Wheezing

Patient is four and a half year old boy who is the grandson of our nurse. He woke up this morning having increase in wheezing and shortness of breath and having retraction. Mom gave him multiple doses of albuterol and it did not seem to be helping. She also checked his pulse ox reading and it was going below 90. She was concerned so she brought him in.

He does have some nasal sneezing, nose rubbing, clear nasal discharge, postnasal drainage at this time. They denied any frequent infections, frequent bad colds, or frequent ear infections.

He tends to have some mild-to-moderate wheezing episodes yearly, winter seems to be the worst and sometimes in the spring. He is allergic to pets as well as other seasonal allergens and it may be triggered when he is around animals. Mom states that she did help clean the house on Tuesday and her son was with her and he began having flare of his asthma symptom at that time. This house had multiple cats and dogs in it.

They deny any problems with eczema or atopic dermatitis. He has never evaluated for allergies before.

ASSESSMENT:
1. Wheezing.
2. Cough possible upper respiratory infection.
3. Allergic rhinitis.

PLAN:
1. At this time, we provided a nebulizer to use albuterol in the office, it did resolve his wheezing but he continues to have some coughing, and it appears that he may be infectious of an upper respiratory infection.
2. I would like to start him on Pulmicort Respules 0.5 mg twice daily for the next two weeks to help through this flare of wheezing and cough.
3. I also encouraged her to use his albuterol with spacer every four hours for the next couple days and then reduce to as needed thereafter.
4. We also went over asthma action plan to help with further incidences of acute wheezing or coughing. We also provided her a sample of QVAR 40 mcg to use one to two puffs twice daily with spacer if he has trouble again and does not have access to a nebulizer.
5. We will keep in touch with Barby and she will let us know if Lucas needs to come in for a recheck after the two weeks or if he is doing much better.

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