Asthma follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for a ‍asthma follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimprovedworsenedvariable in intensityresolved



Current symptoms:

‍shortness of breath

‍wheezing

‍chest tightness

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍increased sputum production

‍change in sputum color

‍runny nose, ‍clearcolored

‍hemoptysis

‍decreased exercise tolerance

‍fatigue

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍fever, up to ‍°, over ‍ ‍hoursdays

‍acid reflux



Smoking: ‍neversmokerformer smoker, ‍ pack-years

Physical activity: ‍adequateaveragesedentary

Impact on daily activities: ‍minimalmoderateseveredebilitating

Overall quality of life: ‍goodaveragepoor ‍



Pulmonary function tests: ‍

Chest X-ray: ‍ ‍normalunchanged



Exacerbations in the past year: ‍ ‍none123, ‍self-treated, ‍primary care visits, ‍ER visits, ‍hospitalizations



Medications:

‍LABAs, ‍LAMAs, ‍corticosteroids (ICS), ‍SABAs, ‍SAMAs, ‍Oxygen therapy, ‍LABA+ICS, ‍LABA+LAMA combinations

Adherence: ‍goodaveragepoor

Action plan available: ‍no ‍antibiotics, ‍prednisone

Use of rescue inhaler: ‍neverrarelyfew times weeklydailymultiple times a day

Inhaler technique: ‍correctincorrectnot reviewed



Allergies reviewed: ‍none, ‍pollen, ‍dust mites, ‍cat dander, ‍dog dander, ‍animal dander, ‍mold



Vaccinations:

Pneumococcal: ‍up-to-dateincompleteunvaccinated

Influenza: ‍up-to-dateincompleteunvaccinated

Covid: ‍up-to-dateincompleteunvaccinated





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

‍Asthma ‍likelysuspectedpossible, ‍well-controlled

DDx: asthma, asthma exacerbation, COPD, COPD exacerbation, acute bronchitis, pulmonary embolism, pneumonia, heart failure, vocal cord dysfunction, GERD, allergic rhinitis, sinusitis, anaphylaxis, medication noncompliance, environmental allergies, occupational exposures, psychogenic dyspnea, sleep apnea





PLAN:

Investigations:

- Chest X-ray

- Pulmonary function tests

- Allergy testing

- Methacholine challenge test

Treatments:

- ‍Short-acting bronchodilators (SABAs)

- ‍Long-acting bronchodilators (LABAs)

- ‍Long-acting muscarinic antagonists (LAMAs)

- ‍Inhaled corticosteroids (ICS)

- ‍Combination inhalers

- ‍Montelukast

- ‍PPIs

- ‍Nasal Steroids

- Asthma action plan: ‍Antibiotics + ‍Steroids

- Ensure proper inhalation technique and spacer use if necessary

- Avoidance of irritants and allergens

- Avoidance of NSAIDs and aspirin

- Smoking cessation counseling

- Immunization: pneumococcal, annual influenza, covid

Further care:

- Referral to asthma educator

- Referral to pulmonologist

- Referral to allergist

- Follow-up in ‍ ‍monthsyears

- Return sooner if symptoms worsen