Clinical Context
A 35-year-old patient with a history of persistent asthma presents to a primary care clinic for a routine follow-up visit to assess asthma control. The patient reports intermittent wheeze, increased rescue inhaler use (albuterol twice weekly), occasional daytime symptoms, and no recent hospitalizations or systemic steroid courses. The provider performs a focused history including symptom frequency, night awakenings, activity limitation, rescue inhaler use, and exacerbation history. Physical exam emphasizes respiratory assessment (inspection, auscultation for wheezes, respiratory rate, and accessory muscle use). The provider reviews current medications (inhaled corticosteroid, long-acting bronchodilator), adherence, inhaler technique, and triggers (allergens, smoke). Objective measures may include peak expiratory flow rate and spirometry if available. The clinician documents assessment of asthma control across all elements—symptoms, exacerbations, lung function, medication adherence—and documents a plan which could include adjustments to controller therapy, an asthma action plan, education, and follow-up. Typical sites of service are outpatient primary care or specialty ambulatory clinics. Typical service type: evaluation and management focused on chronic disease control assessment and documentation.