The patient is a five-year-old female complaining of a cough. She presents with her mother who states the cough started one week ago.
Subjective
The patient is a five-year-old female complaining of a cough. She presents with her mother who states the cough started one week ago.
Her mother also states she has been short of breath, and having difficulty breathing since yesterday. The cough is nonproductive and worsens in the evening. The patient has a past medical history of asthma and no other comorbidities on record and is primarily in good health otherwise. The patient has a rescue albuterol inhaler that she uses twice daily but has not been getting any relief. Her mother also admits that the child is exposed to secondhand smoke through her smoking.
General: no acute distress
Neuro: alert, oriented x 3
Chest: symmetrical
Heart: no organic murmurs, regular rhythm
Lungs: expiratory wheezes heard bilaterally
GU/GI: no abnormalities
Musculoskeletal: normal ROM
Skin: clear, no significant lesions
Objective
Temp: 98.2
HR: 82 bpm
BP: 110/62
RESP: 22
O2: 99%
Lungs were auscultated and bilateral wheezes were heard. An otoscope was used to examine both ears and nose and throat. Ears and nose were both negative for any abnormal findings. Throat showed slight cobbling indicating some postnasal drip present.
Assessment
Only a physical assessment was performed. No lab work or imaging done at this time.
Plan
Consult to ENT was ordered for asthma maintenance
Order PFT (pulmonary function test)
Nebulizer was ordered to continue with albuterol breathing treatments every 6 hours as needed when wheezing is present.
Pulmicort (steroid) respules 0.5mg to be used in a nebulizer once daily until symptoms subside.
Follow up in 1 week if symptoms do not improve or worsen. If the patient is severely short of breath, call 911 or go to the nearest Emergency room.
References
Lizzo JM, Cortes S. Pediatric Asthma. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK551631/
Mba, A. B. P. (2023, January 24). Pulmicort dosage. https://www.medicalnewstoday.com/articles/drugs-pu…
UpToDate. (n.d.). UpToDate. https://www.uptodate.com/contents/pulmonary-functi…
Voter, K. Z., & McBride, J. T. (1998b). PULMONARY FUNCTION TESTING IN CHILDHOOD ASTHMA. Immunology and Allergy Clinics of North America, 18(1), 133–147. https://doi.org/10.1016/s0889-8561(05)70352-0
Requirements: 1 page
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