What is the diagnosis for a 15-year-old patient with a past medical history (PMH) of asthma, who reports improved breathing symptoms on current maintenance medication, with infrequent daytime coughing, no nighttime symptoms, and no concerns or side effects from medications?

From the Guidelines

The 15-year-old patient's asthma is well-controlled on his current maintenance medication regimen, and therefore, no changes to his medication are recommended at this time. The patient reports significant improvement in his respiratory symptoms, with very infrequent daytime coughing episodes occurring less than once per month, and denies any nighttime symptoms 1. He also reports good medication adherence and denies any side effects or concerns related to his current asthma medications. According to the Expert Panel Report 3 (EPR-3) guidelines, the goal of asthma management is to achieve and maintain control of asthma symptoms, and the patient's current regimen appears to be effective in achieving this goal 1.

The patient's symptoms and medication adherence should be continuously monitored to ensure that his asthma remains well-controlled. It is also important to review his rescue inhaler use, ensure he has an up-to-date asthma action plan, and confirm proper inhaler technique 1. Additionally, assessing any seasonal triggers, exercise-induced symptoms, or environmental exposures would be prudent to maintain his current level of asthma control. The EPR-3 guidelines emphasize the importance of patient education and self-monitoring in asthma management, and the patient should be encouraged to continue monitoring his symptoms and adjusting his treatment as needed 1.

Some key points to consider in the patient's management plan include:

• Continuation of current maintenance medication regimen
• Regular review of rescue inhaler use and asthma action plan
• Confirmation of proper inhaler technique
• Assessment of seasonal triggers, exercise-induced symptoms, and environmental exposures
• Patient education and self-monitoring to maintain asthma control. The guidelines also recommend a stepwise approach to asthma management, and the patient's treatment should be adjusted as needed to maintain control of his symptoms 1.

From the Research

History of Present Illness (HPI)

The patient is a 15-year-old male who presents to the clinic with his father, who has a past medical history (PMH) of asthma. The patient reports that his breathing has improved significantly on his current maintenance medication. He experiences very infrequent daytime coughing, occurring less than once a month, and no nighttime symptoms.

• The patient's symptoms have decreased in frequency and severity, indicating good control of his asthma 2.
• The patient denies any concerns or side effects from his medications, suggesting that his current treatment regimen is effective and well-tolerated 3, 4.
• The patient's father's history of asthma may be relevant, as asthma can have a genetic component, but the patient's own symptoms and response to treatment are the primary focus of his care 5, 6.

Asthma Control and Treatment

The patient's report of improved breathing and decreased symptoms suggests that his asthma is well-controlled on his current medication.

• According to current guidelines, the goal of asthma treatment is to achieve and maintain control of symptoms, prevent exacerbations, and minimize the use of rescue medications 2.
• The patient's current treatment regimen appears to be effective in achieving these goals, and he reports no side effects or concerns 3, 4.
• Studies have shown that long-acting beta2-agonists (LABAs) and anti-leukotrienes can be effective add-on therapies to inhaled corticosteroids (ICS) for patients with persistent asthma, but the patient's current treatment regimen is not specified 5, 6.