Pediatric Respirology Consult_New

Consent to use AI scribe documented. Dear Dr. Smith, Emily Johnson is a 7-year-old female who was seen for respirology consultation today on 1 November 2024. **Reason for Referral:** Persistent cough and wheezing. **History of Presenting Illness:** - Emily has been experiencing a persistent cough and wheezing for the past three months. Her symptoms worsen with exercise and during cold weather. She has had two emergency department visits in the last year due to respiratory distress. Emily has been using a blue inhaler with a yellow aerochamber with a facemask, which provides temporary relief. Her parents report hearing wheezing, and healthcare providers have confirmed this during examinations. **Respiratory Review:** - Past hospitalizations for respiratory symptoms: 1 (March 2024) - Past ED/urgent care visits for respiratory concerns: 2 (January 2024, September 2024) - Number of oral steroid courses in last 12 months: 1 - Asthma triggers: Exercise, cold, smoke/pollution - Previous pneumonias: None - Previous respiratory investigations (PFTs, chest x-rays): PFTs performed, chest x-ray showed no concerns - History of chronic cough (>4 weeks): Yes - Foreign body aspiration/choking: No - Exercise intolerance/dyspnea: Yes - Episodes of stridor: No - Sleep apnea symptoms: No **Atopic History:** - History of eczema: Yes - Environmental allergies/allergic rhino-conjunctivitis: Yes - Food/drug allergies: No - Previous skin prick testing: Yes **Past Medical History:** - Asthma, eczema "Otherwise healthy. No previous surgeries." **Pregnancy and Birth History:** - Full-term birth, no respiratory distress at birth, no NICU admission. **Medications:** - Salbutamol inhaler with yellow aerochamber with facemask **Immunizations:** - Immunizations are up to date. **Family History:** - Mother has asthma, father has eczema, no siblings. **Social History:** - Emily attends school. The family has private health insurance. Mother is a teacher, father is an engineer. **Environmental History:** - No smoking or vaping at home, no pets, carpets in the bedroom, no cockroaches, mice, or mold noticed. **Review of Systems:** Constitutional: Negative HEENT: Negative Cardiac: Negative Endocrine: Negative GI: Negative **Physical Exam:** - General: Well appearing, no distress, no obvious dysmorphic features - ENT: Oropharynx was clear, tonsils were grade 1-2. No lymphadenopathy. Tympanic membranes were normal bilaterally. Nasal mucosa was slightly erythematous bilaterally, no polyps - Respiratory: No increased work of breathing and normal chest wall. Good air entry bilaterally, no crackles or wheeze. No digital clubbing. - CVS: Normal s1/s2 and no extra heart sounds or murmurs. Warm well perfused. - Abdomen: Soft, non-tender and non-distended. No HSM. - MSK: No scoliosis noted. - Skin: No obvious eczema or rashes. **Investigations:** - PFTs: Showed mild obstruction - Imaging: Chest x-ray showed no concerns. **Impression:** - In summary, Emily Johnson is a 7-year-old female who was seen in consultation today for persistent cough and wheezing. Her symptoms are consistent with asthma, exacerbated by exercise and cold weather. There is a family history of asthma and eczema. Emily has had two emergency department visits for respiratory distress and has responded to inhaler therapy. 1. Asthma 2. Allergic rhinitis 3. Eczema **Plan:** 1. Continue salbutamol inhaler as needed. 2. Start inhaled corticosteroid therapy. 3. Schedule follow-up in 3 months. 4. Educate family on asthma management and trigger avoidance. "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."