S: SUBJECTIVE DATA: (information the patient/caregiver tells you)

PA39
5 y/o, African American, male
patient and mother are informants
Chief Complaint (CC):
Patient presents as a new patient to the clinic with the need of medication refills
for previously diagnosed asthma. In addition to medication refills he is
experiencing a mild cough and nasal congestion. Patients asthma is chronic with
no acute exacerbation.
History of present illness (HPI):
Patient has previous diagnosis of asthma (March 2014) and has been under
treatment since diagnosis. The patient has been experiencing a mild cough with
nasal congestion for the last two days. Patients mother reports patient received
an influenza vaccine IM one week ago.
Cough from chest; nasal congestion
intermittent
asthma is chronic; cough and congestion is described as mild
two days
symptoms are not specific to a setting
prescribed medications keep asthma under control; patient has taken OTC
Pediacare for cough with adequate cough suppression
symptoms are specific to cough and nasal congestion; denies other symptoms
Past Medical History (PMH):
Current Medications:
Flovent HFA 44mcg/actuation aerosol inhaler: 1 puff qhs
Ventolin HFA 90mcg/actuation aerosol inhaler: 1-2 puffs PRN
Albuterol Sulfate 0.63mg/3mL solution for nebulizer: 1vial in nebulizer
QID
Montelukast 4mg chewable tablet: 1 tablet every evening
Patient has been on these medications since March 2014 with no reported
problems or side effects. Medication was prescribed at previous primary care
providers office. Establishing care and medication at Pediatric Associates at
this visit.

Latex allergy
Prior illnesses and injuries: asthma (March 2014-present) and pneumonia (fall 2013)
No previous operations
No previous hospitalizations
Up to date with immunizations as evidenced by medical records: Pentacel (DTap, IPV,
HIB) x 4; Hep B; Prevnar x 4; Rotateq x 3; Varicella x 2; Hep A x 2; MMR x 2, Kinrix
(DTap, IPV). Patient received Influenza vaccine 1 week ago.
Family History (FH):

Mother- 28 y/o, HTN, otherwise healthy, alive

Father- 29 y/o, HTN, Asthma, alive
No siblings
Maternal grandmother- unknown age, HTN, allergies, alive
Maternal grandfather, paternal grandmother, and paternal grandfather: HTN,
alive, unknown age
Social History (SH):
Lives with mother and father in West Point, GA
Student at West Point Elementary
No history of use of drugs, alcohol or tobacco
Kindergarten
No sexual history
Review of Systems (ROS):
(1) constitutional symptoms: denies fever, chills, poor appetite, or problems sleeping
(2) eyes: denies swelling, redness, itching, or drainage
(3) ears, nose, mouth and throat: positive for nasal congestion and occasional snoring/
denies ear pain, tinnitus, or hearing loss; denies discharge and sinus tenderness; denies
any dental pain, last dental exam August 2014; denies throat pain
(4) cardiovascular: denies chest pain or palpitations and exertional SOB
(5) respiratory: positive for cough/ denies shortness of breath or wheezing; denies
exposure to TB; denies hemoptysis or night sweats
(6) gastrointestinal: denies nausea, vomiting, diarrhea, or gastrointestinal reflux; reports
daily, formed bowel movements, denies blood in stools
(7) genitourinary: denies any dysuria, pelvic pain, urinary urgency, frequency; denies
urinary incontinence
(8) musculoskeletal: denies any joint pain, neck pain, or back pain
(9) integument (skin and/or breast): denies any changes in skin, rashes, hair loss, or
bruises
(10) neurological: denies severe headaches, numbness, tingling, weakness, or dizziness
(11) psychiatric: denies mood changes, depression, anxiety, nervousness, or insomnia
(12) endocrine: denies cold/heat intolerance, weight changes, or polydipsia, polyphagia,
and polyuria
(13) hematological/lymphatic: denies fatigue and history of anemia
(14) allergic/immunologic: positive history of allergic rhinitis and asthma

O: OBJECTIVE DATA: (information you observe with your senses, lab results,
and/or chart notes)
(1) Constitutional: alert and oriented x3; appears to be in no distress; well-nourished and
appropriately developed; normal gait and posture. BP: 116/79, RR: 22, Temp 97.2, HR:
119, HT: 44in, WT: 51lb, BMI: 18.52
(2) Eyes: conjunctiva normal, sclera white, PERLA, eye lids normal with no exudate
present
(3) ENT/mouth: grey tympanic membranes with no bulging or cerumen present; nasal
turbinates erythematous and congested; uvula and tongue midline without tonsil
hypertrophy, erythema, or edema of the mouth or throat
(4) Cardiovascular: regular rate and rhythm, with no murmurs, rubs, or gallops; bilateral
2+ pulses at radial and dorsalis pedis pulses; all four extremities warm with no edema
(5) Respiratory: clear to auscultation bilaterally and normal respiratory effort; chest wall
is normal, symmetric, and without use of accessory muscles in breathing; chest is nontender upon palpation
(6) GI: abdomen soft with no tenderness noted on palpation; normal bowel sounds in all
four quadrants; no masses upon palpation; no guarding, hepatosplenomegaly, or
rebound tenderness
(7) GU: upon palpation bladder was not distended; genital exam was not performed at
this visit
(8) Musculoskeletal: normal tone and 5/5 strength with upper and lower extremities; gait
within normal limits
(9) Skin: integument appeared warm, dry, and intact with no rashes, lesions, or
changing moles noted on exam
(10) Neurological: oriented x 3; eye movements are normal; communication within
normal limits, attention normal with normal concentration ability
(11) Psychiatric: mood and affect are normal
(12) Hematological/lymphatic/immunologic: left cervical adenopathy noted on exam; no
bruising or discoloration was noted on exam
(13) Developmental: social-patient is gender aware, shows more independence, wants
to have friends, shows sympathy/ language- speaks clearly with fill sentences and future
tense/ cognitive- counts and prints numbers and letters/ physical- able to skip, use fork
and spoon, independent toilet use, climbs
Labs/Diagnostic Tests
No labs were ordered or completed at this visit.
A: ASSESSMENT / ANALYSIS:
New patient, Level 4, 99204

Diagnoses:
Asthma (493)
Positives- previously diagnosed as evidenced by medical records; well controlled
on current medications; no acute exacerbation at this visit
Allergic Rhinitis (477)
Positives- nasal turbinates congestion and erythema; mild cough; positive family
history of allergies; positive history of asthma; left cervical adenopathy
Establishing Care/Routine Child Health Check (V20.20)
Positives- patient presents as new patient to establish care and to receive refill
prescriptions on current medications; complete medical history (with medical
records) and family history were obtained; ensured immunizations were up to
date; assess developmental status; performed physical assessment
Acute self-limited problems
Allergic Rhinitis is an acute problem at this visit; however, the patient can continue
having problems due to chronic allergies. The patient has been taking
Singulair/Montelukast until the last week due to running out of his prescription. His
montelukast will be restarted to treat his allergies and rhinitis, as well as prevent
asthma attacks. If the patient continues to have problems after restarting the
medication he will return to clinic for reassessment and possible medication change,
addition, or referral to ENT.
Chronic health problems
Asthma is a chronic health problem for this patient. He was diagnosed earlier in the
year (March 2014 at another providers clinic) and has been well controlled on
medications as evidenced by low use of rescue inhaler and minimal exacerbations.
The patient and mother have been educated on asthma, on correct use of each
medication, and on exacerbation prevention. The patient will continue Flovent
inhaler, Albuterol via nebulizer, Ventolin inhaler, and Montelukast.
Health maintenance
Patient will need to continue medications as directed to treat allergic rhinitis and
maintain asthma. The patient will remain up to date on immunizations until age
11 or 12 when he will need the Tdap, Meningococcal, and Varicella
immunizations. His medication is given with limited refills to ensure that he
returns within 4 months for a recheck of his asthma status. Healthy lifestyle
modifications were discussed with the mother and patient regarding balanced diet
(limit sodium, caffeine, sugar/ ensure adequate lean protein, vegetables, fruits,
and carbohydrates), exercise/active lifestyle, importance of good
grades/academic success, and avoidance of allergic or asthmatic triggers.
P: PLAN / INTERVENTION / MANAGMENT
Asthma
Albuterol for nebulizer (0.63mg/3mL solution for nebulization)1 vial in nebulizer qid prn
Treatment of asthma, Bronchodilator, treatment or prevention of bronchospasm
Relaxes bronchial smooth muscle by action on beta2-receptors with little effect on heart
rate
0.63-1.25mg 3-4 times daily/ q 4-6 hrs prn
Available as name brand and generic- AccuNeb/Albuterol

Walgreens: $10 for 30 days (#75) and $20 for 90 days ($225)
CVS: $11.99 for 90 days
Walmart: $4 for 30 days; $10 for 90 days
Other interventions to include:
No diagnostic or lab tests needed at this time; future spirometry, pulmonary function
tests, cbc (eosinophils), and arterial blood gases may be indicated
Follow-up : Patient is to follow up within 4 months for recheck of asthma status and
evaluation of medication. The patient should follow up sooner if symptoms worsen or do
not improve. Patient and mother are aware that it will take several days for the
medication to begin to suppress the allergic rhinitis symptoms. Patient will continue to
be monitored with asthma as well as developmental milestones and immunization
status through childhood and adolescence.
Consultation/Referrals: If patient has no relief of symptoms or rhinitis remains after
treatment- patient may be referred to ENT. Asthma seems to be well controlled at this
time; if exacerbations begin that cannot be controlled patient may need to be referred
to pulmonologist.
Patient education needs: balanced diet, physical activity, course of asthma and how to
recognize early exacerbation symptoms, course of allergic rhinitis, when and how to use
each medication, medication compliance, medication side effects, when to follow up,
importance of keeping appointments, immunization status and needs, importance of
annual dental and eye exams
Current treatment plan: Flovent HFA 44mcg, 1 puff QHS/ Albuterol for nebulizer, 1 vial
QID PRN/ Montelukast 4 mg, 1 tab every evening/ Ventolin HFA 90mcg, 2 puffs Q4-6HRS
PRN
Health promotion : prevention of asthma exacerbations; treatment of asthma and
allergic rhinitis; annual dental exams; annual eye exams; annual well child exams;
completion of vaccinations as indicated; annual influenza vaccination; balanced diet;
adequate physical activity; adequate sleep
Health maintenance: medication adherence and completion; return to clinic if symptoms
worsen or new symptoms present; avoid asthma and/or allergic trigger factors; return to
clinic within 4 months for recheck and medication refills
Disease prevention: stay up to date with immunizations; attend annual health promotion
visits (well child, dental, eye); achieve and maintain normal weight through BMI
Intervention
Medication: Flovent HFA 44mcg, 1 puff QHS/ Albuterol for nebulizer, 1 vial QID PRN/
Montelukast 4 mg, 1 tab every evening/ Ventolin HFA 90mcg, 2 puffs Q4-6HRS PRN
Education: course of asthma and how to recognize early exacerbation symptoms, course
of allergic rhinitis, when and how to use each medication, medication compliance,
medication side effects, when to follow up, importance of keeping future appointments

Consultation: No consultation or referral required at this time.

Evaluation
Patient to follow up within 4 months for recheck and evaluation of asthma status and
medication, sooner if new symptoms present or current symptoms worsen. Patient will
be managed in clinic for asthma unless exacerbations become more regular and
medication maintenance no longer provides adequate relief. Diagnostic tests and
referrals if indicated in the future.