---

🫁 KNOWN ASTHMATIC PATIENT — FULL CLINICAL ASSESSMENT

"Doctor, I'm overwhelmed…"

---

━━━━━━━━━━━━━━━━━━━━━━━━━━━

PAGE 1 — PRESENTING COMPLAINT & HISTORY OF PRESENT ILLNESS

━━━━━━━━━━━━━━━━━━━━━━━━━━━

Identifying Data

---

Chief Complaint

---

History of Present Illness (HPI)

A. Cardinal Symptoms — Ask About Each:

• Onset: sudden vs. gradual?
• Duration and frequency per week
• Continuous or episodic?
• Worse at night / early morning? (nocturnal asthma — circadian cortisol rhythm)
• Precipitated by a specific event?

• At rest vs. exertion?
• Can they climb stairs? Walk flat?
• Orthopnea? (suggests CHF overlap)
• Paroxysmal nocturnal dyspnea?
• Dynamic hyperinflation — sensation of "can't get air in"

• Productive vs. dry?
• Character of sputum: clear/white/yellow/green (yellow/green = airway inflammation, NOT necessarily infection)
• Cough-variant asthma: cough as sole symptom?
• Worse at night?
• Post-exercise cough (exercise-induced asthma — symptoms at END of exercise)

• Location, radiation?
• Associated with wheeze?
• Chest tightness in young patients is highly specific for asthma

B. Timing Pattern

C. Triggering Factors — Systematic Inquiry

D. Current Inhaler Use — The RED FLAG Questions

Overuse of SABA is the single most important marker of poor control.

• Name of inhaler(s) — reliever? controller?
• How many times per day using reliever?
• More than 2 days/week? (poor control)
• How many canisters per month? (>1 canister/month = poor control)
• Has the inhaler lost its expected effect?
• Using LABA or ICS regularly? Technique?
• Missed doses?
• Any oral steroids recently?

E. Impact on Daily Life

• Nights woken per week due to asthma?
• Days of school/work missed?
• Exercise limitation?
• Has asthma changed quality of life?
• Any ER visits / hospitalizations in the past year?
• ICU admission / intubation ever? (near-fatal asthma — highest risk marker)

---

━━━━━━━━━━━━━━━━━━━━━━━━━━━

PAGE 2 — PAST HISTORY, DRUG HISTORY, FAMILY & SOCIAL HISTORY

━━━━━━━━━━━━━━━━━━━━━━━━━━━

Past Medical History

Asthma-Specific History

Comorbidities (All Directly Affect Asthma Control)

---

Drug History

Current Medications

Drug Allergies / Sensitivities

• Aspirin / NSAIDs → aspirin-exacerbated respiratory disease (Samter's triad)
• Beta-blockers (including topical ophthalmic drops) → severe bronchospasm
• ACE inhibitors → chronic cough may worsen asthma symptoms
• Sulfa drugs, penicillin?

Vaccinations

• Annual influenza vaccine? (GINA recommended — reduces exacerbations)
• Pneumococcal vaccine? (especially in severe/frequent exacerbations)

---

Family History

---

Social History

Smoking Status — CRITICAL

Smokers with asthma have accelerated FEV₁ decline, greater airway neutrophilia, and poorer response to ICS.

Occupational & Environmental Exposure

• Type of work
• Exposure to chemicals, dust, fumes, paint, latex, flour, animals
• Symptoms improve on weekends/vacations? (Hallmark of occupational asthma)
• Time away from work symptoms change?

Housing Environment

• Carpets, soft furnishings, pets? (dust mite, dander)
• Mold / damp walls?
• Type of heating/cooking fuel?
• Cockroaches?

Exercise & Diet

• Exercise tolerance
• Dietary history — sulfite-containing foods (wine, preserved foods)?

Alcohol Use

• Sulfites in red wine → asthma exacerbation in susceptible patients

---

━━━━━━━━━━━━━━━━━━━━━━━━━━━

PAGE 3 — REVIEW OF SYSTEMS & PHYSICAL EXAMINATION

━━━━━━━━━━━━━━━━━━━━━━━━━━━

Review of Systems

Respiratory

• Hemoptysis? (malignancy, bronchiectasis, TB)
• Recurrent pneumonias? (bronchiectasis, ABPA)
• Pleuritic chest pain?
• Symptoms of URTI preceding this attack?

ENT

• Nasal obstruction, rhinorrhea, sneezing?
• Post-nasal drip?
• Facial pain / pressure? (sinusitis)
• Smell disturbance? (nasal polyps)
• Snoring / apneas during sleep? (OSA)

Cardiac

• Palpitations?
• Ankle edema?
• Paroxysmal nocturnal dyspnea? (differentiates from cardiac asthma)
• Distinguishing nocturnal asthma from cardiac causes: asthma symptoms relieved by bronchodilators; cardiac causes not

GI

• Heartburn, regurgitation?
• Worse symptoms after meals, when lying flat?

Systemic

• Fever? (infectious trigger)
• Weight changes?
• Rashes, urticaria?
• Joint pains?

---

Physical Examination

General Appearance

• Distress: mild / moderate / severe?
• Can speak full sentences? (measure of severity)
• Cyanosis?
• Accessory muscle use?
• Nasal flaring?
• Tripod positioning?

Vital Signs

HEENT

• Nasal mucosa: pale/boggy/congested? (allergic rhinitis)
• Nasal polyps?
• Conjunctival injection, tearing? (allergic conjunctivitis)
• Pharyngeal cobblestoning? (post-nasal drip)
• Periorbital darkening? ("allergic shiners")

Chest Examination

• Barrel chest? (air trapping in chronic/severe disease)
• Intercostal / subcostal retractions?
• Use of sternocleidomastoid / scalene muscles?
• Prolonged expiratory phase?

• Trachea midline?
• Tactile fremitus: may be reduced with hyperinflation

• Hyper-resonance → air trapping
• Dullness → pneumonia, pleural effusion (complication or alternative dx)

⚠️ A completely silent chest in a breathless patient = medical emergency. Absence of wheeze does NOT mean improved.

Abdominal

• Hepatomegaly? (cor pulmonale in chronic severe asthma)

Extremities

• Clubbing? (not typical of asthma → think ABPA, bronchiectasis, malignancy, CF)
• Ankle edema? (cor pulmonale)
• Peripheral cyanosis?

Skin

• Eczema? (atopic march)
• Urticaria? (allergic phenotype)

---

━━━━━━━━━━━━━━━━━━━━━━━━━━━

PAGE 4 — INVESTIGATIONS & ASTHMA CLASSIFICATION

━━━━━━━━━━━━━━━━━━━━━━━━━━━

Diagnostic Algorithm

---

Investigations

1. Spirometry (Pre- and Post-Bronchodilator) — CORNERSTONE

Reversibility criterion: post-bronchodilator FEV₁ or FVC increase by ≥12% and ≥200 mL (15 min after inhaled SABA)

Spirometry may be normal between attacks — does not exclude asthma.

2. Peak Expiratory Flow (PEF) Monitoring

• Daily home monitoring: morning + evening readings
• Diurnal variation >20% = diagnostic for asthma
• Zones:
  • 🟢 Green: 80–100% personal best → continue current regimen
  • 🟡 Yellow: 50–80% → adjust therapy per action plan
  • 🔴 Red: <50% → seek emergency care

3. Bronchial Provocation / Challenge Test

• Indicated when: symptoms suggestive + spirometry normal
• Methacholine challenge: PC₂₀ <8 mg/mL = positive (airway hyperresponsiveness)
• Alternatives: exercise challenge, mannitol, hypertonic saline
• Highly sensitive, less specific — positive in other conditions too

4. FeNO (Fractional Exhaled Nitric Oxide)

• Measures eosinophilic airway inflammation

• 25 ppb = elevated (suggest type 2/eosinophilic inflammation, ICS-responsive)

• Used to: aid diagnosis, guide ICS therapy, predict steroid response
• GINA and NAEPP 2020: recommend FeNO as adjunct in ≥5 years, not for predicting exacerbation risk

5. Blood Tests

6. Skin Prick Testing / Allergy Testing

• Identifies specific aeroallergen sensitization (dust mite, pet dander, pollen)
• Guides allergen avoidance and immunotherapy eligibility

7. Chest X-Ray (CXR)

• Not routinely required for asthma diagnosis
• Indicated: atypical presentation, fever, unilateral wheeze, first severe exacerbation
• Asthma CXR findings: hyperinflation, peribronchial thickening (in chronic disease), patchy atelectasis
• Rules out: pneumonia, PTX, pneumomediastinum (complications), foreign body, malignancy

8. Body Plethysmography (if needed)

• Increased RV and TLC → air trapping
• Increased airway resistance
• Normal DLCO (distinguishes from COPD/emphysema where DLCO is reduced)

---

Classification of Asthma Severity

Asthma Control Assessment (for patients ON therapy)

---

━━━━━━━━━━━━━━━━━━━━━━━━━━━

PAGE 5 — FULL MANAGEMENT PLAN

━━━━━━━━━━━━━━━━━━━━━━━━━━━

Management Overview: 4 Pillars

"Control symptoms + Minimize risk + Treat comorbidities + Empower the patient"

---

PILLAR 1: PHARMACOLOGICAL MANAGEMENT — STEPWISE APPROACH

2021 Asthma Management Continuum (GINA/CTS):

---

Step-by-Step Therapy (NAEPP 2020 / GINA)

Step 1 — Intermittent Asthma

• SABA PRN (salbutamol/albuterol 100–200 mcg inhaled, up to 4×/day as needed)
• Alternative (≥12 yrs): PRN budesonide/formoterol (SMART) instead of SABA alone if at higher risk
• No daily controller needed IF truly intermittent

Step 2 — Mild Persistent Asthma (Preferred)

• Low-dose ICS daily (e.g., budesonide 200 mcg/day, fluticasone 100 mcg/day) + SABA PRN
• Alternative: daily LTRA (montelukast 10 mg OD) — less effective than ICS
• Key 2020 update: consider short-course ICS at onset of URI in step 1–2 intermittent wheeze (children 0–4 yrs)

Step 3 — Moderate Persistent Asthma (Preferred)

• Low-to-medium dose ICS + LABA (e.g., budesonide/formoterol 160/4.5 mcg BD, salmeterol/fluticasone)
• OR: SMART therapy — ICS/formoterol as both maintenance AND reliever (single inhaler, both daily + PRN)
  • SMART reduces exacerbations significantly vs. fixed ICS + SABA PRN
• Alternative: medium-dose ICS alone; or low-dose ICS + LTRA

Step 4 — Severe Persistent Asthma (Preferred)

• Medium-to-high dose ICS + LABA (e.g., budesonide/formoterol or fluticasone/salmeterol)
• SMART therapy preferred
• +/− LTRA (montelukast)
• Consider adding LAMA (tiotropium, umeclidinium) — NAEPP 2020: add-on LAMA preferred at step 5, option from step 3+
• Subspecialist referral recommended

Step 5 — Very Severe / Difficult-to-Treat (Add-On Therapy)

• High-dose ICS + LABA
• Add LAMA (tiotropium 18 mcg/day OD)
• Biologics — assess phenotype:

  Biologic	Target	Indication
  Omalizumab (anti-IgE)	IgE	Allergic asthma, total IgE 30–1500 IU/mL, perennial allergen sensitization, ≥6 yrs
  Mepolizumab (anti-IL-5)	IL-5	Eosinophilic asthma, blood eos ≥150/μL, ≥12 yrs
  Benralizumab (anti-IL-5Rα)	IL-5 receptor	Eosinophilic, eos ≥300/μL, ≥12 yrs
  Dupilumab (anti-IL-4/13)	Type 2 inflammation	Eosinophilic or oral steroid-dependent, ≥12 yrs
  Tezepelumab (anti-TSLP)	Broad T2/non-T2	Broad severe asthma, ≥12 yrs

Step 6 — Oral Corticosteroids (Last Resort)

• Oral prednisolone lowest effective dose, alternate-day preferred
• Document side effects: osteoporosis, hyperglycemia, adrenal suppression, cataracts
• Always add bone protection (calcium + Vitamin D; bisphosphonate if ≥3 months OCS)

---

Quick-Reference Drug Table

---

PILLAR 2: NON-PHARMACOLOGICAL / TRIGGER AVOIDANCE

---

PILLAR 3: ASTHMA ACTION PLAN (Written)

Green Zone (Doing Well — PEF 80–100% personal best)

Yellow Zone (Caution — PEF 50–80%)

Red Zone (Medical Alert — PEF <50%)

---

PILLAR 4: MONITORING & FOLLOW-UP

At Every Visit — REASSESS 6 Parameters:

1. Symptom control — daytime symptoms, night awakenings, SABA use, activity limitation
2. Risk of exacerbation — ER visits, oral steroid courses, eosinophil count
3. Lung function — spirometry (FEV₁) or PEF % predicted
4. Inhaler technique — demonstrate and re-teach at every visit
5. Adherence — count remaining doses, explore barriers (cost, fear of steroids)
6. Comorbidities — rhinitis, GERD, obesity, anxiety, OSA

Stepping Up vs. Stepping Down

• Step up: if uncontrolled for ≥3 months (first exclude: wrong diagnosis, poor technique, non-adherence, ongoing triggers)
• Step down: if well-controlled for ≥3 months → reduce ICS dose by 25–50% at a time; never stop ICS completely without specialist review
• Review every 1–3 months initially; every 3–12 months once controlled

Vaccinations

• Annual influenza vaccine (inactivated — not live attenuated) — reduces asthma exacerbations
• Pneumococcal vaccine (PPSV23 / PCV) — especially in severe/step 4–6 asthma

Referral Indications

• Diagnostic uncertainty
• Severe persistent asthma (step 4–6)
• Suspected occupational asthma
• Consideration for biologic therapy
• Near-fatal attack history
• Asthma not controlled despite step 3 therapy after 3 months

---

MANAGEMENT OF ACUTE EXACERBATION (Bonus — For the Overwhelmed Patient Presenting in Distress)

---

Patient Education Checklist

• What is asthma? (Inflammation + bronchospasm)
• Difference between reliever (SABA) and preventer (ICS) inhalers
• Correct inhaler technique — demonstrated, patient demonstrates back
• Spacer device provided and instructed (improves pulmonary deposition by 4× vs. MDI alone)
• Triggers identified and avoidance plan made
• Written asthma action plan issued
• Peak flow meter issued + personal best established
• Follow-up appointment scheduled
• Emergency contacts and when to go to ER explained
• Medication side effects discussed (steroid card if on high-dose ICS/OCS)
• Smoking cessation if applicable
• Annual flu vaccination arranged

---

---

1. Frequent SABA use = poor control → step up therapy
2. Always assess inhaler technique before stepping up — it's the most common fixable cause of failure
3. Treat the comorbidities (rhinitis, GERD, anxiety) — they directly perpetuate poor asthma control
4. Issue a written action plan — it's the single most effective self-management tool
5. Consider SMART therapy (single ICS/formoterol inhaler as both maintenance + reliever) — it significantly reduces exacerbations

History of Present Illness (HPI)

Written as a clinical narrative — the way you'd document it in the notes

---

Paragraph 1 — Onset & Cardinal Symptoms

---

Paragraph 2 — Timing & Pattern

---

Paragraph 3 — Triggering & Aggravating Factors

---

Paragraph 4 — Current Medication Use & Control

---

Paragraph 5 — Impact on Daily Life & Red Flag Assessment

---

Clinical summary: Known asthmatic with a [X]-year history, presenting with a multi-week deterioration characterized by daily symptoms, frequent nocturnal awakenings, near-daily SABA overuse, poor preventer adherence, incorrect inhaler technique, and significant functional impairment — consistent with uncontrolled moderate-to-severe persistent asthma requiring immediate clinical review, step-up pharmacotherapy, inhaler technique correction, and a written asthma action plan.

Management of the Overwhelmed Asthmatic Patient

Uncontrolled Moderate-to-Severe Persistent Asthma

---

STEP 1 — IMMEDIATE IN-CLINIC ASSESSMENT

• SpO₂, RR, HR, ability to speak in full sentences
• Auscultate chest — wheeze vs. silent chest
• PEF % personal best

• Ask the patient to demonstrate their current technique
• Correct errors: shake → exhale → actuate + slow deep inhale simultaneously → hold breath 10 seconds
• Prescribe a spacer device — increases lung deposition by up to 4× compared to MDI alone

• Rule out vocal cord dysfunction, COPD, cardiac failure if any atypical features

---

STEP 2 — PHARMACOLOGICAL MANAGEMENT

A. Treat Today's Exacerbation First

---

B. Step Up Long-Term Controller Therapy

SMART = Single Maintenance And Reliever Therapy One inhaler (ICS/formoterol) used as BOTH the daily preventer AND the as-needed reliever. Evidence shows SMART reduces exacerbations and oral steroid courses more effectively than fixed ICS + SABA PRN.

---

C. When to Consider Biologic Therapy (Step 5–6)

---

STEP 3 — TREAT COMORBIDITIES

---

STEP 4 — NON-PHARMACOLOGICAL MEASURES

• Remove or keep cat out of bedroom; use HEPA air purifier
• Allergen-impermeable mattress and pillow covers; wash bedding in hot water (≥60°C) weekly
• Remove carpets where possible
• Pre-exercise: salbutamol 2 puffs 15–30 minutes before activity
• Avoid cold air exposure; use a scarf over mouth in cold weather

• If current smoker → smoking cessation is the single most impactful intervention
• Offer NRT + varenicline + behavioral support
• Household smoking ban even if patient is a non-smoker

---

STEP 5 — WRITTEN ASTHMA ACTION PLAN

---

STEP 6 — MONITORING & FOLLOW-UP

1. Symptom frequency (day + night)
2. SABA use (canisters/month)
3. Activity limitation
4. Lung function (FEV₁ or PEF)
5. Inhaler technique (demonstrate each time)
6. Adherence and barriers

---

STEP 7 — PATIENT EDUCATION (Before Leaving the Clinic)

• Explain the difference between preventer (ICS — reduces inflammation, must be used daily even when well) vs. reliever (SABA — opens airways fast but does NOT treat inflammation)
• Emphasize: "Using your blue inhaler every day means your asthma is not controlled — it is not a solution, it is a warning sign"
• Demonstrate and have the patient demonstrate back the correct inhaler + spacer technique
• Explain the written action plan in the patient's own language
• Book annual flu vaccination today
• Provide emergency contact number and clear instructions on when to go to ER
• Address the patient's anxiety — validate that feeling overwhelmed is common, and that with the right plan, most patients achieve full control

---

Summary of Today's Management in One View

TODAY:
├── Salbutamol 4–8 puffs via spacer (in clinic)
├── Prednisolone 40 mg OD × 7 days (oral)
├── Fix inhaler technique + issue spacer
└── Step up to ICS/LABA (SMART: budesonide/formoterol)

SHORT-TERM (2–4 weeks):
├── Add montelukast 10 mg ON if rhinitis present
├── Treat GERD / rhinitis / other comorbidities
├── Trigger avoidance plan
└── Written action plan + PEF meter

LONG-TERM (3+ months):
├── Review control → step down if appropriate
├── Reassess for LAMA add-on if uncontrolled
├── Refer if still uncontrolled → consider biologics
└── Annual flu vaccine + spirometry

Key Questions to Ask in an Asthma HoPi

The must-ask checklist — nothing skipped

---

🔑 1. THE 4 CARDINAL SYMPTOMS

---

🔑 2. TIMING — THE MOST DIAGNOSTIC QUESTIONS

The pattern tells you more than the symptom itself.

• "Are symptoms worse at night or early morning?" (Nocturnal/early-morning = classic asthma — circadian pattern)
• "Do symptoms come and go, or are they always there?" (Episodic and reversible = asthma; constant = think COPD or other)
• "How many days per week do you get symptoms?" (Classifies severity: ≤2 = intermittent; daily = persistent)
• "How many nights per week do you wake up because of it?" (>1×/week = at least moderate persistent)

---

🔑 3. TRIGGERS — GO THROUGH THEM ONE BY ONE

---

🔑 4. INHALER USE — THE CONTROL QUESTIONS

• "What inhalers are you on? Show me how you use them." (Technique is wrong in >70% of patients — the most fixable cause of poor control)
• "How many times a day are you using your blue/reliever inhaler?" (>2 days/week = poor control; daily use = significant red flag)
• "How many canisters of the reliever have you used in the past month?" (>1 canister/month = poorly controlled)
• "Are you taking your preventer inhaler every day, even when you feel well?" (Most patients stop it when symptoms improve — this is a key education gap)
• "Has your inhaler stopped working as well as it used to?" (Reduced effect = worsening inflammation, not tolerance)

---

🔑 5. IMPACT ON DAILY LIFE

• "How many nights have you woken up because of asthma this week?"
• "Has asthma stopped you from doing normal activities — exercise, work, housework?"
• "How many days of work or school have you missed?"
• "Can you climb a flight of stairs without stopping?"
• "Does asthma affect your sleep?"

---

🔑 6. PAST ASTHMA HISTORY — THE RISK MARKERS

• "Have you ever been admitted to hospital because of asthma?"
• "Have you ever been in ICU or put on a breathing machine?" ← Near-fatal history — highest risk
• "How many courses of steroid tablets have you had in the past year?" (≥2 = severe/uncontrolled)
• "Have you ever needed a nebulizer in A&E?"
• "When were you last well-controlled?"

---

🔑 7. COMORBIDITIES THAT DRIVE POOR CONTROL

• "Do you have a blocked or runny nose, or sneeze a lot?" → Allergic rhinitis
• "Do you get heartburn or acid reflux, especially at night?" → GERD
• "Do you have eczema or skin allergies?" → Atopic march
• "Has anyone told you that you stop breathing in your sleep / snore loudly?" → OSA
• "Do you feel anxious or down in mood?" → Anxiety/depression — very common in asthma

---

🔑 8. SMOKING & ENVIRONMENT

• "Do you smoke — cigarettes, shisha, vaping?" (pack-years; type)
• "Does anyone in your home smoke?"
• "Do you have carpets, soft furnishings, pets at home?"
• "Is there any damp or mold in your home?"
• "What do you do for work? Any chemical or dust exposure?"

---

🔑 9. DRUGS TO ALWAYS ASK ABOUT

---

Quick-Fire Memory Aid

"WHAT TRIGGERS MY ASTHMA DOCTOR?"

---