From the Guidelines
I strongly recommend creating a pediatric asthma assessment note for this 10-year-old girl with acute wheezing responsive to her mother's inhaler, focusing on a comprehensive evaluation and management plan to reduce morbidity, mortality, and improve quality of life.
Key Components of the Note
- Chief complaint: wheezing relieved by mother's inhaler
- History of present illness: detailing symptom onset, duration, and severity
- Past medical history: focusing on previous respiratory issues
- Family history: of asthma or allergies
- Review of systems: emphasizing respiratory symptoms
- Physical examination findings: including vital signs and lung assessment
- Assessment: indicating suspected asthma exacerbation
- Plan: outlining treatment, patient education, and follow-up recommendations
Treatment Considerations
- Albuterol treatment: 2 puffs via spacer every 4-6 hours as needed, as recommended by the expert panel report 3 (epr-3) guidelines for the diagnosis and management of asthma 1
- Possible short course of oral prednisolone: 1-2 mg/kg/day for 3-5 days if moderate symptoms, considering the benefits of reducing impairment and risk of exacerbations in young children with asthma 1
- Patient education: on proper inhaler technique, asthma trigger avoidance, and the importance of adherence to treatment, as emphasized in the guidelines for reducing morbidity and mortality in asthma management 1
Long-term Management
- Consideration of long-term control therapy: based on the child's response to treatment, symptom severity, and risk of exacerbations, as recommended by the guidelines for the diagnosis and management of asthma 1
- Selection of medications: based on individual drug efficacy studies, FDA-approved medications for young children, and consideration of delivery devices and doses, as outlined in the expert panel report 3 (epr-3) guidelines 1
- Monitoring response to therapy: closely, with consideration of step-down therapy if symptoms are well-controlled, and alternative therapies or diagnoses if treatment is not effective, as recommended by the guidelines for the management of asthma in young children 1
From the FDA Drug Label
Albuterol sulfate inhalation solution is indicated for the relief of bronchospasm in patients 2 years of age and older with reversible obstructive airway disease and acute attacks of bronchospasm. The patient is a 10 year old girl with a history of wheezing that was relieved by using her mom's inhaler.
- The patient's symptoms and response to the inhaler suggest bronchospasm and reversible obstructive airway disease.
- Given the patient's age and symptoms, albuterol may be an appropriate treatment option 2. A simple note template for this patient could include:
- Chief Complaint: Wheezing
- History of Present Illness: Patient has a history of wheezing that was relieved by using her mom's inhaler
- Assessment: Bronchospasm, reversible obstructive airway disease
- Plan: Consider albuterol inhaler for relief of bronchospasm 2
From the Research
Patient Information
- Age: 10 years old
- Sex: Female
- Chief Complaint: History of wheezing relieved by using mom's inhaler
Medical History
- Wheezing symptoms
- Relief of symptoms with inhaler use
Physical Examination
- No information provided
Diagnostic Considerations
- Asthma diagnosis based on symptoms and response to bronchodilator therapy 3
- Consider bronchial provocation test if FEV1 ≥ 70% predicted 3
- Diagnostic anti-inflammatory therapy may be initiated to confirm diagnosis 3
Treatment Options
- As-needed low-dose ICS-formoterol for patients with limited to occasional transient daytime symptoms 3
- Consider step 2 treatment for asthma: as-needed low-dose ICS-formoterol 3
- Long-term treatment of inhaled corticosteroids (ICS) with recommended clinical dose range is safe in asthma patients 3
Monitoring and Follow-up
- Follow-up visits should be scheduled every 2-4 weeks after initial therapy, then every 1-3 months if there is a response 3
- Regular training of patients in the correct use of inhaler techniques is essential for optimal asthma control 3