What is the diagnosis and recommended treatment for a 4-year-old male patient presenting with fever, cough, cold, green phlegm, and tight airways, who has been taking Solmux (guaiaphenesin)?

Medical Assessment and Treatment Plan

Diagnosis

This 4-year-old male patient has Acute Viral Bronchiolitis with Bronchospasm (or Acute Bronchitis with Reactive Airway Disease if preferred terminology for PhilHealth encoding).

Clinical Reasoning

The presentation of fever, productive cough with green phlegm, rhinorrhea, and tight airways in a 4-year-old following an acute respiratory infection is consistent with post-viral bronchospasm rather than bacterial infection. 1

• Green sputum does not indicate bacterial infection - colored sputum does not reliably differentiate between bacterial and viral lower respiratory tract infections, and viruses are responsible for more than 90% of acute bronchitis cases 1
• Antibiotics are not indicated - this is a viral illness and antibiotics should only be used if pertussis is suspected or the patient is at high risk for pneumonia (age ≥65 years), neither of which applies here 1
• The "tight airways" indicate bronchospasm requiring bronchodilator therapy rather than just mucolytic treatment 2

Treatment Plan

Medications to Dispense (Within 300 Peso Budget):

1. Salbutamol Syrup 2mg/5mL

• Dose: 2.5mL (1mg) three times daily 3
• Dispense: 100mL bottle
• Duration: 7 days
• Rationale: Primary bronchodilator for relief of bronchospasm in children 4 years and older 3

2. Ipratropium + Salbutamol Nebulizer Solution

• Dose: 1 nebule (Ipratropium 0.5mg + Salbutamol 2.5mg) three times daily for 3 days, then as needed for severe symptoms 2
• Dispense: 9 nebules (for 3 days of regular use)
• Rationale: Combination therapy is recommended for acute bronchospasm management, particularly when initial bronchodilator response is inadequate 2, 4

3. Discontinue Solmux (Guaifenesin)

• Rationale: Recent high-quality evidence shows guaifenesin has no measurable effect on sputum volume or properties in acute respiratory tract infections and is unlikely to function as an expectorant 5

Non-Pharmacological Management:

• Adequate hydration 2
• Monitor for worsening respiratory distress (increased respiratory rate, intercostal retractions, inability to complete sentences) 2
• Avoid smoke exposure 6

Follow-Up Instructions

• Return immediately if: Cannot complete sentences, respiratory rate >25/min, pulse >110/min, or worsening symptoms despite treatment 2
• Routine follow-up: Within 48 hours to assess treatment response 2
• Expected duration: Symptoms typically last about 3 weeks 1

Medical Certificate

Diagnosis: Acute Viral Bronchiolitis with Bronchospasm

Recommendation: Home management with bronchodilator therapy, adequate hydration, and close monitoring. Patient may return to school once fever-free for 24 hours and respiratory symptoms are improving (typically 3-5 days). Fit to return to school when afebrile and breathing comfortably without significant respiratory distress.

Purpose: This medical certificate is issued upon request for school absence due to acute respiratory illness.

Important Caveats

• Do not use antibiotics unless fever persists beyond 5 days or clinical deterioration occurs suggesting secondary bacterial infection 1
• Monitor closely for the first 48 hours as bronchospasm can worsen, particularly in afternoon/evening 2
• Lower threshold for hospital referral if any life-threatening features develop (silent chest, cyanosis, exhaustion, oxygen saturation <92%) 2