Pediatrics Admission Note

Ling Jie Wang

MS3, Saba Univesity

Chief Complaint: Dyspnea x 5 days

History of Present Illness

17 y/o female with a history of asthma presents to ED with a 4 day history of progressive dyspnea and
pleuritic chest pain. She describes the pain as a dullness in her chest, non-radiating, rated 5/10 at baseline,
increases to 10/10 on deep inspiration. She also reports non-productive cough, nasal congestion and
subjective fever. Shis morning, she was woken up from sleep at 4AM, feeling like she was unable to
breath, leading to her presentation to the ED.

She reports her symptoms first started 2 weeks ago in school, with persistent cough, nasal congestion, and
chills. Pt states that her temperature at the time taken by the school nurse, she was told her temperature
was 109F, she was given Tylenol. She had not taken her temperature after this episode until her
presentation to ED, though reports subjective fevers and chills. Her symptoms progressed throughout the
next two weeks, with worsening SOB, cough, nasal congestion and dysphagia. During this time, she felt
increasing weakness and dyspnea on exertion.

Her chest pain and dyspnea began on Monday. At the time, she was unable to walk more than 10 minutes
without having to stop due to respiratory distress. This has persisted until her presentation. She reports
feeling exhausted from breathing alone while at rest, this occurs roughly once per hour. She also reports
dizziness and loss of appetite. Pt states she eats about half as much as she normally does and had lost
about 5lbs in the past two weeks. She denies any headache, vomiting, constipation, diarrhea, travel
history.

She began using her albuterol inhalers more, ~ 2 times a day PRN, compared to less than once per day at
baseline, usually only after vigorous exercise. She did not take anything for her symptoms except
albuterol. She admits to recent sick contacts in her younger sister, who had pneumonia one month ago.

Review of Systems

Constitutional: Cold intolerance; denies weight gain,

HEENT: denies conjunctivitis, otodynia. Denies recent neck enlargement, hair loss,

Respiratory: Denies hemoptysis.

Cardiovascular: Denies palpitations, edema

Gastrointestinal: Denies vomiting, diarrhea,

Neurological: Dizziness, Denies headache, ataxia, fainting.

Past Medical History:

Birth: Normal uncomplicated vaginal delivery at 38 weeks, cannot recall birth weight.

Primary physician is Dr. Steven Gillman, whom she visits at least once per year.

Development: No history of developmental delays.

Diet: A mix of junk food with fruits and vegetables. Pt reports she usually eats ‘two plates’ per
meal, plus frequent snacks.

Asthma: Asthma was first diagnosed at the age of five due to an acute exacerbation, which she
was triggered by the fog at a party. She had only one hospitalization for asthma exacerbation
since then, at the age of 11, which had required ICU admission and intubation. She was
hospitalized for 5 days at that time. She goes to the clinic 1-2 times per year for asthma
exacerbation, usually secondary to a respiratory infection.

Asthmatic symptoms are triggered by vigorous exercise, dust, pollen, pet dander and respiratory
infections.

She believes her symptoms have been well-controlled. She had night time symptoms <1/week,
and <1/day daytime exacerbations.

Hypothyroidism: Patient states she was diagnosed with Hashimoto’s thyroiditis 6 months ago,
she is unsure what prompted this investigation. She is not on levothyroxine or any other thyroid
medications. She denies all hypothyroid symptoms except cold-intolerance.

Gynecologic History: Pt has not started menstruation and has never been pregnant. Patient
reports she was started on metformin more than 1 year ago (September 2016) for having no
period. She cannot recall her diagnosis, suspect PCOS based on symptomology and medication.

PSH: None

Medications:

Albuterol Inhaler PRN, FloVent BID, unspecified steroid PO PRN for asthma exacerbation, metformin
PO QD. Dosages unknown.

Allergies: None

Family History:

Asthma, Diabetes, Hypertension, Breast cancer, Gastric cancer, Heart Disease, Hyperlipidemia, CVA,
CAD.

No family history of thyroid disorders, metabolic disorders, genetic diseases or metabolic disorders.

Social History:
Pt lives in a 3 bedroom house, there is no smoking or carpet in the house. She also denies carpets or
upholstery. There is a pet fish and no other pets, she does not normally come into contact with furry
animals.

She lives with 6 other people, her mother, brother, two sisters, mother’s boyfriend and maternal uncle.
She argues with her stepfather but states they ‘always make up’ in the end. Her parents are divorced, she
reports her father visits her ‘a couple of times a month’.

She is going to grade 11 at Victoria Collegiate, is doing well in school, and has no problems with teachers
or peers. She does volunteer work in her spare time.

She enjoys hanging out with friends and has no trouble with gym class. At baseline, she is able to get
through gym class without needing albuterol inhaler.

She reports eating a varied diet of healthy food and junk food.

She is not sexually active.

She reports feeling safe, denies ever been threatened with physical or sexual violence.

She reports a history of wanting to hurt herself, which started about 6 years ago when her grandmother
passed. She thought about overdosing on metformin. She never executed any acts of self-harm. She has
no current thoughts of self-harm.

Immunizations: Received all vaccinations per patient, including flu vaccine; unverified at this time.

ED course:

Pt brought to ED by mother, alert and oriented with diffuse respiratory wheeze, in no acute distress. She
also presented with cough and nasal congestion. She was afebrile with tachycardia at 144. Vitals are
otherwise within normal limits, oxygen saturation at 95%. She was given a clinical asthma score of 4.
CBC, BMP, CXR and urine beta-hCG were tested. IV NS was started. Patient was admitted to pediatrics
for management for acute asthma exacerbation.

Physical Exam:

Vitals: BP: 121/86; Temp 98.5; Pulse: 144; Resp: 20: Pulse Ox: 95%; Weight 95kg, Height:
165cm

General Appearance: Well-developed obese (BMI 34.9) female lying in no acute distress, able
to speak in complete sentences. Alert and oriented x 3. Cooperative.
 HEENT: Head Atraumatic, Non-Icteric Sclerae . No conjunctival injection. Tympanic membrane
clear and grey bilaterally. Mild bilateral tonsillar erythema without exudate. Nose congested
bilaterally. No frontal or maxillary sinus tenderness. Thyromegaly notable on visual
inspection, no palpable nodules. No palpable cervical lymphadenopathy.

Cardiovascular: Normal S1, Normal S2, Regular Rhythm, tachycardia at ~ 100bpm. No

murmurs, gallops or rubs.

Lungs: No visible chest deformity. Mild nasal flaring on respiration, no use of accessory
muscles. Chest expansion symmetrical, no chest wall tenderness, no increase in tactile fremitus.
No notable dullness or hyperresonance on percussion. .Diffuse respiratory wheeze in all
anterior and posterior lung fields, louder on expiration than inspiration. Bilateral basilar
crackles. No rubs. No egophony on auscultation.

Abdomen: Symmetric without deformities, non-distended. Normoactive bowel sounds in all

four quadrants. Soft, non-tender. No palpable mass, no hepatosplenomegaly.

GU: Exam not performed

Extremities: Distal pulses 2+, no edema, capillary refill <3 seconds, strength 5/5

Neurological: Normal speech, Normal tone, Cranial nerves grossly within normal limits

Psych: Mood is ‘okay’, pleasant with full range of affect, affect is appropriate. Thought process
logical and goal-oriented. Pt denies changes in interest, feelings of guilt, decreased concentration,
psychomotor retardations. Admits to sleep disturbances, decreased energy and appetite secondary
to fever and cough per HPI. Denies current passive or active thoughts of suicide/self-harm.

Skin: Dry, warm to touch, no visible lesions or rashes

Labs:

BMP:

Sodium (136 - 145 mmol/l) 142

Potassium (3.5 - 5.1 MMOL/L) 4.7

Chloride (98 - 107 MMOL/L) 109 (Elevated)

Carbon Dioxide (21 - 32 mmol/l) 29

BUN (7 - 18 mg/dl) 8

Creatinine (0.55 - 1.3 mg/dl) 0.75

Glucose (74 - 106 mg/dl) 116 (Elevated)

 Calcium (8.50 - 10.10 mg/dl) 9.3

Hematology

WBC (5.0 - 13.0 K/UL) 13.00

RBC (3.8 - 5.1 M/UL) 5.030

Hgb (12.2 - 15.0 G/DL) 14.7

Hct (30.5 - 43.0 %) 42.4

MCV (82 - 98 FL) 84.4

MCH (26 - 32 PG) 29.2

MCHC (31 - 36 GR/DL) 34.7

RDW (10.0 - 14.0 %) 11.8

Plt Count (130 - 400 K/UL) 335

MPV (6.8 - 13.0 FL) 7.7

Neutrophils % (50.0 - 70.0 %) 85.6 (Elevated)

Lymphocytes % (25 - 50 %) 9.3 (Low)

Monocytes % (1 - 13.0 %) 2.3

Eosinophils % (0.5 - 6.0 %) 2.8

Basophils % (0 - 2 %) 0.1

Urine Beta-hCG: negative

Studies:

2 View CXR:

Positive for mild peribronchial thickening which may be seen with reactive airway disease.

No consolidation, acute infiltrate or pleural effusion. Cardiac silhouette is unremarkable, thoracic ribcage
intact.

Assessment
17 year old female w/ hx of asthma presents with 5 day history of progressive respiratory distress and
increased need for inhaler; CBC shows left shift, CXR consistent with reactive airway disease; physical
exam revealed diffuse wheezing. Patient is admitted to pediatrics for respiratory support for asthma
exacerbation.

Plan:

Respiratory: Pt with history of asthma presents with dyspnea, pleuritic chest pain for 5 days, as well as
cough, nasal congestion and subjective fever for 2 weeks. She has some asthma control on inhaled SABA
PRN, inhaled ICS, PO steroids PRN, with need for PRN SABA ~ once a day and PRN steroid ~ once a
week.

This is likely secondary to asthma exacerbation vs pneumonia vs bronchitis

Her CBC showed a left shift (85.6%), consistent with pneumonia/bronchitis. However, given history of
asthma with exacerbations, symptoms lasting >2 weeks, afebrile, clear CXR and non-productive cough,
this is most likely asthma exacerbation. URI is possible, in which case it is most likely viral or atypical
due to lack of fever and prolonged course.

 Regarding Current exacerbation:

o Monitor RR and SaO2 Q4H
o Inhaled albuterol 3 ml Q2H, advance as tolerated
o PO Prednisolone 60mg QD x 5 days
o Supplemental Oxygen if O2 sat < 94% awake or <91% asleep.
o Peak O2 flow q12H; peak O2 was decreased at 160 while in ED
o Pro-calcitonin pending, will consider choice of antibiotics based on clinical improvement
and pro-calcitonin results
 Regarding Baseline Asthma
o Continue home albuterol, ICS, PO steroid
o May recommend starting inhaled sameterol 25mg, given limited asthma control, which is
best done by her pulmonologist due to the need for consistent follow-up. This might also
decrease her need for PO steroids.
o Asthma Action Plan to be devised prior to discharge, explained to the family
o Patient to follow-up with Primary Doctor in 2-3 days and Pulmonologist is required
within 2 months of discharge

Cardio: Patient presented with tachycardia up to 144 while in ED. This quickly resolved after appropriate
fluid administration. Given her suspected infection, her cardiovascular symptoms are likely due to
dehydration and therefore require no workup.

 Monitor HR Q4H and BP Q12-24Hrs.

FENGI: Decreased appetite likely related to infection. No acute concerns.

  Discuss with patient regarding normal dietary intake and weight management. This is necessary
given her current obesity, PO steroid use and possible PCOS.
 Encourage PO fluid intake

ID: Afebrile on presentation. One report of fever of 109F 2 weeks ago, otherwise no record of fever.

 Monitor temperature Q4Hrs

 If Temp is > 100.4, give Tylenol and if not responding to it, consider Motrin

EBM

This article contributes to an increasing trend of using pro-calcitonin (PCT) as a method of directing
antibiotic treatment in infectious respiratory disease. PCT is an inflammatory marker that is hypothesized
to increase more in bacterial respiratory tract infections than viral infections.

This was a randomized controlled trial with 225 participants who had suspected asthma attacks. These
patients were divided into two comparable groups: a control group, where all patients were treated with
antibiotics based on attending discretion, and a pro-calcitonin group, where the recommendations of
antibiotic usage was given to the attending physician based on PCT levels. At PCT <0.1μg/L, antibiotics
were strongly recommended against, PCT>0.25μg/L where antibiotic use was recommended. At PCT 0.1-
0.25μg/L, antibiotic usage was recommended. 74.8% of patients in the control group were prescribed
antibiotics, compared to 46.1% in the PCT group (p < 0.001.95% CI 0.441-0.713). Two groups had
otherwise equivocal results on 6 week follow-up in terms of secondary ED visits, hospital re-admissions,
repeated needs for steroids.

Tang J, Long W, Yan L, et al. Procalcitonin guided antibiotic therapy of acute exacerbations of asthma: a
randomized controlled trial. BMC Infect Dis 2013;13:596. 10.1186/1471-2334-13-596