Focused history and examination of a young person with difficult asthma

History or examination domainQuestions to elucidate asthma severity, phenotype and comorbidities
Age and mode of onsetAge of symptoms and asthma onset, any relation to puberty
Symptoms patternDyspnoea pattern (episodic versus constant), presence and phase of wheeze (inspiratory/expiratory), cough, sputum production and colour, propensity for LRTI
Allergies and triggersRhinitis, hay fever, atopic dermatitis, food and aeroallergies, nonspecific triggers (e.g. strong smells, changing temperature), aspirin intolerance, perimenstrual exacerbation
Asthma control and severity measuresFrequency of OCS and antibiotic use, SABA use (inhaled or nebulised), emergency room visits, hospitalisation, high dependency and intensive care unit admission, and intubation history
Upper airways symptomsHistory of rhinitis, polyps, blocked nose, post-nasal drip, and any features of ILO (e.g. throat level symptoms, sensation of strangulation, breathing through a straw, or difficulty to breathe in)
Breathing pattern disorderFeatures of hyperventilation syndrome such as air hunger, perioral and extremities paraesthesia during attacks, constant dyspnoea, disproportionate level of exercise limitation
Past medical historyObesity, sleep apnoea, metabolic syndrome, cardiac disease, congenital anomalies, etc.
Psychological factorsChildhood traumatic experience, schooling difficulties, panic, anxiety, depression, personality traits, home and family factors
Personal and social historyHome, number of people at home, indoor pollution (pets, moulds, dust), outdoor pollution, smoking (passive/active), alcohol and illicit drug use
School and occupational historySchooling and sport performance and attendance, triggers at school or work
Physical examinationHeight, weight, BMI, nose and throat assessment, breath sounds, presence of wheeze (polyphonic and variable versus monophonic and fixed), breathing pattern such as apical breathing, stigmata of other diseases including skin and any OCS-related side-effects

LRTI: lower respiratory tract infection; SABA: short acting β2-agonist; OCS: oral corticosteroids; BMI: body mass index; ILO: inducible laryngeal obstruction.