Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with recurrent episodes of wheezing, dyspnea, and non-productive cough, typically triggered by exposure to known environmental allergens (e.g., pollen, dust mites, pet dander). Symptoms exhibit diurnal variation, often worsening at night or early morning. Patient reports associated allergic rhinitis symptoms including sneezing, nasal congestion, and pruritus. No history of fever or systemic infection. Current symptoms are [mild/moderate/severe], limiting daily activities.
Clinical Examination Findings
General: Patient appears in no acute distress, speaking in full sentences. Respiratory: Tachypnea absent. Auscultation reveals bilateral expiratory wheezing, most prominent in the lower lung fields. No crackles or rhonchi. Chest wall expansion is symmetric. Accessory muscle use: [absent/present]. O2 saturation: [XX]% on room air. HEENT: Nasal turbinates are pale and boggy with clear rhinorrhea; oropharynx clear.
Treatment Protocol
1. Avoidance of identified triggers (e.g., allergen-proof bedding, air filtration). 2. Controller therapy: Inhaled Corticosteroid (ICS) [Drug/Dose] BID. 3. Rescue therapy: Short-acting Beta-2 agonist (SABA) [Drug/Dose] PRN for acute symptoms. 4. Adjunctive therapy: Oral antihistamines or leukotriene receptor antagonists as indicated. 5. Asthma Action Plan provided and reviewed. Follow-up in [X] weeks to assess control.