History of Present Illness
Chief Complaint: Cough and shortness of breath
History of Present Illness:
The patient is a [age]-year-old [gender] with a known history of asthma who presents with a 2-day history of progressive cough and shortness of breath. The patient reports worsening respiratory symptoms over the past 48 hours, with increased dyspnea on exertion and persistent cough. The patient denies any fever, body aches, or chills. There is no reported recent upper respiratory infection symptoms, though viral triggers remain a common precipitant of acute asthma exacerbations 1, 2. The patient denies any recent changes in medication adherence, new allergen exposures, or use of nonsteroidal anti-inflammatory drugs 1, 2.
On physical examination, lung auscultation reveals diminished breath sounds bilaterally, which is concerning for significant airflow obstruction and potential severe airflow limitation 3. The presence of diminished breath sounds is a clinical indicator that may predict severe airflow obstruction and warrants immediate objective assessment 2.
Past Medical History:
- Asthma (specify duration, severity, and baseline control)
- [Other relevant medical conditions]
Current Medications:
- [List current asthma medications including inhaled corticosteroids, bronchodilators, and any recent oral corticosteroid use]
Social History:
- [Smoking status, occupational exposures, pet exposures]
Clinical Assessment and Management
Immediate Assessment Required
This patient requires urgent severity assessment as diminished lung sounds in the context of acute asthma symptoms may indicate acute severe asthma, which can be life-threatening if not promptly recognized and treated 3.
Critical Assessment Parameters
Immediately assess and document the following objective measures 3:
- Respiratory rate: Severe if ≥25 breaths/min 3
- Heart rate: Severe if ≥110 beats/min 3
- Ability to speak: Severe if unable to complete sentences in one breath 3
- Peak expiratory flow (PEF): Severe if <50% predicted or personal best 3
- Oxygen saturation: Measure before oxygen administration; values >90% are reassuring but do not exclude CO₂ retention 1, 2
Severity Classification
Acute Severe Asthma is present if ANY of the following 3:
- Cannot complete sentences in one breath
- Pulse >110 beats/min
- Respirations >25 breaths/min
- PEF <50% predicted or best
- Diminished breath sounds (as in this patient)
Life-threatening features include 3:
- Silent chest, cyanosis, or feeble respiratory effort
- Bradycardia, hypotension, confusion, exhaustion, or coma
- Oxygen saturation <92% despite supplemental oxygen
Immediate Management Algorithm
If Acute Severe Asthma Features Present
Initiate treatment immediately and seriously consider hospital admission if more than one severe feature is present 3.
First-Line Treatment 3, 4:
Oxygen: Administer 40-60% oxygen immediately to maintain saturation >90% 3
Nebulized bronchodilators:
Systemic corticosteroids (critical - do not delay):
Add ipratropium bromide:
Monitor Response at 15-30 Minutes 3, 4:
If severe features persist after initial treatment:
- Arrange immediate hospital admission 3
- Repeat nebulized bronchodilators 3
- Consider subcutaneous terbutaline or epinephrine if inadequate response to continuous nebulization 5, 6
Absolute criteria for hospital admission 3:
- Any life-threatening features present
- Any features of acute severe asthma persist after initial treatment, especially PEF <33% predicted 3
If Moderate Exacerbation (No Severe Features)
If assessment reveals:
- Speech normal
- Pulse <110 beats/min
- Respirations <25 breaths/min
- PEF >50% predicted or best 3
- Nebulized salbutamol 5 mg or terbutaline 10 mg
- Monitor response at 15-30 minutes
- If PEF 50-75% predicted: Give prednisolone 30-60 mg and step up usual treatment 3
- If PEF >75% predicted: Step up usual treatment 3
Home management is acceptable ONLY if 3:
- Response to treatment is adequate before leaving
- Follow-up arranged within 48 hours 3, 4
- Patient has peak flow meter and self-management plan 3, 4
Critical Pitfalls to Avoid
Common factors contributing to asthma deaths 3, 4:
- Doctors failing to assess severity by objective measurement 3
- Patients or relatives failing to appreciate severity 3
- Underuse of corticosteroids 3, 4
- Delayed administration of systemic corticosteroids 4, 1
Key clinical caveat: Patients with severe or life-threatening asthma may be distressed and may not exhibit all expected abnormalities; the presence of ANY severe feature should prompt aggressive treatment 3.
Diminished breath sounds specifically warrant heightened concern as they may indicate severe airflow obstruction or impending respiratory failure, even in the absence of other severe features 2.
Lower Threshold for Admission If 3:
- Attack occurs in afternoon or evening 3
- Recent nocturnal symptoms 3
- Recent hospital admission or previous severe attacks 3
- Patient expresses concern about their condition 3
- Unable to assess own condition or challenging social circumstances 3
Follow-Up Requirements
For Severe Exacerbations 3, 4:
- Review within 24 hours 3, 4
- Continue prednisolone course for 3-10 days total 4
- Monitor symptoms and PEF on chart 3, 4
- Provide written self-management plan 3, 4
- Modify treatment according to chronic asthma guidelines 3
For Moderate Exacerbations 3, 4:
- Review within 48 hours 3, 4
- Ensure patient has adequate supply of usual medications 3
- Verify correct inhaler technique 3, 4
- Provide PEF meter and action plan 3, 4
Additional Considerations
Investigate potential triggers 1, 2:
- Viral respiratory infections (most common) 1, 2
- Medication nonadherence 1, 2
- Allergen exposure (pets, mold such as Alternaria) in atopic individuals 1, 2
- NSAID exposure in aspirin-sensitive patients 1, 2
- Irritant inhalation (smoke, paint) 1, 2
- Insufficient use of inhaled or oral corticosteroids 1, 2
Intravenous fluids: Many patients are dehydrated and at risk for hypotension if positive pressure ventilation becomes necessary 6.