Asthma Review Clinic

PT NAME: Sarah Jenkins DOB: 12/03/1985 HOSP NO: SJ851234 WARD: Outpatient Clinic PLAN: * Continue current ICS/LABA therapy (Flutiform 250/10 mcg, 2 puffs BD). * Initiate a 5-day course of oral prednisolone (30mg daily) due to recent exacerbation. * Prescribe a new SABA inhaler (Salbutamol 100mcg/puff PRN) and provide refreshed inhaler technique training. * Referral to pulmonary rehabilitation for breathing pattern disorder assessment and management. * Discuss smoking cessation resources and nicotine replacement therapy options. * Schedule a follow-up appointment in 4-6 weeks to review asthma control and treatment effectiveness. WHEN AND WHERE WAS PT DIAGNOSED WITH ASTHMA: Diagnosed in childhood at approximately 7 years old by a GP, confirmed by a paediatrician following recurrent wheezing episodes and nocturnal cough. FAMILY HISTORY: Maternal grandmother had asthma. Father had chronic bronchitis. ARE THEY A SMOKER: YES CIGARETTES, PIPE, CIGARS, TOBACCO: Cigarettes HOW MANY A DAY: 10 HOW MANY YEARS?: 15 PACK YEARS: 7.5 PASSIVE SMOKER? EXPOSURE AS CHILD?: YES - Exposed to parental smoking at home during childhood. RECREATIONAL DRUG SMOKING: NO ATOPY/ECZEMA: YES / History of childhood eczema, currently well-controlled with emollients. MEDICATIONS/FOOD ALLERGIES: No known drug allergies. No known food allergies. OTC MEDICATIONS TAKEN: - Paracetamol for occasional headaches. - Ibuprofen for muscle pain, as needed. ASTHMA TRIGGERS: - Cold air - Dust mites - Pet dander (cats) - Exercise - Stress ANIMALS/PETS AT HOME: YES / One cat, 'Whiskers'. Patient reports symptoms worsen after close contact. FACTORS AT HOME AFFECTING CHEST: YES / Old carpet in bedroom, patient believes it exacerbates dust mite allergy. OCCUPATIONAL FACTORS: NO CURRENT/PREVIOUS JOBS: Currently works as an office administrator. Previously worked in retail. TIME TAKEN OFF WORK: YES / 3 days in the last month due to asthma exacerbation. ANY EXERCISE ISSUES? WHAT IS EXERCISE TOLERANCE? WHEN OCCURRING? HOW LONG TO RESOLVE? DO THEY NEED RELIEVER MEDS? DO THEY HELP: Reports exercise-induced asthma. Can walk briskly for about 10 minutes before experiencing shortness of breath and wheezing. Symptoms usually resolve within 15-20 minutes with rest. Requires SABA prior to exercise, which helps significantly. SYMPTOMS SUGGESTIVE OF ILO – STRIDOR, UPPER CHEST TIGHTNESS, SWALLOWING/CHOKING PROBLEMS, SENSATION LUMP IN THROAT, LARYNGEAL SENSITIVITY, COUGH: Reports occasional sensation of a lump in her throat during severe exacerbations, but no true stridor or swallowing difficulties. BREATHING PATTERN DISORDER: Reports occasional sighing and breath-holding, especially when stressed. Denies hyperventilation episodes. DO THEY SNORE?: YES EPISODES FALLING ASLEEP/FATIGUE?: YES APNOEIC EPISODES?: NO REFER OVERNIGHT OXIMETRY: YES PRESENTING SYMPTOMS: Increased wheezing, shortness of breath, and nocturnal cough for the past 2 weeks, requiring increased SABA use. COUGH: Persistent, dry cough, worse at night and with exertion. Occasionally productive of clear sputum during exacerbations. PHLEGM: Clear, non-purulent, minimal. WHEEZE/TIGHTNESS: Audible wheeze, significant chest tightness, especially on exhalation. SOB: Dyspnoea at rest during exacerbations, otherwise on exertion (modified MRC Grade 2). ANY PEDAL OEDEMA/NOCTURNAL ORTHOPNOEA/DYSPNOEA, ANY SUGGESTION OF HF: Denies pedal oedema, nocturnal orthopnoea, or paroxysmal nocturnal dyspnoea. No clinical signs suggestive of heart failure. NASAL SYMPTOMS: YES HOW LONG FOR? ANY PREVIOUS TREATMENTS TRIED? MOUTHBREATHER? BPD? PND? H/O POLYPS: Chronic nasal congestion and rhinorrhoea for several years. Has tried over-the-counter antihistamines with some relief. Not a habitual mouth breather. Denies post-nasal drip. No history of nasal polyps. SABA USE: 4-6 times daily in the last 2 weeks, normally 2-3 times per week. IS IT EFFECTIVE WHEN TAKEN?: YES / Provides temporary relief for 2-3 hours. ANY OESOPHAGEAL REFLUX: YES / Reports occasional heartburn, especially after large meals, but denies direct correlation with asthma symptoms. MENTAL HEALTH: YES - Reports increased stress and anxiety due to asthma symptoms affecting daily life. Referral to CBT considered. HAVE THEY TRIED THINGS TO HELP AVOID/REDUCE TRIGGERS: Regularly cleans to minimise dust, tries to avoid cat dander, uses a scarf in cold weather, but adherence varies. ADMISSIONS OR ATTENDANCES TO A&E OR OOH SERVICES WITH EXACERBATION IN PRECEDING 12 MONTHS: YES - One attendance to A&E 3 months ago, managed with nebulised salbutamol and oral steroids, discharged same day. NUMBER OF ORAL PREDNISOLONE/ABX COURSES IN LAST 12 MONTHS: YES - Two courses of oral prednisolone (one for A&E attendance, one for a community-managed exacerbation). No antibiotic courses in the last 12 months. RESPONSE TO PREDNISOLONE?: YES / Significant improvement in symptoms within 24-48 hours. CURRENT INHALERS/TREATMENTS: - Flutiform 250/10 mcg (Fluticasone Propionate/Formoterol) 2 puffs twice daily. - Salbutamol 100mcg/puff PRN. CONCORDANCE WITH ICS IN 12/12 AS %: 70% SPACER PRESCRIBED: YES ICS: YES ICS/LABA: YES LAMA: NO SABA: YES LTRA: NO MUCOLYTICS: NO THEOPHYLLINES: NO ANTIHISTAMINES: NO COMPLIANCE: Patient admits to occasional skipping of regular inhaler doses, especially when feeling well. INHALED STEROID REQUESTS IN LAST 12 MONTHS: 4 BRONCHODILATOR REQUESTS IN LAST 12 MONTHS: 6 PREVIOUS INHALERS/TREATMENTS TRIALLED: Seretide (Fluticasone/Salmeterol) 250/50 mcg, discontinued due to patient preference for current inhaler. INVESTIGATIONS SPUTUM C&S DATES/RESULTS: 15/10/2024 - No significant bacterial growth. Negative for fungi. ACQ6/7: ACQ7 score: 3.5 (poorly controlled) PAST MEDICAL HISTORY: Childhood eczema, Gastro-oesophageal reflux disease (GERD). HRCT RESULT: Not performed. BLOOD RESULTS – FBC/EOS LATEST: 28/10/2024 - FBC normal, Eosinophils: 0.5 x 10^9/L (elevated) HIGHEST EOS LAST YR: 0.7 x 10^9/L (01/03/2024) ANCA/CORTISOL: ANCA negative, AM Cortisol: 350 nmol/L (normal) FENO – DATE & VALUES: 01/11/2024 - 1.PPB: 45 ppb - 2.PPB: 42 ppb - 3.PPB: 43 ppb MIXED GRASS: YES HDM: YES TIM GRASS: NO PEAK FLOW – BEST / 75% / 50%: Best: 450 L/min / 75%: 338 L/min / 50%: 225 L/min ASP FUM/CHEST MOULDS: NO SPIROMETRY RESULTS – DATE: 01/10/2024 FEV1 (L, %): 2.4 L (75% predicted) FVC (L, %): 3.2 L (80% predicted) RATIO (%): 75% FEF 25–75%: 2.0 L/s (60% predicted) TOTAL IgE: 150 kU/L DIFF FAC%: Not available CAT DANDER: YES DOG DANDER: NO OTHER INVESTIGATIONS: Skin prick tests: Positive for house dust mite, cat dander, and mixed grass pollen. HISTORY – OTHER IMMUNOLOGY BLOODS: No other immunology bloods requested or performed.