Letter Back to Referring Clinician

Paediatrician's Clinical Letter Patient's full name and date of birth: Master Thomas Smith, born 15 June 2020 Dear Dr Henderson, Problem(s) List: - Acute Bronchiolitis - Mild Asthma (new diagnosis) Investigations: Chest X-ray was performed on 28 October 2024, showing hyperinflation but no focal consolidation. Nasal swab for RSV and other respiratory viruses was negative. Medications: Salbutamol 2.5mg nebuliser, PRN, as needed for wheezing. Prednisolone 2mg/ml oral solution, 3ml once daily for 3 days, starting 30 October 2024. Weight: 14.5 kg Height: 95 cm Master Thomas Smith, aged 4, was reviewed in clinic today with his mother. He has presented with a recurrent cough and wheeze, particularly worse over the last two weeks, following a viral upper respiratory infection. His past medical history includes two previous episodes of bronchiolitis in infancy. On Examination: Thomas was alert and interactive. Respiratory rate was 28 breaths per minute with mild subcostal recession. Auscultation revealed bilateral expiratory wheeze, more prominent on the right side. Capillary refill time was less than 2 seconds. Oxygen saturation was 97% on room air. Discussion: The discussion focused on the recent exacerbation of respiratory symptoms and the likelihood of a new diagnosis of mild asthma, triggered by viral infections. Thomas's mother expressed concerns about the frequency of these episodes. We reviewed the Chest X-ray and nasal swab results, which were reassuring. We discussed the benefits of starting a short course of oral steroids and the introduction of a reliever inhaler for symptomatic relief. Educational material on asthma management and inhaler technique was provided to the mother. Lifestyle Modifications: - Physical exercise 30 minutes a day, 7 days a week. Plan: Continue with Salbutamol as needed for wheezing. Commence Prednisolone oral solution for 3 days. Prescribe a spacer device for better inhaler delivery. Advise mother to monitor for worsening symptoms such as increased respiratory effort or poor feeding. Provide an asthma action plan. Follow Up: Review in clinic in 2 weeks or sooner if symptoms worsen. Copy To: Mrs Sarah Smith Dr Emily White (Practice Nurse)