Structured GP Consultation Note for EMIS

Problem

• Acute exacerbation of asthma

History

• 5/7 Hx productive cough (clear sputum), nocturnal wheeze, and exertional SOB. Triggered by recent URTI. Using salbutamol (Ventolin®) inhaler 6–8x daily with minimal relief. No CP, haemoptysis, or fevers.
• PMHx: Asthma, seasonal allergic rhinitis.
• DHx: salbutamol 100 mcg INH PRN, beclometasone dipropionate (Clenil Modulite®) 100 mcg 2 puffs INH BID (admits poor compliance recently), cetirizine 10 mg PO OD.
• NKDA.

Examination

• Alert, speaking in full sentences, not tachypnoeic at rest.
• Vitals: T 36.8 °C, HR 88 bpm, BP 124/78 mmHg, RR 18/min, SpO2 97 % on RA.
• Chest: Bilateral expiratory polyphonic wheeze throughout, good air entry bilaterally, no focal crepitations.
• PEFR: 380 L/min (predicted/best 450 L/min, ~84 %).

Social

• Non-smoker, no vapes. Lives with partner, keeps 1 cat. Works as an accountant.

Comment

• Mild-to-moderate acute asthma exacerbation secondary to viral URTI and suboptimal ICS compliance.
• Start prednisolone 40 mg PO OD for 5/7.
• Advised to restart regular beclometasone dipropionate 100 mcg 2 puffs INH BID and checked inhaler technique (good with spacer).
• Provided updated written Personal Asthma Action Plan.
• RV in 1/52 with practice asthma nurse, or sooner/A&E if PEFR < 50 %, struggling to speak, or salbutamol required > 4-hourly.