Consult

Subjective: Patient Identification: 3-year-old female with a diagnosis of asthma Reason for consult: Follow-up for asthma management and recent upper respiratory infection. Main issues: 1. Asthma exacerbation 2. Upper respiratory infection 3. Developmental delay Medications: - Albuterol inhaler 2 puffs every 4 hours as needed for wheezing - Budesonide inhaler 1 puff twice daily - Allergies: No known allergies Immunizations: Up-to-date on all immunizations. Make-a-Wish : Not applicable Code Status: Full code Community MD: Dr. Emily Carter Equipment at Home: Nebulizer, spacer Financial Supplements: Family is receiving financial supplements. History of Present Illness: Patient presented with increased cough, wheezing, and shortness of breath over the past 3 days. Symptoms worsened overnight, prompting a visit to the clinic. She also had a runny nose and mild fever. Past Medical History: 1. Asthma diagnosed at 18 months 2. Recurrent upper respiratory infections 3. Mild developmental delay, speech is delayed Admissions/ER Visits: Admitted to hospital 6 months ago for asthma exacerbation. Surgeries: None Family History: Mother has asthma, father has seasonal allergies. Psychosocial History: Patient lives with both parents and a younger sibling. Safe home environment. Attends preschool. No family conflicts reported. Review of Systems: Neuro: No muscle weakness, able to walk, run, and climb stairs. Resp: Wheezing, cough, shortness of breath. ORL/Audiology: No drooling, no ear infections, hearing intact. Cardio: No palpitations, no chest pain. Nutrition/GI: Diet consists of a variety of foods. No choking with feeds. No vomiting, regurgitation, constipation, or diarrhea. GU: No issues. Endo: No issues. Heme: No issues. Derm: No eczema or acne. MSK: No issues. Rehab/Equipment: Not applicable School: Attends preschool. Development/Behaviour: Mild developmental delay, speech delay. General: Sleep: Falls asleep easily, sleeps through the night. Dentistry: Brushes teeth twice daily, no cavities. Ophthalmology: Vision appears normal, last eye exam 6 months ago. Physical Examination: Vital Signs: Temperature 37.8°C, Pulse 110 bpm, Respiratory rate 32 breaths/min, Blood Pressure 90/60 mmHg, Oxygen Saturation 96% on room air. Weight: 15 kg, last weight 14.5 kg on 1 September 2024. Height: 95 cm, last height 94 cm on 1 September 2024. General Appearance: Mild respiratory distress, alert and interactive, good capillary refill. Skin: No rashes or lesions. HEENT: Head normocephalic, eyes clear, ears without infection, nose with clear discharge, throat clear. Chest/Lungs: Wheezing bilaterally, mild retractions. Cardiovascular: Regular heart rate, no murmurs. Abdomen: Soft, non-tender. Genitourinary: Normal. Musculoskeletal: Normal. Neurological: Normal. Investigations: - Chest X-ray: Mild peribronchial thickening. Impression and Plan: 1. Asthma exacerbation: Continue albuterol and budesonide. Increase albuterol to every 2 hours as needed. Consider oral steroids if no improvement. Referral to pulmonology if no improvement. 2. Upper respiratory infection: Supportive care, rest, fluids. Monitor for worsening symptoms. 3. Developmental delay: Continue monitoring. Refer to speech therapy.