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Difficult to manage asthma desktop guide: referral letter (UK version)
Key information to include in a referral letter
for a patient with difficult-to-manage asthma
To get the most value from a referral for a
Example of a referral letter that includes
patient with difficult-to-manage asthmaaim to include the following information in
all of the key pieces of information
• Reason for referral today / current concern
Here is an example of a letter that includes all of the
(for example: poor control despite optimal
information that a secondary care respiratory specialist wants
treatment, to confirm diagnosis of asthma,
to have for a patient referred for difficult-to-manage asthma:
for management suggestions; what isconcerning or bothering the patientregarding their asthma)
diagnosis was made if available(for example: symptoms; demonstration of
I would value your assessment of this 42 year-old woman with asthma
because she has had several severe exacerbations in the last two years
She was diagnosed with asthma in childhood based on spirometry and
has been on inhaled steroids more or less continuously since then, but
in the past 8 to 10 years she has become more difficult to manage,
exacerbations in the last year, steroid use,
hospitalisation, need for mechanicalventilation, life-threatening asthma
She is currently being prescribed Seretide 500 Accuhaler twice daily,
and Singulair 10mg at night but continues to require a Ventolin inhaler
weekly. In addition, she has had two hospital admissions and at least
six additional visits to Accident and Emergency and our practice with
• Inhaler technique checked by observing
She receives steroids on each of these occasions and I have been
(Link to Difficult to manage asthma resources when online )
concerned about her level of steroid exposure. Because of this, I
• Adherence with asthma therapy checked
reviewed these episodes and they do sound like asthmatic
exacerbations with appropriate physical signs and reduced peak flow.
On at least one of these presentations, she performed spirometry in the
practice and this demonstrated airflow obstruction.
Her Seretide and Singulair prescription records are consistent with
good prescription filling and her inhaler technique seems excellentbased on observation.
• Smoking history; other domestic / work
She has no obvious co-morbidities other than some background rhinitis,
which we have treated effectively with Nasonex. Her body mass index
(BMI) is 26 and she has never smoked tobacco. There has been no
• Other factors in a patient’s life (such as
obvious change in her circumstances in the past few years and the
depression, psychological factors etc) that
home situation seems fairly stable. She is a housewife.
may affect asthma management, which thedifficult-to-manage asthma service could
She had a normal chest X-ray six months ago and I have requested a
bone scan because of her significant steroid exposure.
information, consider if it can be gatheredbefore sending the referral because this willimprove the effectiveness of the referral.
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