• 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 Terri had trouble breathing, and the doctor in the emergency room found that she could only speak in four- to five-word sentences. She had subcostal retractions, tracheal tugging, and 54 breaths per minute of tachypnea. Her weight was 22.7 kg, and her heart rate was 160 beats per minute. Her blood pressure was 115/59, and her temperature was 38.8°C.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.
