Paed Letter - Initial (Medical)

1 November 2024 Dr. Emily Carter 123 Pediatric Lane Anytown, CA 91234 Dear Dr. Carter, Re: Olivia SMITH DOB: 15/06/2020 (Age 4 years 4 months) Address: 456 Oak Street, Anytown, CA 91234 Section: Issues 1. Asthma (AST) 2. Eczema (ECZ) Section: Medications * Albuterol inhaler, 2 puffs every 4 hours as needed for wheezing * Fluticasone propionate cream 0.05% applied to affected areas twice daily Section: Services * Allergist Section: Growth Parameters - Weight: 18 kg (50th centile) - Height: 105 cm (50th centile) - Head Circumference: 50 cm (50th centile) Section: Consultation Summary "Thank you for referring Olivia for concerns of asthma and eczema. I had the pleasure of reviewing her, along with her mother, in my paediatric clinic today." Olivia presented with a history of recurrent wheezing and coughing, particularly at night and during exercise, suggestive of asthma. She has been using albuterol inhaler as needed, which provides temporary relief. She also has a history of eczema, with flare-ups on her elbows and knees. She has been using fluticasone propionate cream, which has provided some relief. We discussed the importance of asthma management, including environmental control measures and the use of a daily inhaled corticosteroid. We also discussed the management of her eczema, including the use of emollients and topical corticosteroids. Olivia's mother also expressed concerns about her picky eating habits. She is a very active child and is growing well, but she is not eating a wide variety of foods. Olivia's past medical history includes a diagnosis of asthma and eczema. She has no known allergies. She is up-to-date on her immunisations. Olivia lives with her mother and father. She attends preschool. There is no family history of asthma or eczema. Olivia's diet consists primarily of fruits, vegetables, and dairy products. She has a good appetite, but she is a picky eater. Olivia sleeps through the night, but she sometimes has difficulty falling asleep. Section: Physical Examination Olivia is a well-appearing, active child. Her vital signs are stable. Her lungs are clear to auscultation. Her skin shows mild eczema on her elbows and knees. Blood pressure was 100/60 mmHg. Section: Discussion with Family We discussed the diagnosis of asthma and eczema with Olivia's mother. We reviewed the management plan, including medications, environmental control measures, and follow-up appointments. We also discussed the importance of a healthy diet and sleep hygiene. Section: Recommendations 1. Continue albuterol inhaler as needed for wheezing. 2. Start daily inhaled corticosteroid (e.g., fluticasone) as prescribed. 3. Continue fluticasone propionate cream for eczema flare-ups. 4. Schedule a follow-up appointment in 3 months to assess asthma control. - However, if there are any more concerns in the meantime, then I am happy to see Olivia sooner. "Should you have any further questions regarding Olivia, please do not hesitate to contact me."