Bronchial asthma case history

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Reading File

Based on information from Textbook of Family Medicine and Murray & Nadel's Textbook of Respiratory Medicine, here is a comprehensive guide on taking a bronchial asthma history and a full case study with diagnosis and management.

Bronchial Asthma: History Taking & Case Study

PART 1 — HOW TO TAKE A HISTORY

Definition (for orientation)

Asthma is a chronic inflammatory disorder of the airways characterized by reversible airway obstruction, airway inflammation, and increased bronchial hyperresponsiveness to a variety of stimuli. It presents with recurrent breathlessness, chest tightness, wheezing, and cough — particularly at night.

A. Presenting Complaints — Ask About the "Cardinal Four"

Symptom	Key Questions
Wheeze	Onset, frequency, bilateral? Audible or only on auscultation?
Dyspnoea	Exertional or at rest? Nocturnal? How limiting?
Chest tightness	Duration, association with triggers?
Cough	Dry or productive? Worse at night/early morning? Sputum color/amount?

Important: "Not all wheezing is asthma, and not all asthma has wheezing." — Textbook of Family Medicine

B. History of Presenting Illness

Onset: Acute/subacute/chronic? Age at first episode?
Duration and pattern: Episodic vs. persistent? Diurnal variation (worse at night/early morning)?
Severity: Can the patient complete sentences? Interrupted sleep?
Progression: Getting better, worse, or same?

C. Precipitating / Trigger Factors (Essential)

Always ask about:

Category	Triggers
Environmental allergens	House dust mites, pollen, molds, cockroach excreta, animal dander
Irritants	Tobacco smoke, strong odors, air pollutants, wood smoke
Exercise	Exercise-induced bronchospasm?
Infections	Viral respiratory infections (especially in children)
Drugs	Aspirin, NSAIDs, beta-blockers, ACE inhibitors
Occupational	Workplace chemicals, dusts, fumes (occupational asthma)
Emotional stress	Anxiety, crying, laughing
Hormonal	Premenstrual worsening, pregnancy
GERD	Nocturnal symptoms worsened by reflux

D. Past Medical History

Previous asthma attacks, hospitalizations, ICU admissions, intubations (indicates severity)
History of atopy: eczema, allergic rhinitis, urticaria
Sinusitis or nasal polyps
GERD
History of pneumonia or respiratory infections
Childhood wheeze or bronchiolitis

E. Drug History

Current medications — especially beta-blockers (contraindicated), aspirin/NSAIDs
Current asthma medications: inhalers (reliever vs. preventer), oral steroids
Compliance with medications
Correct inhaler technique?

F. Family History

Parental history of asthma (present in ~50% of childhood cases, though PPV is 11–37%)
Family history of atopic conditions (eczema, allergic rhinitis)

G. Social & Environmental History

Smoking (active and passive)
Occupation — dust, fumes, chemicals, baking, animal handling
Home environment — carpets, pets, dampness, mold
Housing conditions

H. Functional Impact

School/work absences
Sleep disturbance (nocturnal asthma = marker of poor control)
Exercise tolerance
Quality of life / asthma control questionnaire scores

I. Review of Systems

Rhinosinusitis symptoms (nasal congestion, post-nasal drip) — control of rhinitis often necessary to improve asthma control
Skin (eczema/urticaria)
GI (GERD symptoms)

PART 2 — SAMPLE CASE STUDY

Patient Details

Name: Mr. A.K. | Age: 28 years | Sex: Male | Occupation: Baker

Chief Complaint

Recurrent episodes of breathlessness, wheeze, and nocturnal cough for 3 years, worsening over the past 2 weeks.

History of Presenting Illness

Mr. A.K. presents with a 3-year history of episodic wheezing and breathlessness, predominantly at night and in the early morning. Episodes last 30–60 minutes and partially relieve spontaneously. Over the past 2 weeks, symptoms have worsened with daily wheeze, disturbed sleep 4–5 nights per week, and increasing use of his salbutamol inhaler (>3 times/day). He reports associated dry cough, worse at night. No fever or purulent sputum. He cannot climb one flight of stairs without stopping.

Triggers identified: Flour dust at work, cold air, and upper respiratory tract infections. He reports worsening when he forgets his preventer inhaler.

Past Medical History

Childhood eczema (resolved)
Allergic rhinitis since age 15
No previous hospitalizations for asthma
No history of GERD or sinusitis

Drug History

Salbutamol (SABA) 100 mcg MDI — PRN (currently using 4–5 puffs/day)
Beclomethasone 200 mcg MDI BD — often omitted
No beta-blockers, NSAIDs, or ACE inhibitors

Family History

Mother: bronchial asthma
Father: allergic rhinitis

Social History

Baker for 5 years (occupational exposure to flour dust)
Non-smoker
Lives in a ground-floor flat with carpet and a cat
No alcohol

Physical Examination

Finding	Result
General	Dyspnoeic on mild exertion, can speak in short sentences
RR	22 breaths/min
HR	100 bpm
SpO₂	94% on room air
Chest	Hyperinflated; bilateral expiratory polyphonic wheeze
Percussion	Resonant throughout
Auscultation	Reduced air entry at bases; prolonged expiratory phase
No cyanosis, no clubbing, no pedal edema

Investigations

Spirometry (post-bronchodilator):

FEV₁: 62% predicted
FVC: 82% predicted
FEV₁/FVC ratio: 0.65 (obstructive pattern)
Reversibility: 22% increase in FEV₁ after salbutamol → confirms reversible airway obstruction

Peak Expiratory Flow Rate (PEFR):

Current: 55% of personal best
Diurnal variation >20%

Other:

Chest X-ray: Hyperinflation; no consolidation, no pneumothorax
CBC: Eosinophilia (700 cells/μL)
Total IgE: Elevated
Skin prick test: Positive to house dust mite, cat dander, flour

Diagnosis

Primary: Bronchial Asthma — Uncontrolled, Moderate Persistent (based on NAEPP/GINA criteria)

Daily symptoms
Nocturnal awakening >4 nights/week
SABA use >2 days/week
FEV₁ 60–80% predicted

Contributing factors:

Occupational asthma component (flour dust — baker's asthma)
Allergic triggers (cat, HDM)
Non-compliance with inhaled corticosteroids (ICS)

Differential diagnoses considered and excluded:

COPD (young, non-smoker, reversible obstruction)
Cardiac failure (no orthopnoea, no JVP elevation, CXR clear)
Vocal cord dysfunction (no inspiratory stridor)
Pulmonary embolism (no pleuritic pain, no risk factors)

Management

Immediate (Acute)

Oxygen — titrate to SpO₂ 94–98%
SABA (Salbutamol) — 2.5–5 mg nebulized every 20 min for 3 doses, then as needed
Ipratropium bromide 0.5 mg nebulized (add for moderate-severe attack)
Systemic corticosteroids — Prednisolone 40–50 mg orally for 5 days
Monitor SpO₂, PEFR, respiratory rate, and ability to speak

Long-Term (Step-Up Therapy — GINA Step 3)

Drug Class	Drug	Dose
ICS	Beclomethasone	400 mcg BD (double previous dose)
LABA (add-on)	Formoterol or Salmeterol	Add due to uncontrolled symptoms
SABA (reliever)	Salbutamol	PRN only
LTRA (consider)	Montelukast	Useful with allergic rhinitis

Trigger Avoidance & Education

Occupational: Discuss workplace modification; consider flour dust mask or re-deployment
Home: HEPA vacuuming, allergen-proof mattress covers, remove carpet, rehome cat
Rhinitis control: Intranasal corticosteroid (e.g., fluticasone nasal spray)
Inhaler technique: Demonstrate and verify correct MDI technique with spacer
Written Asthma Action Plan: Green/Amber/Red zone based on PEFR and symptoms
PEFR diary: Monitor morning and evening values

Follow-Up

Review in 4–6 weeks
Spirometry repeated at 3 months
Reassess asthma control at every visit (symptom frequency, SABA use, exacerbations, sleep disturbance)
Referral to pulmonologist / allergy specialist for occupational asthma evaluation and consideration of allergen immunotherapy

Asthma Severity Classification (for reference)

Classification	Symptoms	Nighttime Symptoms	FEV₁
Mild Intermittent	<2 days/week	≤2/month	≥80%
Mild Persistent	>2 days/week	3–4/month	≥80%
Moderate Persistent	Daily	>1/week	60–80%
Severe Persistent	Throughout the day	Frequent	<60%

Sources: Textbook of Family Medicine, 9th ed. — Murray & Nadel's Textbook of Respiratory Medicine, 2-Volume Set

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