Patient Name: Nor Haida  

Age: 50 years  

Gender: Female  

Date: March 12, 2025

Medical History:

• Diagnosis: Asthma (since childhood)
• Onset: Diagnosed at the age of 10 years.
• History of Symptoms:

  - Frequent episodes of wheezing, especially during 2 exercise and in cold weather.

  - Shortness of breath and chest tightness, particularly at night and early morning.

  - Has experienced a few asthma attacks in the past, requiring emergency care (about 2 times a year).

Family History:

• Family History of Asthma: Yes
• Mother: History of asthma
• Sibling: Has allergic rhinitis
• Other Relevant Family Conditions: No family history of significant respiratory issues.

Social History:

• Occupation: Administrative Assistant (limited exposure to dust and allergens in an office setting).
• Living Situation: Lives in a smoke-free environment but has 2 cats at home, which may trigger symptoms.
• Lifestyle: 

  - Non-smoker.

  - Exercises lightly (walking) but avoids strenuous activities like running due to fear of exacerbating asthma symptoms.

Current Medications:

• Inhaled Corticosteroids: Fluticasone propionate 250 mcg, 2 puffs twice daily.
• Long-acting Beta-agonists (LABA): Salmeterol 50 mcg, 2 puffs twice daily.
• Rescue Inhaler: Albuterol 90 mcg, use as needed, typically 1-2 times a week.
• Allergy Medications: Cetirizine 10 mg daily as needed for allergy symptoms.

Asthma Management Plan:

• Monitoring: Uses a peak flow meter, average peak flow readings around 350 L/min (personal best is 450 L/min).
• Trigger Avoidance: Identified triggers include pollen, dust mites, cats, and cold air. Uses air purifier at home.
• Action Plan:

  - If peak flow readings drop below 80% of personal best, use rescue inhaler.

 - If symptoms worsen or do not improve within 24 hours, seek medical attention.

Symptoms:

1. Currently experiencing mild intermittent symptoms, with a frequency of about 2 days per week, responsive to rescue inhaler.
2. No recent exacerbations reported since last follow-up 3 months ago.

Recent Assessments:

• Physical Examination: 

  - Lung auscultation: No wheezing, clear breaths sounds bilaterally.

  - No signs of respiratory distress.

• Spirometry Results:

  - FEV1: 75% of predicted

  - FVC: 80% of predicted

  - FEV1/FVC ratio: 0.7 (indicating moderate persistent asthma)

Recommendations:

• Continue current medication regimen and base treatment upon current symptom control.
• Schedule follow-up appointment in 3 months to reassess asthma control and medication effectiveness.
• Consider referral to a pulmonologist for further evaluation if symptoms do not improve.

Patient Education:

• Reviewed inhaler techniques, including the importance of proper usage.
• Discussed the importance of monitoring symptoms and recognizing warning signs of exacerbations.
• Suggested avoiding known triggers and considering allergy testing for potential improvements.