Asthma Intake - Pediatric

Subjective:
Chief Complaint:
Ongoing cough post-COVID-19 infection.

Allergies:
- No known allergies

Current Medications:
- Symbicort: one click per dose, twice daily

Family History:
- No family history of asthma
- No known family history of atopic conditions

History of Present Illness:
The patient, a young female, presents with concerns of an ongoing cough following a COVID-19 infection. The symptoms began after the COVID-19 episode and have persisted continuously, rather than occurring sporadically. Approximately three years after the onset of the cough, the patient was started on Symbicort, which she has been using for about a year, typically twice daily, although she occasionally forgets the evening dose. The cough has improved but is not completely resolved, occurring less frequently now. The patient experiences wheezing during physical exertion, such as playing rugby. There is no family history of asthma or allergies, and the patient has not been officially diagnosed with asthma. The household includes cats, but there is no significant allergic reaction noted. Environmental modifications, such as removing carpets, have been implemented to reduce potential allergens. The patient has no known allergies and no history of respiratory infections other than the initial COVID-19 episode.

Past Medical History:
- Previous episodes of respiratory distress following COVID-19
- No history of allergies
- No history of eczema
- No previous hospitalizations

Past Surgical History:
- Not mentioned

Social History:
- Primary caregivers: Not mentioned
- Daycare or school attendance: Not mentioned
- Pets at home: Cats, no sneezing or coughing around them
- Smoke exposure: Not mentioned

The Review of Systems:
- Constitutional: No fever, weight loss, or general malaise
- Eyes: No redness, discharge
- ENT: No nasal discharge or frequent infections
- Cardiovascular: No cyanosis or heart murmurs
- Respiratory: Reports of wheezing, coughing, shortness of breath; no known recurrent pneumonia
- Gastrointestinal: No vomiting, diarrhea, or significant reflux symptoms
- Genitourinary: Normal urination
- Musculoskeletal: Normal movements of extremities
- Skin: No current rashes or lesions
- Neurological: No seizures; normal reflexes for age

Pregnancy History:
- Maternal health during pregnancy: Not mentioned
- Maternal medications and supplements: Not mentioned
- Prenatal complications: Not mentioned
- Mode of delivery: Not mentioned

Birth and Development History:
- Birth weight and length: Not mentioned
- Apgar scores: Not mentioned
- Neonatal complications: Not mentioned
- Developmental milestones: Not mentioned

Environmental History:
- Housing conditions: Not mentioned
- Environmental allergens or pollutants: Not mentioned
- Recent travel: Not mentioned

Assessment:
Differential Diagnosis:
- Reactive airway disease
- Bronchiolitis
- Allergic rhinitis
- Gastroesophageal reflux disease (GERD)

Problem:

1. Suspected asthma

Evaluation:
- Patient exhibits signs suggestive of asthma based on history and physical examination
- Consider additional testing to confirm diagnosis

Diagnosis Rational Discussion:
- Diagnosis based on typical presentation of symptoms, medical history, and physical examination findings

Objective:
Physical Examination:
- General: Well-appearing female in no acute distress
- Head: Normocephalic, atraumatic
- Eyes: Pupils equal, round, reactive to light, no discharge
- ENT: Tympanic membranes clear, nasal mucosa without significant edema or discharge, oropharynx clear
- Neck: Supple, no masses or tenderness
- Cardiovascular: Regular rate and rhythm, no murmurs or abnormal heart sounds
- Respiratory: Normal breath sounds bilaterally, possible wheezing; no crackles or rhonchi
- Abdomen: Soft, non-tender, normal bowel sounds
- Genitourinary: Normal external genitalia, no masses
- Musculoskeletal: Full range of motion, no deformity or swelling
- Skin: Possible dry, eczematous patches
- Neurological: Normal tone, reflexes appropriate for age

Test Results:
- Peak Flow measurements: Not mentioned
- Spirometry: Not mentioned
- Chest X-ray: Not mentioned

Vital Signs:
- Weight: Not mentioned
- Height: Not mentioned
- Temperature: Not mentioned
- Respiratory rate: Not mentioned
- Heart rate: Not mentioned
- Oxygen saturation: Not mentioned

Plan:

• Order pulmonary function tests: Spirometry, Peak Flow  
• Consider immunological testing; referral to an allergist if indicated  
• Discuss avoidance of known precipitants: pet dander, smoke, allergens  
• Educate parents and patient on asthma manifestations, triggers, and management strategies  
• Provide asthma action plan and demonstrate inhaler/medication devices  
• Referral to pulmonologist or asthma specialist if necessary  
• Follow-up appointment in May to review test results and adjust treatment plan as necessary  

Treatments:
- Medications: Inhaled corticosteroids, bronchodilators with dosage and instructions as needed
- Behavioral Therapy: Education on breathing exercises