A 29-year-old Caucasian female with a history of allergies to pollen, taking Claritin (loratadine) 10mg as needed, and a family history of asthma, presents with a persistent, non-productive cough, wheezing, breathlessness, chest tightness, and hoarseness, worsening at night and triggered by outdoor air exposure, what is the primary diagnosis and recommended treatment plan for her condition?

SOAP Note: Allergic Asthma

SUBJECTIVE

29-year-old Caucasian female with strong family history of asthma (father, grandfather, brother) presents with one-month history of persistent non-productive cough with classic asthma symptoms: wheezing, breathlessness during episodes, chest tightness, and hoarseness. 1 Symptoms demonstrate hallmark asthma characteristics—variable, intermittent, worse at night, and triggered by outdoor air exposure (pollen allergy documented). 1 Nocturnal symptoms significantly disrupt sleep, causing daytime fatigue. 2 Cough has caused vomiting twice during intense episodes. No relief from Robitussin. Denies fever, productive sputum, recent URI, or dyspnea at rest. Takes Claritin 10mg PRN for pollen allergies and oral contraceptives.

OBJECTIVE

Vitals: T 98.5°F, P 70, R 16, BP 124/85, BMI 31
General: Well-groomed, no acute distress
HEENT: Clear nasal discharge, no pharyngeal edema, tonsils 2+ without exudates
Respiratory: Chest symmetrical, no accessory muscle use, resonant to percussion, diaphragmatic excursion 5 cm, diffuse expiratory wheezes throughout chest, no crackles
Cardiovascular: RRR, S1S2 present, no murmurs/gallops, no JVD or edema
Other systems: Unremarkable
POCT: Spirometry and Peak Flow pending

ASSESSMENT

Primary Diagnosis: Allergic Asthma triggered by environmental allergens (pollen)

This patient presents with textbook allergic asthma: persistent cough, wheezing, breathlessness, chest tightness worse at night and triggered by outdoor allergen exposure in a patient with documented pollen allergy and strong family history of asthma. 1, 3 The presence of diffuse expiratory wheezes on examination confirms airway obstruction. 1 Her symptoms meet diagnostic criteria with variable, intermittent symptoms that are worse at night and provoked by allergen triggers. 1 The nocturnal predominance is characteristic, as 74% of asthma patients experience nocturnal symptoms with airway inflammation peaking at 4:00 AM. 2 Environmental allergen exposures (pollen) can trigger both allergic rhinitis and asthma. 1

PLAN

Immediate Pharmacologic Management

Intranasal corticosteroids are the cornerstone of initial therapy for patients with allergic asthma and concurrent allergic rhinitis, as they effectively treat allergic rhinitis while simultaneously improving asthma control, reducing bronchial hyperreactivity, and decreasing asthma-related hospitalizations. 3

First-Line Therapy:

• Initiate intranasal corticosteroid (e.g., fluticasone propionate 2 sprays each nostril daily or mometasone furoate 2 sprays each nostril daily) 3
• Initiate inhaled corticosteroid as first-line anti-inflammatory therapy for persistent asthma (e.g., fluticasone 88-220 mcg twice daily or budesonide 180-360 mcg twice daily) 4
• Prescribe short-acting beta-2 agonist (albuterol 2 puffs every 4-6 hours as needed for acute symptoms) 4

Adjunctive Therapy:

• Add leukotriene receptor antagonist (montelukast 10mg PO daily) when both asthma and allergic rhinitis are present 3
• Continue Claritin 10mg daily (not PRN) for additional rhinitis symptom control, particularly for sneezing and itching 3

Rationale for Treatment Approach

Treating allergic rhinitis aggressively is essential because inadequately controlled rhinitis contributes to increased asthma exacerbations and poorer symptom control. 3 The combination of intranasal plus inhaled bronchial corticosteroids should remain standard practice for patients with both conditions. 3 Intranasal corticosteroids improve pulmonary function tests, diminish asthma symptoms, and reduce bronchial hyperresponsiveness. 3

Diagnostic Confirmation

• Complete spirometry with bronchodilator response today (≥12% and ≥200 mL increase in FEV1 indicates reversibility and confirms asthma diagnosis) 2
• Initiate peak flow monitoring twice daily (morning and evening) for 2 weeks; variability ≥20% with minimum change of 60 L/min is highly suggestive of asthma 1
• Consider skin-prick testing or specific IgE antibodies to identify specific allergen triggers for targeted avoidance strategies 1

Environmental Modifications

• Minimize outdoor exposure during high pollen counts (check daily pollen forecasts) 1
• Keep windows closed at night, use air conditioning with HEPA filters 1
• Shower and change clothes after outdoor exposure to remove pollen 1
• Avoid exposure to secondhand smoke (both parents are smokers—counsel on avoiding exposure) 1

Patient Education

• Proper inhaler technique demonstration and teach-back to ensure adequate medication delivery 5
• Asthma action plan with clear instructions for medication use and when to seek emergency care 5
• Warning signs of severe asthma: inability to complete sentences, respiratory rate >25, heart rate >110, silent chest, confusion—seek immediate emergency care 5
• Nocturnal symptoms are a critical marker of disease severity; up to 80% of fatal asthma attacks occur overnight or early morning 2

What NOT to Do

• Do NOT use oral antihistamines as monotherapy for asthma, as they are not recommended for asthma treatment despite modest effects on symptoms 3
• Do NOT use topical decongestants beyond 3-5 days, as this causes rhinitis medicamentosa 3
• Do NOT prescribe antibiotics for this chronic cough without evidence of bacterial infection 3
• Do NOT use single-dose or recurrent parenteral corticosteroids, as they are contraindicated due to long-term side effects 3

Follow-Up and Monitoring

• Reassess in 2-4 weeks to evaluate nasal symptoms, asthma control, quality of life, and medication adherence 3, 5
• Monitor for progressive worsening of symptoms, decreasing response to rescue medications, increasing need for rescue medications, and nocturnal awakenings as indicators of exacerbations 5
• Track peak flow readings and bring log to follow-up appointment 1

Criteria for Specialist Referral (Pulmonology/Allergy)

• Symptoms persist despite appropriate therapy after 4-6 weeks 3
• Need for systemic corticosteroids 3
• Symptoms interfering with sleep or work performance despite treatment 3
• Consider allergen immunotherapy, which may prevent development of new allergen sensitivities and reduce future asthma risk 3
• Comorbid asthma requiring optimization or treatment failure 3

Additional Considerations

• Weight loss counseling (BMI 31) as obesity can worsen asthma control 5
• Annual influenza vaccination recommended for all asthma patients (patient currently declines flu shots—counsel on importance) 5
• Assess for gastroesophageal reflux disease (GERD) if symptoms do not improve, as GERD commonly causes nocturnal cough and wheeze and may require antireflux diet modifications plus proton pump inhibitor 2