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With the information provided below, what are the medication treatments for this patient (dose, frequency, and durations)?
With the information provided below, what are the medication treatments for this patient (dose, frequency, and durations)?
HPI: Margaret Jones is a 56-year-old, Caucasian female who has recently moved to Arizona from Minnesota and is a new patient to your office. She has a history of COPD and seasonal allergies. She has been feeling tired lately, which she attributes to her allergies. She has taken Claritin® in the past, but for the past month it has not been working well. She complains of a running nose that is worse in the morning and is associated with sneezing and an itchy throat. She also complains that her breathing is more difficult. She becomes dyspneic on minimal exertion and can hear herself wheezing at night. Her productive morning cough seems worse, but the color of her sputum has not changed. She denies discolored nasal drainage, HA, facial pain, loss of appetite, chest pain, edema, and fevers.
Medical history: Chronic obstructive pulmonary disease (COPD) and seasonal allergies; complaining of recent inability to sleep through the night.
Family history: Her family is noncontributory.
Medications: Claritin® 10 mg q am and albuterol MDI 2 puffs q 4 hours prn.
Allergies: Seasonal
Social history: Smoked 2 ppd x 30 years; quit 2 years ago.
Physical examination: This is a w/d, w/n who is appropriate and cooperative.
Vital signs: BP 128/72, P88 and regular, RR 20, O2sat 90% at room at rest.
She has dark circles under both eyes (allergic shiners), lungs have bilateral basilar wheezing, heart is regular without murmurs, abd is soft, nontender, and BS present.
Labs: Spirometry reveals: FEV1 = 45%, FEV1/FVC = 65%.