Began on vaccinations

Patient comes in for a recheck. Mom states that he is doing a lot better lately since the weather has been a lot warmer. She was supposed to be able to start Singulair 4 mg granules daily and cetirizine half teaspoon daily, however, there was a miscommunication and these medications were not filled at the pharmacy, so she has not filled these, but has been very pleased with his progression since the warm weather has began. I do feel like this is a very good thing that he is doing much better in the hot weather and that we can continue to monitor patient’s progression and see if he can clear out these frequent infections he has had this last winter. She has decided not to vaccinate him with the Prevnar at this time, but we may consider this again in the future. Otherwise, there have been no changes. He is snoring a lot. He has not had any infections recently or any trouble breathing.

ASSESSMENT:
1. Reactive airway disease.
2. History of hospitalization due to lung infections twice.
3. Developmental delay with decreased muscle tone.
4. Began on vaccinations.

PLAN:
1. At this time, I discussed with mom that we can continue to watch and see how patient progresses through the summer. If he continues to do very well in the hotter weather, then we cannot pursue any intervention at this time.
2. If he does have anymore troubles with breathing or if she begins to have more concerns of his health then she can begin the medication we discussed last time of Singulair 4 mg granules daily to help protect his lungs as well as cetirizine half teaspoon daily to help with nasal congestion. He was negative on skin testing and for all food allergies, so I am not sure how the cetirizine will help, but we can certainly try to prevent more lung infections in the future. We have discussed the need to do a Prevnar vaccination to help prevent any lung infections in the winter as well as possibly pursue immunodeficiency workup if he continues to get sick. I did encourage her to think highly on pursuing vaccinations, so he does not continue to have some of these sicknesses.
3. We will follow up in two months to see how patient is doing.

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