Ifthereisamedicalreasontorequireabrandnamedrug(thathasa
genericequivalent),“BrandMedicallyNecessary”mustbewrittenontheprescription.
Prescriber’sSignatureandLicenseNumber
Thesignatureoftheprescriberisrequired.Itshouldbelegibleandshouldbetheperson’slegalsignature.
Thestateregulations varyregardingtheinclusionof the prescriber orcollaborating physician’license
numberon theprescription.Insomeinstances,theNPInumber oftheprescriberis also required. The
DEA numberis required forprescribingaCSandsometimesneededwhenprescribingbetweenstates.
Figure 1.3 illustrates a blank prescription and a completed prescription. Each state has specific
requirementsforobtainingthecomponentsonaprintedprescription.Thepractitionermustcomplywith
stateregulations andmayprescribeonlyinthestate inwhichheorsheholds a license. Althoughthe
prescription may be filled inanother state(ifallowed by stateregulations),a DEAnumber is usually
required. An NPI number must be included on each prescription along with a serial number of the
prescriptionform.Ifthepractitionerisafederalemployee,heorshemayprescribeinanyfederalfacility.
Any drug prescribed should be documented in the medical record with date of order, dosage, the
amountprescribed,andthenumberofrefills.Itishelpfultohaveaspecificareainthemedicalrecordto
record alldrugstakenbythepatient—prescription,OTC,andCAM—foreaseofaudit,reference,and
communicationamonghealthcareprofessionals.
FIGURE1–3Exampleofablankprescriptionform(left)andacompletedform(right).
ElectronicPrescriptions
Electronicprescribinghasbecomeincreasinglypopular andmandatedbymanystates.Federally, CMS
hasmandatedthatallPartDprescriptionsbe generatedelectronicallyfromJanuary2021 onward. The
benefits of using health care technology are the reduction of medication errors with the use of drugcheckingsoftware, whichchecksthemedicationdose, potentialinteractionswithothermedicationsthe
patientmaybetaking,andthepatient’sknownallergies.Thisdrug-checkingsoftwaremaybepartofthe
EHRorafreestandinge-prescribingsystem.IntegratedEHRscancalculatedosingbasedonapatient’s
weightandcarryoutothercontextualmedicationcheckingagainstapatient’slaboratoryresults,age,and
disease states. Also, computer systems provide pick lists of frequently selected medications with a
precalculated dose, frequency, and route. This list reduces the opportunity for clinicians to order
inappropriateamountsofmedicationswiththewrongfrequencyandrouteofadministration.
E-prescribingimprovesthelegibilityofprescriptionsandtherateofcompletedprescriptions.There
are manybenefits topatientswhenmedication is e-prescribed. Patientsnolonger needto carrypaper
copiesofaprescriptiontoapharmacy,formulary-compliantmedicationsareprescribed,andtheorderis
waitingforthemwhentheyarriveatthepharmacy.Therefore,e-prescribingleadstopatientconvenience,
shorterwaittimes,andincreasedcompliancewithformularyrequirements.E-prescribinghasyieldeda
12%to20%decreaseinadversedrugreactions(Figge,2009).
ADHERENCEISSUES
A prescribed drug must be used correctly to produce optimal benefits. Patient nonadherence to a
prescribedregimenleadstoless-than-optimaloutcomes,suchasprogressionofthediseasestateandan
increasedincidenceofhospitalizations.Studiesdemonstratethatthemorecomplexthetreatmentregimen,
thelesslikelythepatientistofollowit.Benner(2009)studied5,759patientstakingantihypertensiveand
lipid-loweringdrugs.Inpatientswith0,1,and2priormedications,41%,35%,and30%ofpatientswere
adherent,respectively,toantihypertensiveandlipid-loweringtherapy.Ofpatientswith10ormoreprior
medications,20%wereadherent.
Karter(2009) foundthat22% ofpatients hadthe prescriptionfilled0 or 1 time. The proportionof
newlyprescribedpatientswhoneverbecameongoinguserswaseighttimesgreaterthantheproportion
who maintained ongoing use but with inadequate adherence. Four percent of those who had the
prescriptionfilledatleasttwotimesdiscontinuedtherapyduringthe24-monthfollow-up.Nonadherence
wassignificantlyassociatedwithhighout-of-pocketcostsandclinicalresponsetotherapy.
Severalvariablesareassociatedwithimprovedadherencetoadrugregimen.Theseincludevariables
associatedwiththepatient’sperceptionoftheencounterandofthebenefitofthetreatment.Ifapatientis
nonadherent to the prescribed regimen, it is important to document that in the chart. The risks of
nonadherencearediscussed,andthatdiscussionisdocumented.Itisessentialtoaskwhythepatientisnot
following the prescribed treatment, and actions to rectify the problem should be taken. All of this is
documented. One issue may be that the patient is unable to swallow the pill. The medicine may be
available in liquid form, or the pill may be split or crushed. The practitioner needs to review and
understandthefactorsthataffectadherencetoaregimen(Box1.4).
UPDATINGDRUGINFORMATION
Manysourcesofdruginformationcanbeaccessedbypractitioners,whomustkeepcurrentonchangesin
drug therapy and continually update their fund of knowledge. Resources include reference books,
pharmacists (who are expertly informed about drugs, interactions, dosages, etc.), easy-to-carry drug
handbooksandpocketguidesforquickreference,andonlinedatabasesandprogramsformobiledevices
anddesktopcomputers(Tables1.2and1.3).
Box1.4 FactorsInfluencingthePatient’sAdherencetoaMedicationRegimen
•Approachabilityofthehealthcareprovider
•Perceptionofrespectwithwhichthepatientistreatedbythepractitioner
•Beliefthatthetherapyisbeneficial
•Beliefthatthebenefitsoftherapyoutweightherisksorsideeffects
•Degreetowhichthepatientparticipatesindevelopingthetreatmentregimen
•Costoftheregimen
•Simplicityoftheregimen
•Patient’sunderstandingofthetreatmentregimen
•Degreetowhichthepatientfeelsthatexpectationsarethepractitionerbeingmet
•Degreetowhichthepatientperceiveshisorherconcernsareimportantandbeingaddressed
•Degreetowhichthepractitionermotivatesthepatienttoadheretotheregimen
•Degreetowhichtheregimeniscompatiblewiththepatient’slifestyle
TABLE1.2
CommonDrugReferenceBooks
Reference Features
AmericanHospitalFormulary
Service.Bethesda,MD:American
SocietyofHealthSystem
Pharmacists.
Drugentriesareindexedbygenericandbrandnamesandorganizedby
pharmacologic–therapeuticclass.
DrugFactsandComparisons.
Philadelphia,PA:WoltersKluwer
Health.
Drugsareindexedbygenericandbrandnamesandorganizedbymajor
classesofdrugs.Updatesareissuedmonthly(inprintandCD-ROM).
Physician’sDeskReference(PDR).
Montvale,NJ:MedicalEconomics.
Drugsareindexedbymanufacturername,brandname,genericname,and
productcategory.Volumecontainsproductidentificationsection.Information
replicatestheofficialpackageinsertfromthedrugmanufacturer.
TABLE1.3
OnlineDrugReferenceData
Reference Address Features
AHRQ www.ahrq.gov GuidelinesforclinicalpracticefromtheAHRQ,NationalGuidelines
Clearinghouse,U.S.PreventiveServicesTaskForce
CenterWatch
ClinicalTrials
www.centerwatch.com Listsclinicalresearchtrialsanddrugtherapynewlyapprovedbythe
U.S.FDAandtheFDANewDrugListingService
Coreynahman www.coreynahman.com Pharmaceuticalnewsandinformation
Givesachoiceofmanysitesforinformation
Epocrates www.epocrates.com Websitewithdruginformation,interactions,etc.
Mediconsult www.mediconsult.com Professional-andconsumer-focused
Detailedmedicalanddruginformation
Medscape www.medscape.com Drugsearchdatabase
Linkstoonlinejournals
RxList—The
InternetDrugIndex
www.rxlist.com Cross-indexofU.S.prescriptionproducts
AHRQ,AgencyforHealthcareResearchandQuality;FDA,FoodandDrugAdministration.
CASESTUDY1
ThefirstpatientintheclinictodayisA.J.,whoisa16–year–oldwhohasjuststartedsoccerpractice
atschool.Shecomplainsofincreasedshortnessofbreathwithexerciseanddescribeshavingahard
timecatchingherbreathwhensheruns,whichshedoesfivetosixtimesaweek.Shedoesnotwakeup
atnightwithacoughorshortnessofbreathandhasnoproblemsatanyothertimeexceptinthespring
whenthetreesstarttoblossom.ThesoccercoachadvisedA.J.’smothertoseekhealthcarebecause
A.J.hadaverydifficulttimebreathingatpracticethatafternoon.A.J.alsohasahistoryofeczemaand
seasonalallergiesforwhichshetakesanover-the-counterantihistaminewhensymptomsgetsevere.
Socialhistory:Nonsmoker.Livesinanurbanareawithmother,father,andbrother.Doesnotuse
streetdrugs.
Familyhistory:Fatherhasahistoryofasthma.
Physicalexamination:
Nose:Mucosapaleandboggybilaterally
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