Asthma

Sinai-Grace Internal Medicine Residency Ambulatory Clinic Documentation Guides

Asthma

• HISTORY

  • Any shortness of breath, cough, wheeze – daytime/nighttime frequency?

  • Any post-nasal drip/GERD symptoms?

  • Any ED visits/hospitalizations/ICU admission/intubations since last visit?

  • Current maintenance therapy and rescue therapy

    • Known triggers

    • Exposure to cigarette smoke

    • Any exposure to animal dander/cockroaches/dustmites

    • Any carpeting in the room, mattress box not wrapped in plastic, feather pillow?

    • Baseline Peak Flows

    • Any PFTs in the past?

    • Number of yearly ED visits/hospitalizations/ICU admission/intubations

    • Last systemic steroids use

    • Last Pneumovax and flu shot

• PHYSICAL EXAM

  • Peak Flows – each visit if patient brings in their meter.

  • General – shortness of breath, able to speak in full sentences, level of conciousness, accessory respiratory muscle use

  • Ears – tympanic membrane

  • Sinuses - tenderness

  • Nose – enlarged turbinates, discharge

  • Throat and Oral Cavity – posterior pharyngeal wall erythema or exudates

  • Lungs – wheezes, rhonchi, signs of consolidation

  • Abdomen – epigastric tenderness

• INVESTIGATIONS

  • Peak Flows – each visit if patient brings in their meter.

    • PFTs -baseline

    • CXR – baseline

Items in BOLD should be addressed every visit.