History of Present Illness (HPI) - Bronchial Asthma

Presenting Complaints: Breathlessness and Cough

1. Onset and Duration

• When did the breathlessness/cough first start? (Age at first episode, date of current episode)
• Was the onset sudden or gradual?
• Is this the first episode or a recurrent problem?
• If recurrent: frequency of attacks, time between episodes, and whether the patient has been diagnosed with asthma previously

2. Character of Breathlessness (Dyspnea)

• Is it episodic or continuous?
• Does it occur at rest, on exertion, or both?
• Is there an associated wheeze (expiratory wheeze is characteristic)?
• Is there chest tightness? (a sense of pressure or constriction in the chest)
• Severity: Can the patient complete a full sentence? Is activity limited?
• Is it inspiratory, expiratory, or both? (asthma is predominantly expiratory)

3. Character of Cough

• Productive or dry? - Asthma cough is typically dry, non-productive and non-paroxysmal
• If productive: color, consistency, and amount of sputum (thick mucoid plugs may occur)
• Is the cough paroxysmal (in bursts)?
• Is there hemoptysis (coughing blood)? - A red flag; suggests alternate/additional diagnosis
• Does coughing itself trigger breathlessness?

4. Timing and Pattern

• Diurnal variation - Symptoms are classically worse at night and early morning (2-4 AM). This is related to decreased mucociliary clearance, airway cooling, and low endogenous catecholamines.
• Nocturnal symptoms: Does the patient wake from sleep coughing or breathless?
• Peak expiratory flow (PEF) is lowest in the morning and highest at mid-day; variation >20% over the day is characteristic.
• Seasonal variation: worse in spring/autumn (pollen), winter (cold air, viral infections)?
• Duration of each episode: minutes, hours, days?

5. Precipitating / Triggering Factors

6. Relieving Factors

• Does the breathlessness/cough relieve spontaneously or does it require medication?
• Does a bronchodilator (salbutamol inhaler) relieve symptoms? (Complete or partial relief is characteristic of reversible airflow obstruction)
• Does sitting upright help?
• Does removing the trigger (leaving a smoky room, stopping exercise) relieve symptoms?

7. Associated Symptoms

• Wheeze: audible or noticed by family? (expiratory polyphonic wheeze)
• Rhinitis: blocked/runny nose, sneezing, nasal discharge - suggests atopic state
• Eczema or urticaria: atopic triad
• Conjunctivitis: allergic component
• Chest pain: usually tight, diffuse; sharp/pleuritic pain suggests another cause
• Fever: suggests infective exacerbation or pneumonia
• Postnasal drip: can co-exist and worsen cough
• Heartburn/GERD: GERD is a common asthma trigger and co-morbidity
• Weight loss / hemoptysis / hoarseness: red flags suggesting malignancy or other diagnosis

8. Severity Assessment (Current Episode)

• PEFR (if available): compared to personal best
• Can the patient speak in full sentences?
• Exercise tolerance: distance walked before breathlessness, ability to climb stairs
• Sleep disturbance: how many nights per week?
• Daytime symptom frequency: more than 2 days/week = not well controlled
• Rescue inhaler use: more than 2 days/week?

9. Previous Attacks and Hospital Admissions

• Age of first diagnosis of asthma
• Number of attacks per year
• Ever admitted to hospital or ICU for asthma? (Indicates severe/brittle asthma - high risk)
• Ever intubated or required mechanical ventilation?
• Ever required oral corticosteroids (prednisolone)?
• Frequency and duration of previous exacerbations

10. Past Medical History

• History of atopic disease: allergic rhinitis, eczema, food allergies
• Previous diagnoses: COPD, GERD, sinusitis, nasal polyps, bronchiectasis
• Childhood history: recurrent bronchitis, bronchiolitis, croup - many children with recurrent bronchitis actually have undiagnosed asthma
• Any previous pulmonary function tests or spirometry?

11. Drug History

• Current and previous asthma medications: inhalers (reliever vs. preventer), oral steroids, theophylline, leukotriene antagonists
• Compliance with preventer therapy (inhaled corticosteroids)
• Inhaler technique: ask the patient to demonstrate
• Use of spacer device?
• Drugs that can cause or worsen asthma: beta-blockers, NSAIDs/Aspirin, ACE inhibitors

12. Family History

• Asthma, allergic rhinitis, eczema, or atopy in parents or siblings
• Family history suggests genetic/atopic predisposition

13. Social and Environmental History

• Smoking: current/ex-smoker (pack-years); passive smoking exposure
• Occupation: dusty environments, chemical exposures, healthcare workers (latex), bakers (flour), farmers; ask if symptoms improve on weekends or holidays (occupational asthma)
• Housing: carpets, dampness, mold, pets, feather pillows/duvets
• Exercise: level of physical activity; does exercise trigger symptoms?
• Impact on daily life: school/work absences, activity limitation

Key Differential Diagnosis to Consider in HPI

• COPD: significant smoking history, age >40, progressive rather than episodic
• Cardiac failure: orthopnea, PND, bilateral leg edema (ask about cardiac history)
• Vocal cord dysfunction (VCD): inspiratory wheeze/stridor, voice changes, throat tightness
• Pulmonary embolism: pleuritic chest pain, hemoptysis, leg swelling
• Allergic rhinitis (often co-exists): postnasal drip worsening cough

Summary: The Classic Asthma HPI Pattern

"A 25-year-old male presents with a 3-day history of breathlessness and dry cough, worse at night and in the early morning. He reports audible wheeze and chest tightness. Symptoms worsen with exercise and when he is around his cat. He has a background of childhood eczema and hay fever. He uses a salbutamol inhaler PRN, which partially relieves symptoms within 15 minutes. He has had 2 similar episodes in the past year, neither requiring hospitalization. His family history is positive for asthma in his mother."