Case study

  

1. What additional information is needed to fully assess this patient?

2. What nondrug therapies might be useful for this patient?

3. Develop a plan for follow-up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.

· Answer questions # 1, 2, 3 Based on this case study

Chief Complaint

“My daughter has had a bad fever, and now she is having trouble breathing, and 

albuterol

 doesn’t help.”

HPI

Terri Collins is an 8-year-old African-American girl who presents to the ED with a 2-day history of fevers, malaise, and nonproductive cough. The mother gave 

acetaminophen

 and 

ibuprofen

 to help control the fever. Mother stated that “a lot of other kids in her class have been sick this fall, too.” Terri started having trouble breathing the morning of admission, and the mother gave her 
albuterol, 2.5 mg via nebulization twice within an hour. Terri still sounded wheezy to the mother after the 
albuterol, and Terri stated it was “hard to breathe.” Terri was previously well controlled regarding asthma symptoms. Previous clinic notes reported symptoms during the day only with active play at school or at home and rare nighttime symptoms. She uses PRN 
albuterol to help with symptoms after playing. Her assessment in the emergency department revealed Terri to have labored breathing, such that she could only complete four- to five-word sentences. She had subcostal retractions, tracheal tugging with tachypnea at 54 breaths/min. Her other vital signs were a heart rate of 160 bpm, blood pressure of 115/59, temperature of 38.8°C, and a weight of 22.7 kg. The initial 

oxygen

 saturation was 88%, and she was started on 
oxygen at 1 L/min via nasal cannula. Bilateral expiratory and inspiratory wheezes were noted on examination. A chest x-ray revealed a right lower lobe consolidation consistent with pneumonia and possible effusion. After receiving three 
albuterol/

ipratropium

 nebulizations, her breath sounds and oxygenation did not improve, so she was started on 
albuterol via continuous nebulization at 10 mg/hr and her 
oxygen was titrated to 3 L/min. She was also given a dose of 25 mg IV 

methylprednisolone

 and a dose of 600 mg IV magnesium sulfate. Terri was then transferred to the PICU for further treatment and monitoring.

PMH

Asthma; last hospitalization 4 years ago, and has had two courses of oral corticosteroids in the past year

FH

Asthma on father’s side of the family

SH

Lives with mother, father, and two siblings, both of whom have asthma. There are two cats and a dog in the home. Father is a smoker but states that he tries to smoke outside and not around the kids. She is in the second grade and is very active on the playground.

Meds

Albuterol 2.5 mg nebulized Q 4–6 H PRN wheezing

Fluticasone propionate 44 mcg MDI two puffs BID

Acetaminophen 160 mg/5 mL—10 mL Q 4 H PRN fever

Ibuprofen 100 mg/5 mL—10 mL Q 6 H PRN fever

All

NKA

ROS

(+) Fever, cough, increased work of breathing

Physical Examination

Gen

Alert and oriented but in mild distress with difficulty breathing

VS

BP 125/69, P 120, T 37.9°C, RR 40, O2 sat 94% on 3 L/min nasal cannula

Skin

No rashes, no bruises

HEENT

NC/AT, PERRLA

Neck/LN

Soft, supple, no cervical lymphadenopathy

Chest

Wheezes throughout all lung fields, still with subcostal retractions

CV

RRR, no m/r/g

Abd

Soft, NT/ND

Ext

No clubbing or cyanosis

Neuro

A&O, no focal deficits

Labs

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Na 141 mEq/L

WBC 34.2 × 103/mm3

K 3.1 mEq/L

 Neut 91%

Cl 104 mEq/L

 Lymph 5%

CO2 29 mEq/L

 Mono 4%

BUN 16 mg/dL

RBC 5.07 × 106/mm3

SCr 0.52 mg/dL

Hgb 13 g/dL

Glu 154 mg/dL

Hct 41%

 

Plt 310 × 103/mm3

Respiratory viral panel nasal swab: positive for influenza A

Chest X-Ray

RLL consolidation

Assessment

Asthma exacerbation with viral pneumonia

Questions

1. What additional information is needed to fully assess this patient?

2. What nondrug therapies might be useful for this patient?

3. Develop a plan for follow-up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.