Submit a Short Case for Review

	Case Submission Form
	Personal Information First Name Last Name Email Address Location Case Submission Keywords: Age Group Less Than 20 21-40 41-60 Over 60 Gender: Male  Female Afflicted with diagnosed asthma/COPD:   weeks months years  W/M/Y Description of encounter: Scenario: Contributors to exacerbation Select one Non-compliance Improper/insufficient drug regimen Improper technique Diagnosis Select One COPD Asthma(acute or chronic) Medications COPD/Asthma related Short-acting beta-agonist #   weeks months years W/M/Y Long-acting beta-agonist #   weeks months years W/M/Y Anticholinergics #   weeks months years W/M/Y Inhaled Corticosteroids #   weeks months years W/M/Y Oral Corticosteroids #   weeks months years W/M/Y Leukotriene Modifiers/Antagonists #   weeks months years W/M/Y Theophylline #   weeks months years W/M/Y Other prescriptions   Select One Other Prescription1 Other Prescription2 Other Prescription3 Other Prescription4 Other Prescription5 Other Prescription6 Over-the-counter/Misc.   Asthma monitoring values(if applicable) Amount of albuterol use    puffs/day    canisters/month FEV1    liters PEFR    liters/min. FVC    liters Case assessment: Related Questions: Other Information: