Problem:
Patient Info: Emily, female, age 7 Chief Complaint: Difficulty breathing and coughing Presenting History: Emily is presents to the clinic with her mother. She has complaints of difficulty breathing and persistent coughing over the past 3 days. The cough appears to be worsening and is waking the patient up at night. Has been sleeping elevated on two pillows. Mom can hear wheezing periodically throughout the day. Emily has complaints of her chest and neck itching. Vitals: T-99.2, P-110, R-28 BP-98/60 O2 Sat-94%; Wt: 65 lbs.; Height: 50". Peak flow meter reading 60% Assessment: Head: PERRLA, Ears clear bilaterally, tympanic membrane visible. No rhinorrhea or nasal congestion. Throat-no erythema or exudate. No lymphadenopathy. Chest: respirations even, labored, with use of accessory muscles bilaterally, Expiratory wheezing noted throughout. HRR, no murmurs or gallops. Abdomen: flat, non-tender, BS x4. Medical History: Asthma (diagnosed at age 4). Allergies to dust, mites, and seasonal allergies. Medications: Fluticasone 50 mcg inhaler 2 puffs twice daily Albuterol 90 mcg inhaler 2 puffs every 4 hours as needed Immunizations: Behind on immunizations: Did not receive 5th dose of DTaP, 4th dose of IPV, 2nd dose of MMR, 2nd dose of Varicella. Refused Influenza and Covid vaccinations.