Asthma Clinical Case Review

Roshni Naik, MD, allergist at Mount Sinai Health System, discusses the history of present illness for a case of severe asthma with nasal polyps:

"Patient is a 45 year-old male with a past medical history of severe persistent asthma, former smoker, nasal polyps, and allergic rhinitis, presenting with severe asthma that was not well controlled. Patient reported cough daily, reported wheeze and chest tightness occurring once a week. He denied nighttime awakenings from asthma. He took his albuterol about three to four times a day.

In addition, he took his controller medication therapies, including budesonide-formoterol, 160-4.5 micrograms, two puffs twice a day. Tiotropium bromide, 1.25 micrograms, two puffs daily, and montelukast, 10 milligrams daily.

The patient was diagnosed with asthma two years prior and he had two emergency room visits in the past year for asthma exacerbation. He took two courses of oral prednisone in the past year, and he denied hospitalization for asthma.

In addition, patient reported increased nasal congestion, postnasal drip and anosmia, despite taking fluticasone nasal spray daily and loratadine daily. Patient endorsed history of chronic sinusitis with nasal polyps and underwent sinus surgery twice in the past. He denied allergies to NSAIDs or aspirin, and he was referred to ENT and was found to have nasal polyps bilaterally.

Past medical history was pertinent for asthma and history of nasal polyps and allergic rhinitis. He had two sinus surgery, once in 2015 and one in 2016. He had no known drug allergies.

Social history was pertinent for a former smoker, about half a pack a day for the past 20 years, and he had quit two months prior. Patient's occupation was a bar owner and his home environmental history was pertinent for having a dog at home.

His medication list included albuterol, budesonide-formoterol inhaler, fluticasone nasal spray, montelukast, tiotropium bromide inhaler, and loratadine daily."