Family Medicine · Year 3 · from Family Medicine

Case 1: Adult-Onset Asthma

Patient Demographics

  • Age: 34 years old
  • Sex: Female
  • Occupation: Elementary school teacher

Chief Complaint

"I've had this cough for 2 months that won't go away, and sometimes I feel like I can't catch my breath."

History of Present Illness

Ms. Jennifer Rodriguez is a 34-year-old woman presenting with a persistent dry cough for 2 months. The cough is worse at night and early morning, and she wakes up coughing 2-3 times per week. She also reports episodes of chest tightness and shortness of breath, particularly when exercising or going out in cold air. She has noticed occasional wheezing. Symptoms began after a viral upper respiratory infection 2 months ago. She tried over-the-counter cough suppressants without relief. No fever, hemoptysis, or weight loss. No heartburn or post-nasal drip symptoms.

She had childhood asthma that "resolved" by age 12 and hasn't needed an inhaler since then.

Past Medical History

  • Childhood asthma (ages 5-12)
  • Allergic rhinitis
  • Eczema as a child

Family History

  • Mother: Asthma
  • Father: Allergic rhinitis
  • Sister: Eczema

Social History

  • Never smoker
  • No pets at home currently
  • Lives in an older apartment building
  • Works in an elementary school (dust, viral exposures)

Physical Examination

  • Vital Signs: BP 118/74 mmHg, HR 76, RR 16, SpO2 98% on room air, BMI 24
  • General: Well-appearing, speaks in full sentences
  • HEENT: Nasal mucosa pale, boggy; clear rhinorrhea; no sinus tenderness
  • Neck: No lymphadenopathy
  • Lungs: Faint end-expiratory wheezes bilaterally, no crackles, good air movement
  • Cardiovascular: Regular rate and rhythm

Clinical Image

Image: A metered-dose inhaler (MDI), the most common delivery device for asthma medications. Proper inhaler technique is essential for effective drug delivery to the airways.

Image Source: Wikimedia Commons Attribution: Newbie, Public Domain URL: https://commons.wikimedia.org/wiki/File:Inhaler.jpg

Outpatient Workup

  • Spirometry: FEV1 78% predicted, FEV1/FVC 0.68 (reduced)
  • Post-bronchodilator spirometry: FEV1 improved to 92% predicted (18% improvement)
  • Peak flow: 380 L/min (predicted 450 L/min)
  • Chest X-ray: Normal
  • Allergy testing: Positive for dust mites, mold, grass pollen

Assessment and Diagnosis

  1. Asthma, newly diagnosed (recurrence of childhood asthma) - Compatible history, physical exam with wheezing, spirometry showing reversible obstruction
  2. Allergic rhinitis - Contributing to asthma symptoms
  3. Classification: Mild persistent asthma - Symptoms >2 days/week, nighttime awakenings 3-4x/month, FEV1 >80% predicted

Management Plan

Asthma Controller Therapy:

  • Start low-dose inhaled corticosteroid (ICS): Fluticasone 88 mcg 2 puffs twice daily
  • Provide rescue inhaler: Albuterol MDI 2 puffs every 4-6 hours as needed
  • Spacer device with MDI for improved delivery
  • Demonstrate and observe inhaler technique

Allergic Rhinitis:

  • Intranasal corticosteroid: Fluticasone nasal spray 1-2 sprays each nostril daily
  • Consider adding antihistamine if inadequate response

Asthma Action Plan:

  • Green zone: Symptoms controlled, continue controller medication
  • Yellow zone: Increased symptoms, use rescue inhaler, increase controller if needed
  • Red zone: Severe symptoms, use rescue inhaler, seek emergency care
  • Provide written action plan

Trigger Avoidance:

  • Dust mite precautions: Allergen-proof bedding covers, wash bedding in hot water weekly
  • Address mold exposure in apartment if present
  • Avoid cold air triggers: Scarf over mouth/nose in cold weather
  • Flu vaccination annually

Monitoring:

  • Provide peak flow meter for home monitoring
  • Assess symptom control with ACT (Asthma Control Test) score

Follow-Up

  • Return in 4-6 weeks to assess response
  • Repeat spirometry in 3 months
  • Step down therapy if well-controlled for 3 months
  • Step up if not controlled (add LABA or increase ICS)

Teaching Points

  1. Asthma diagnosis: Episodic symptoms of wheeze, cough, chest tightness, and dyspnea with documented variable airflow limitation (spirometry showing >12% improvement with bronchodilator or positive methacholine challenge).
  1. Adult-onset asthma: Can occur at any age. Prior childhood asthma is a risk factor for recurrence. Other risk factors include allergies, occupational exposures, and viral infections triggering airway hyperresponsiveness.
  1. Asthma classification (GINA):
  • Intermittent: Symptoms <2 days/week, no interference with activity
  • Mild persistent: Symptoms >2 days/week, some limitation
  • Moderate persistent: Daily symptoms, some limitation
  • Severe persistent: Symptoms throughout day, extremely limited
  1. Step therapy: Start ICS for persistent asthma. Step up if not controlled (add LABA, increase ICS dose). Step down if well-controlled for 3+ months.

All cases for this lecture as Markdown