WEEK #4 I HUMAN CASE STUDY FOR 5 YEAR OLD PATIENT REASON FOR ENCOUNTER COUGH AND TROUBLE B, Exams of Integrated Case Studies

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For a 5-year-old patient presenting with cough and trouble breathing , a comprehensive history is essential to guide diagnosis and treatment. Here's how the history should be structured: Chief Complaint (CC):

• Persistent cough and trouble breathing for the past few days History of Present Illness (HPI):
• Onset: When did the symptoms start? Sudden or gradual?
• Duration: How long has the child been coughing and experiencing breathing difficulty?
• Character: Is the cough dry or productive (with mucus)? Any wheezing or stridor?
• Severity: How bad is the trouble breathing? Can the child speak in full sentences?
• Timing: Worse at night, early morning, or after activity?
• Associated Symptoms: Fever, chills, runny nose, sore throat, ear pain, fatigue, vomiting?
• Aggravating Factors: Exercise, cold air, lying flat, exposure to smoke or allergens?

• Exposure to tobacco smoke, pets, dust, mold, or strong odors?
• Daycare or school attendance (increased risk of infections)?
• Recent travel or exposure to sick contacts?
• Any known food or environmental allergies? Review of Systems (ROS):
• Respiratory: Wheezing, shortness of breath, nasal congestion, noisy breathing
• Cardiovascular: Cyanosis (blue lips or fingers), swelling in legs
• Gastrointestinal: Acid reflux (can trigger cough)
• Neurologic: Weakness, lethargy, difficulty eating/drinking ? History of Present Illness (HPI) Patient: 5 - year-old male Chief Complaint: Cough and trouble breathing
• Onset: Symptoms began 3 days ago , progressively worsening.
• Duration: Persistent cough throughout the day and night.
• Character:

o Cough is dry and non-productive , sometimes hacking. o Occasional wheezing and shortness of breath , worse with activity. o Increased work of breathing (e.g., nasal flaring, using accessory muscles).

• Severity: o Child becomes easily fatigued and has difficulty speaking in full sentences. o Parents report breathing appears labored, especially at night.
• Associated Symptoms: o No fever or chills reported. o Mild nasal congestion but no significant runny nose. o No vomiting, diarrhea, or chest pain.
• Aggravating Factors: o Symptoms worsen at night and with physical activity. o Exposure to cold air seems to trigger more coughing.
• Relieving Factors: o Slight improvement when sitting upright. o Humidifier used at home but with minimal effect. o No significant improvement with over-the- counter cough syrup.
• Treatment Tried:

• Temperature: 98.6°F (37°C) (Afebrile)
• Heart Rate: 120 bpm (Tachycardic)
• Respiratory Rate: 32 breaths/min (Tachypneic)
• Oxygen Saturation: 91% on room air (Mild hypoxia) Respiratory Exam:
• Inspection: o Use of accessory muscles (intercostal retractions, nasal flaring) o Increased anteroposterior chest diameter
• Auscultation: o Expiratory wheezing bilaterally o Coarse crackles and rhonchi (may clear with coughing) o Diminished breath sounds in lower lung fields
• Percussion: o Normal (no dullness suggesting pneumonia)
• Palpation: o No tracheal deviation

o No tenderness Cardiovascular Exam:

• Normal heart sounds
• No murmurs or signs of heart failure ENT & Other Findings:
• Nasal congestion, but no purulent drainage
• No tonsillar swelling or exudates
• No stridor or barking cough (suggesting croup is less likely) Diagnostic Tests to Consider

1. Laboratory Tests:

• Complete Blood Count (CBC): o To check for infection/inflammation (e.g., elevated WBC in pneumonia)
• Arterial Blood Gas (ABG): o If respiratory distress is severe (check for hypoxemia, hypercapnia)
• Influenza & RSV Testing:

• If asthma is suspected: Trial of albuterol (bronchodilator) via nebulizer
• If pneumonia is suspected: Consider antibiotics (e.g., amoxicillin)
• If bronchiolitis (RSV) is suspected: Supportive care (hydration, oxygen, suctioning)
• If respiratory distress worsens: Consider hospitalization for oxygen support Would you like a management plan based on a likely diagnosis? Management Plan for 5-Year-Old with Cough & Trouble Breathing Likely Diagnosis: Based on the history and physical exam findings, the most probable diagnosis is asthma exacerbation, though pneumonia or viral bronchiolitis are also considerations.

1. Immediate Management (Acute Episode Treatment) If Asthma Exacerbation is Suspected:
2. Administer a Short-Acting Beta-Agonist (SABA):

o Albuterol (Ventolin) Nebulizer: 2.5 mg every 20 minutes for 3 doses, then every 4–6 hours as needed o If using a metered-dose inhaler (MDI): 4– 6 puffs via spacer every 20 minutes o Reassess after initial doses for improvement

2. Oral Corticosteroids (for Moderate to Severe Cases): o Prednisolone 1–2 mg/kg/day for 3–5 days (max: 40 mg/day) o Helps reduce airway inflammation and prevent worsening symptoms
3. Oxygen Therapy: o If SpO₂ < 92%, provide supplemental oxygen via nasal cannula
4. Monitor for Response: o If symptoms improve, continue bronchodilators and monitor o If symptoms worsen (severe distress, persistent hypoxia, altered mental status) → Consider hospitalization

2. Long-Term Management & Prevention (if Asthma Confirmed)
   • Prescribe an Inhaled Corticosteroid (ICS) for Persistent Asthma: o Low-dose Fluticasone (50 mcg 1–2 puffs BID) o Helps prevent future asthma exacerbations
   • Educate Parents on Asthma Triggers & Action Plan: o Avoid smoke, dust, pets, and cold air exposure o Teach proper inhaler technique with a spacer o Provide an asthma action plan for home management
   • Follow-Up in 2–4 Weeks: o Assess symptom control and adjust medications if needed When to Seek Emergency Care
   • Severe respiratory distress (rapid breathing, inability to talk, drowsiness)
   • Blue lips or skin (cyanosis)

• No improvement with bronchodilators Would you like a structured asthma action plan for the parents? Asthma Action Plan for a 5-Year-Old Child This plan helps caregivers recognize asthma symptoms early and take appropriate action. It is divided into three zones: Green (Controlled), Yellow (Caution), and Red (Emergency). GREEN ZONE: DAILY CONTROL (Doing Well) Symptoms: No coughing, wheezing, or trouble breathing Can play, sleep, and do normal activities Peak flow (if used) is 80 – 100% of personal best What to Do: Daily Controller Medicine (if prescribed for persistent asthma)
• Fluticasone (50 mcg) 1–2 puffs twice daily (morning & night)

• Give Oral Prednisolone (1–2 mg/kg/day, max 40 mg/day) for 3–5 days
• Continue Albuterol every 4 hours as needed Call the Doctor if:
• No improvement after 24 hours
• Symptoms worsen despite using Albuterol RED ZONE: DANGER (Severe Symptoms - EMERGENCY) Symptoms: Severe difficulty breathing (rapid, gasping, struggling to speak) Ribs pulling in with each breath (retractions) Lips or fingertips turning blue (cyanosis) Albuterol not helping after 3 doses in 1 hour Peak flow is below 50% of personal best What to Do: Give Quick-Relief Medicine Right Away:
• Albuterol (4–6 puffs) or Nebulizer (2.5 mg) every 20 minutes (up to 3 times)

• Give Oral Prednisolone (if not already given) Go to the Emergency Room (ER) or Call 911 If:
• Breathing is still difficult after 3 Albuterol treatments
• Child cannot talk, eat, or walk properly
• Lips or nails are turning blue
• Peak flow remains below 50% Additional Notes for Parents: Always use a spacer with the inhaler for better medication delivery Ensure child gets their flu shot and stays away from sick contacts Have an asthma check-up every 3–6 months **Treatment Plan for 5-Year-Old with Asthma Exacerbation

1. Immediate Treatment (Acute Management)** For mild to moderate exacerbation (wheezing, cough, mild shortness of breath): Albuterol (Ventolin) Nebulizer: 2.5 mg every 20

For children with persistent asthma (frequent symptoms, night-time cough, ER visits): Daily Inhaled Corticosteroid (ICS):

• Fluticasone (50 mcg) 1 – 2 puffs twice daily
• Reduces inflammation and prevents asthma attacks Leukotriene Receptor Antagonist:
• Montelukast (Singulair) 4 mg at bedtime (if indicated) 3. Prevention & Education Avoid Triggers: Smoke, pollen, dust, cold air, pet dander Use a Spacer: Inhaler works better with it Flu Shot & COVID-19 Vaccine: Prevent respiratory infections Asthma Action Plan: Teach parents when to adjust medications Follow-Up: In 2 – 4 weeks to check control and adjust medications Stepwise Asthma Treatment Guide for a 5-Year-Old This guide follows the National Asthma Education and Prevention Program (NAEPP) guidelines, using a stepwise approach based on symptom severity.

Step 1: Intermittent Asthma (Symptoms ≤ Days/Week, No Nighttime Symptoms) Symptoms: Cough/wheezing ≤2 days/week No nighttime awakenings No activity limitations Treatment:

• Albuterol (Ventolin) Inhaler as needed o 2 puffs every 4–6 hours as needed for symptoms o Use before exercise if triggered by activity
• No daily controller needed Follow-up every 6 months Step 2: Mild Persistent Asthma (Symptoms > Days/Week, Nighttime 1–2x/Month) Symptoms: Cough/wheezing >2 days/week, but not daily Nighttime symptoms 1–2x/month Minor activity limitations