Emergency Progress Note

Introduction: 10-year-old female from school, brought in by ambulance, accompanied by mother. Issues List: - Acute asthma exacerbation. - Administered salbutamol nebulisers and oxygen, patient responding well. Progress: - Patient's respiratory rate has decreased from 40 breaths per minute to 28 breaths per minute. Oxygen saturation improved from 88% to 96% on 2L of oxygen via nasal cannula. - Discussed asthma management plan with mother, including inhaler technique and signs of worsening symptoms. Physical Examination: - Vital Signs: BP 110/70, HR 110, RR 28, Temp 37.1, SpO2 96% on 2L O2. CEWT score 0. - CEWT Score: 0 - General: Alert and responsive, mild respiratory distress. - Airway: Patent, receiving 2L oxygen via nasal cannula. - Breathing: Mild wheezing bilaterally. - Cardiovascular: Regular rhythm, good perfusion. - Disability: GCS 15, BGL 5.2, no neurological deficits. - ENT: No obvious signs of infection. - Abdo: Soft, non-tender. - MSK: No deformities. - Neuro: Alert and oriented. Investigations: - Pathology: Peak flow reading 250L/min. - Imaging: Chest X-ray clear. - Other: ECG normal. Assessment/Impression: - Acute asthma exacerbation. - The patient is experiencing an acute exacerbation of asthma, requiring immediate intervention. - Pneumonia. Plan/Treatment: - Immediate Management: Salbutamol nebulisers, oxygen, and intravenous fluids administered. - Investigations: Repeat peak flow in 30 minutes. - Referrals: Discussed with on-call paediatrician. - Discharge & Follow-Up: Discharge home with salbutamol inhaler and spacer, and a course of oral prednisolone. Review with GP in 2 days.