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Original Question

Case Two: B.L. Complaint: “My son has been coughing and wheezing for the past 24 hours.” History: B.L. is a 6 year old who presents to the office with symptoms of worsening cough and wheezing for the past 24 hours. B.L. is accompanied by their mother, who is a good historian. She reports that her child started having symptoms of a viral upper respiratory infection 2 to 3 days ago, beginning with a runny nose, low-grade fever of 100.5ºF orally, and loose cough. Wheezing started on the day before the visit, so she administered albuterol metered-dose inhaler (MDI) two puffs before bed and then two puffs at around 2 a.m. The cough and wheezing appear worse today, according to the mother. The child had difficulty taking deep-enough breaths to inhale this morning’s dose of albuterol, even using the spacer. The child has been a patient at the clinic since birth and is up to date on their immunizations, growth and development have been normal, and they have been generally healthy except for mild intermittent asthma. Their asthma is usually precipitated by a viral upper respiratory infection. The patient has required oral prednisone an average of two or three times per year for the past 3 years. They have an albuterol MDI at home with a spacer, which their parents are comfortable using. The child is in first grade. This is the first asthma exacerbation of the school year, and their mother expresses a concern about sending him to school with an inhaler. Assessment: The child is afebrile with a respiratory rate of 36 and a tight cough every 1 or 2 minutes, and weighs 45 pounds. The examination is all within normal limits except for breath sounds. The child has diffuse expiratory wheezes and mild retractions. Pulse oximeter readings indicate oxygen saturation of 93%. 1. What is the initial pharmacotherapy management plan at the clinic? 2. What would be the pharmacotherapy management plan at a follow-up visit if the patient’s asthma is not well controlled? 3. What would be the pharmacotherapy management plan at a follow-up visit if the patient’s asthma is well controlled?

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