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JR  is a 56 yo man with h/o asthma, HTN and hyperlipidemia. He presents to  the ER today with h/o shortness of breath for 45 minutes at rest. He  reports that he was feeling well and in his usual state of health until  about an hour ago, when he smelled something burning. 20 minutes later,  he began to feel short of breath and was wheezing. He tried using his  albuterol inhaler without success, so he proceeded to the ER. Upon  arrival, he was tachycardic, tachypneic, wheezing, using accessory  muscles and hypertensive. His last admission for an asthma attack was 2  months ago. He denies a recent cold or URI and says the albuterol  usually helps him when he feels an attack coming on and tends to use it  on a daily basis. He generally has wheezing and shortness of breath on a  daily basis. JR reports poor sleep due to waking about 2 times a week  for shortness of breath. He has 2 cats, which sleep next to him on his  pillow and he lives in an apartment complex. JR does not smoke, but his  neighbor smokes. JR is a carpenter by occupation. He monitors his peak  flow once a week at home. He reports that his peak flow generally runs  about 325 L/min and his personal best is 480 L/min. His current peak  flow is 175 L/min.Medication Prior to Admission:Albuterol MDI 2 puffs BID-QID PRNSalmeterol Diskus 1 inhalation QIDIpratropium bromide MDI 2 puffs QIDLovastatin 20 mg po HSLisinopril 10 mg po QDQuestions:Classify JR’s asthma severity and  control based on signs and symptoms prior to this most recent  exacerbation and visit to the ED.Classify JR’s exacerbation severity based on PEF and symptoms.Identify the various triggers in JR’s life that may exacerbate asthma and prevent control.Which step should JR have been on prior to ER based on severity and current medications?Which medications are dosed incorrectly and/or inappropriate for JR’s asthma severity?Would a short-burst of oral corticosteroid be indicated at this time? If so, what dose and duration?How would you assess that JR is well-controlled?If JR is well-controlled, how would you step down in therapy?

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