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joanna marie maloto

on 26 September 2014

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HPI (history of present illness)
since the cough started. He did have a fever 3 days prior to admission, and he was given ibuprofen. The previous night before admission, he seemed to be gasping for air and during the present day, he has an increased work of breathing. Mother also notes that he has been fussy, not eating well, and has only two to three urinations in the past 24 hours. His assessment in the emergency department revealed him to have labored breathing that was more difficult with activities.

HPI (history of present illness)
Albuterol 2.5 mg via nebulizer as needed
Phenylephrine/chlorpheniramine/methscopolamine (Dallergy®), dose unknown

Optimal Plan

Patient Presentation
Chief Complaint:


PMH (past medical history)

Asthma, unknown if previous hospitalizations S/P tonsillectomy/adenoidectomy at 2 years of age

HPI (history of present illness)

Peyton Harrison is a 3-year-old African-American boy who presents to the emergency department with a 3-day history of cough and congestion. The mother was giving him albuterol, 2.5 mg via nebulization twice a day since the cough started. She was also giving him an allergy medicine

VS ( vital signs)


His chest x-ray revealed patchy infiltrates consistent with pneumonia. Peyton was complaining of a runny nose and sore throat. He did not have any ear pain. While in the emergency department, he was given three albuterol/ipratropium nebulizations and one dose of prednisolone 15 mg orally. He received one dose of acetaminophen 210 mg. His breath sounds and oxygenation did not improve so he was started on hourly albuterol nebulizations at 5 mg. Peyton was then transferred to the Pediatric Intensive Care Unit for further treatment and monitoring.

“My boy has trouble breathing and he keeps coughing. His albuterol isn’t helping.”

FH (family history)


SH (social history)

Lives with foster mother and two siblings. Birth mother has visitations. Unclear as to reason for foster placement. Positive tobacco exposure in current home.


ALL (Allergies to drugs, food, pets and environmental factors)
ROS (review of system)

Physical Examination

(+) Fever, cough, congestion, increased work of breathing.

NAD, moderate increase in work of breathing

HEENT ( head, eyes, ears, nose, throat)

BP 103/55, P 154, T 36.4°C, R 29, O2 sat 94% at 1.5 L/min nasal cannula

No rashes, no bruises


Neck/Lymph Nodes


CV (cardiovascular)

Soft, supple, no cervical lymphadenopathy

Slight decrease in breath sounds bilaterally, minimal wheezing


Ext (extremities)

Neuro (neurologic)

Soft, NT/ND

No clubbing or cyanosis

A & O, no focal deficits

Lab test:




Na 135 mEq/L

Cl 103 mEq/L

K 3.0 mEq/L

BUN 6 mg/dL

SCr 0.6 mg/dL

Glu 140 mg/dL

135-145 mEq/L

95-105 mEq/L

3.3-4.9 mEq/L

8-25 mg/dl

0.6-1.2 mg/dL

70-110 mg/dL

WBC 6.5 × 103/mm3

RBC 3.84 × 106/mm3

Hgb 12 g/dL

Hct 35%

Plt 252 × 103/mm3

CO2 19 mEq/L

3.6 – 11.0  K/U

12.0 - 15.0


150 – 400 K/UL

19 – 34.MMOL/L

Problem Identification

Desired Outcome

2. What are the acute goals of pharmacotherapy in this case?

•Restore and maintenance of oxygen saturation (95%).
•Resolve tachycardia, tachypnea.
•Return physical exam findings to normal.
•Return patient activity to normal.
•Treat pneumonia.

1.a. Create a list of the patient's drug-related problems.

Asthma exacerbation.
Tachycardia (side effect of B2-agonist).
Hypokalemia; frequent use of albuterol.

Therapeutic Alternatives

3.a. What non-drug therapies might be useful for this patient?

•Foster mother smoke outside and not around the kids.
•Incubation in case of respiratory failure.
•Face mask for aerosolized medication (in children < 4 years

3.b. What feasible pharmacotherapeutic alternatives are available for the treatment of acute asthma?

Continuous nebulization
MDI (meter drug inhaler)
Corticosteroid (oral or I.V)
Anticholinergic (ipratropium)

4.a. What other pharmacotherapy would you recommend in the acute treatment of this patient?

•Hypokalemia (mild): need monitoring, may add I.V potassium if needed.
•Pneumonia: antiviral (child with asthma)
oseltamivir: 45 mg twice for 5 days.

Clinical Course

•Within 48 hours of initiation of the treatment plan for management of the acute exacerbation, Peyton was stable enough to transfer to the general pediatric floor. His vital signs were BP 103/70, P 82, R 35, T 37.2°C, and O2 sat 99% on 1 L/min nasal cannula. Mother states that he is able to speak in full sentences now and no longer seems to have trouble breathing.

Outcome Evaluation

•5.a. Once the patient has transferred to the general medical floor and his vitals have improved, what clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects at that point in the patient's care?

•Symptoms of asthma, respiratory rate, HR, K.

Respiratory viral panel nasal swab: positive for parainfluenza 3
1.b What information ( signs, symptoms, laboratory values) indicates the severity of the acute asthma attack?

Signs: tachycardia, tachypnea, and wheezing

Symptoms: coughing before onset of wheezing or symptoms of shortness of breath, and no improvement of albuterol use

Lab values: Hypokalemia and oxygen saturation
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