Pediatric Respirology Consult Note_Short

Dear Dr. Emily Carter, Oliver Jones is a 6-year-old who was seen for respirology consultation today. Reason for referral: Recurrent wheezing and suspected asthma. History of Presenting Illness: - Oliver has been experiencing recurrent episodes of wheezing, particularly at night and during exercise. He has had a persistent cough for the past 2 weeks. - History of asthma exacerbations: Yes, Oliver has had three asthma exacerbations in the past year, requiring oral steroids on each occasion. - History of wheezing episodes: Yes, Oliver has had multiple wheezing episodes, often triggered by viral infections and exercise. - History of emergency department visits for respiratory issues: Yes, Oliver has visited the emergency department twice in the past year for severe wheezing. - History of oral steroid courses for respiratory issues: Yes, Oliver has received multiple courses of oral steroids for asthma exacerbations. - History of hospitalizations for respiratory issues: No, Oliver has not required hospitalisation for respiratory issues. Past Medical History: - Oliver was born full term and has no significant past medical history. Medications: - Currently taking salbutamol inhaler as needed. Allergies: - No known allergies. Immunizations: - Up to date with all immunisations. Family History: - Father has asthma. Social History: - Lives with both parents and has one sibling. Non-smoker. Environmental Exposures: - Occasional exposure to pets (cat). Assessment and Plan: - In summary, Oliver Jones is a 6-year-old male who was seen in consultation today for recurrent wheezing and suspected asthma. He has a history of wheezing episodes triggered by viral infections and exercise, and has required oral steroids on multiple occasions. There is a family history of asthma. Plan: 1. Initiate inhaled corticosteroid (ICS) therapy with a spacer device. 2. Prescribe a short-acting beta-agonist (SABA) inhaler for rescue use. 3. Provide education on asthma triggers and management. 4. Schedule a follow-up appointment in 4 weeks. "I reviewed asthma pathophysiology, triggers, asthma control, medications (reliever vs. controller) and side effects. I explained the risks of inhaled corticosteroids including but not limited to oral thrush, reduction in growth/height and rarely adrenal insufficiency. I went through proper inhaler technique including dose counting. I provided the family with a written asthma action plan and explained when to seek medical attention including red flags symptoms that warrant presenting to the emergency department or calling 911. Thank you very much for the referral. Dr. Sarah Chen Consultant Paediatric Respirologist