A child was admitted to the emergency department with difficulty breathing, coughing, and fever. His medical history included asthma and a prior tonsillectomy. A physical exam found decreased breath sounds, wheezing, and a fever. Chest x-rays showed patchy lung infiltrates. He tested positive for parainfluenza virus 3. He was treated for an asthma exacerbation, pneumonia, and hypokalemia with nebulizers, steroids, and potassium supplementation. His breathing, vital signs, and lab results would be closely monitored during recovery.

1. FARM NOTES (MODULE 7)
BY: ELIZAMAE A. DOYSABAS

2. FINDINGS:
 Patient complaints:
 Difficulty breathing
 Frequent coughing
 Albuterol is not helping his condition
 Past Medical History:
 Asthma
 S/P tonsillectomy and adenoidectomy (T&A) at 2 years of age
 History of present illness
 3-day history of cough and congestion before coming to the emergency department.
 Fever 3 days prior to admission
 Gasping for air (night before) and increase work of breathing (during the day)
 Has been fussy
 Poor appetite
 Infrequent urinations (2-3 times for the past 24 hrs)
 Has mild retractions with tachypnea (52 breaths per minute)
 Runny nose and sore throat
 Social History
 Positive tobacco exposure in current home

3.  Review of systems:
 Physical examination
 Fever
 Cough
 Congestion
 Increased work of breathing
 Vital Signs
 Blood Pressure (BP): 103/55 (initial: 100/68)
 Pulse/Heart Rate (P): 154 bpm (initial HR: 137 bpm)
 Temperature (T): 36.4oC (initial: 38.9oC)
 Respiratory Rate (R): 29 breaths/min (initial: 52 breaths/min)
 Oxygen/O2 saturation: 94% at 1.5L/min nasal cannula (initial: 88%)
 Chest
 Slight decrease in breath sounds bilaterally
 Minimal wheezing
 Chest X-ray
 Patchy infiltrates throughout lung fields
 Respiratory
 Breath sounds have fair air exchange but with expiratory wheezes

4.  Laboratory results:
 Sodium: 134 mEq/L (Low)
 Potassium: 3.0 mEq/L (Low)
 CO2: 19 mEq/L (Low)
 SCr: 0.4 mg/dL (Low)
 Hemoglobin: 10 g/dL (Low)
 Respiratory viral panel nasal swab: positive for parainfluenza 3
 Medications taken by patient:
 During Admission:
 Acetaminophen 210 mg, one dose
 Albuterol 2.5 mg nebulization, as needed
 Albuterol nebulization 5 mg, hourly
 Albuterol/Ipratropium nebulization (3 nebulizations)
 Phenylephrine / Chlorpheniramine / Methscopolamine
 Prednisolone 15 mg, one dose orally
 Before Admission:
 Albuterol, 2.5 mg via nebulization twice a day
 Allergy medicine
 Ibuprofen – for fever

5. ASSESSMENT:
 Asthma exacerbation, uncontrolled
 Tachycardia (side effect of B2-agonist)
 Hypokalemia; frequent use of albuterol
 Pneumonia

6. RESOLUTION
o The oxygen saturation levels should be restored and maintained at 95%
o Tachypnea should be treated
o We should return physical exam results; continue to take Acetaminophen and Phenylephrine /
Chlorpheniramine / Methscopolamine to reduce to symptoms
o Return patient activity to normal
o Treat pneumonia
o Advise the foster mother to smoke outside and away from the children.
o In the case of respiratory failure, the patient should undergo incubation.
o For aerosolized medications, use a face mask. (in children < 4 years old)
o Use a humidifier in the child's room to reduce coughing and breathing difficulties
o Continuous nebulization
o Continue using MDI (Meter drug inhaler)
o Continue to take corticosteroid medications
o Continue anticholinergic medication
 Continue taking Phenylephrine / Chlorpheniramine / Methscopolamine to reduce symptoms of
parainfluenza 3.

7. MONITORING
 For patient’s low potassium levels have resulted in moderate
hypokalemia, which should be closely watched and treated with oral or
intravenous potassium if necessary.
 As a consequence of his tachypnea (abnormally fast breathing), the
patient's respiratory rate must be closely watched.
 • Return the patient's physical exam findings to normal, monitor his vital
signs, and repeat the chest x-ray and respiratory, electrolyte, and blood
chemistry tests.