Diagnosis: Childhood asthma Treatment Plan and Notes: J.S., an 8-year-old male, was brought to the clinic by his mother after he developed severe breathing difficulties.

 S. was brought to the clinic by his mother at 2:40 PM after developing severe breathing difficulties.
Practice Management:
The visit was at the pediatric clinic and lasted for 50 minutes.

Diagnosis: Childhood asthma
Treatment Plan and Notes:
J.S., an 8-year-old male, was brought to the clinic by his mother after he developed severe breathing difficulties. The mother reports that J.S. has some dust and smoke-related allergies. She notes that she lives in a flat apartment and recently has a new neighbour who smokes a lot late at night. Since the neighbour moved in a month ago, J.S. began experiencing persistent coughs and sometimes breathing fast. J.S. reports that he feels okay at school but experiences the symptoms after school.

J.S. was visibly distressed and had laboured breathing during the visit. The physical examination of his vitals showed his respiratory rate was elevated, and he exhibited wheezing upon auscultation. Oxygen saturation levels were measured and found to be at 92%, which is lower than normal. J.S. does not have any significant physical abnormalities as per the concluded examination. Based on the symptoms J.S. exhibits and the health history provided by the mother and the patient as well, the patient has been diagnosed with childhood asthma.

J.S.’s mother was provided with information on available treatment options, including the risks and side effects of each option. The mother agreed for the treatment to be started, and Beclomethasone was the agreed-upon medication. For the initial dose, the treatment was started with Beclomethasone with 40 mcg to be delivered orally through inhalation twice daily. A maintenance dose for future asthma management will be provided for two weeks. A follow-up appointment was planned for every week. Once J.S. achieves asthma stability, the dosage will be reduced to the lowest dosage possible and only be used based on need. The new neighbour’s late-night smoking habits seem to be the leading trigger for J.S.’s asthma attacks. It is important to eliminate the trigger on time to reduce J.S.’s exposure. The mother was advised to explain to the neighbour about J.S.’s condition and if he could reduce smoking in the house. The services of a social health worker will be available if needed. J.S.’s mother was also advised on how to manage the patient and how to eliminate possible triggers.

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