Gen Peds Consult

Problem List: 1. Asthma 2. Allergic Rhinitis Medications: 1. Albuterol inhaler 2. Cetirizine Discontinued Medications: 1. Montelukast - discontinued due to side effects Chief complaint: Persistent cough and wheezing History of Present Illness: I had the pleasure of reviewing Emily, who is now 8 years old. She attended with her mother, Mrs. Johnson. Emily has been experiencing a persistent cough and wheezing for the past two weeks, which worsens at night and during physical activity. Her mother reports that the albuterol inhaler provides temporary relief, but the symptoms return shortly after. Emily has missed several days of school due to her symptoms, and her mother is concerned about her falling behind. Mrs. Johnson also mentioned that Emily has been more anxious about attending school due to her symptoms. Emily is currently receiving support from a school counselor to help manage her anxiety. Emily lives with her parents and younger brother in a suburban area. Mrs. Johnson expressed concern about the impact of Emily's condition on her ability to complete homework and participate in extracurricular activities. She noted that Emily often feels too tired to engage in after-school sports, which she previously enjoyed. The family is supportive, but Mrs. Johnson admitted to feeling stressed about managing Emily's health and school commitments. Emily is also under the care of a pediatric pulmonologist, Dr. Smith, who she visits every three months. The goal of therapy is to manage her asthma symptoms and improve her quality of life. Emily also sees a speech therapist once a week to address mild speech delays. ROS: Positive for cough and wheezing. Negative for fever, rash, or gastrointestinal symptoms. Birth History: Emily was born at 39 weeks via vaginal delivery with no complications. Past Medical History: Emily has a history of asthma and allergic rhinitis, both of which are currently being managed with medication. Past Surgical History: None Immunizations: Up to date Medications: 1. Albuterol inhaler 2. Cetirizine Allergies: None known Family History: Mother has a history of asthma. Father has seasonal allergies. Social History: Emily lives with her parents and younger brother. The family is middle-class and has access to healthcare. Diet: Emily follows a balanced diet with no dietary restrictions. Development: Emily met all developmental milestones on time. She has a strong bond with her family. PHYSICAL EXAM Vitals: Temperature: 37°C, Pulse: 90 bpm, Respiratory Rate: 22 breaths/min, Blood Pressure: 100/60 mmHg, Oxygen Saturation: 98% Growth parameters: Weight: 25 kg (50th percentile), Height: 125 cm (50th percentile), Head Circumference: 52 cm (50th percentile) Physical Examination: Lungs: Wheezing noted on auscultation. No retractions observed. Labs: CBC normal, IgE levels elevated Diagnostic Imaging: Chest X-ray showed mild hyperinflation, consistent with asthma. Assessment: Emily is an 8-year-old girl with a history of asthma and allergic rhinitis, currently experiencing an exacerbation of asthma symptoms. Her condition is likely triggered by seasonal allergens. Plan: 1. Continue albuterol inhaler as needed for wheezing. 2. Start inhaled corticosteroid to manage asthma symptoms. 3. Follow up with pediatric pulmonologist in one month. 4. Encourage participation in school counseling sessions to address anxiety. Disposition: Emily will continue outpatient management with close follow-up to monitor her response to the new treatment regimen.