Documentation Plan for Pediatric Asthma

Patient Discussion Question 2
Your Name
Subject and Section
November 15, 2022

1. Assessment/Plan

1. Patient is a five-year-old caucasian male who was rushed to the hospital for difficulty breathing. The patient was given a nebulizer treatment which relieved the symptoms. The patient was observed to have difficulty breathing (inhaling and exhaling). Upon interview, the parents noted that the symptoms first manifested months ago. However, they were mere “on and off,” and each episode would only last for a few minutes during the night. They believed that these were caused by dust, so they cleaned the room, and the symptoms went away for a few weeks. However, the patient has experienced a recurring cough at night for the past two weeks. The coughs were also characterized by wheezing sounds and accompanied by short episodes of shortness of breath. It was only last night that the child experienced acute difficulty breathing, which is why the parents rushed the child to the hospital. 
2. 1.      Reactive airways disease

1. Differential list and rationale for final/working diagnosis

One of the possible differential diagnoses for this case is reactive airway disease. This disease presents similar symptoms to asthma and is usually the diagnosis given when asthma is not yet diagnosed (Sharma & Haver, 2021). Nonetheless, pediatric asthma is the more likely diagnosis, given the chronic and long-term onset of the symptoms, like coughs at night, wheezing sounds, and shortness of breath (MacLeod, 2021).  

 

1. b.      Vocal Cord Dysfunction

Similar to Reactive Airways Disease, vocal cord dysfunction also presents the same symptoms as asthma. However, one difference between these two is that VCD does not involve the lower airways. In this case, the patient seems to have difficulty expelling his breath rather than taking a full breath, which suggests asthma (Stojanovic et al., 2022).  

 

1. c.       Hyperventilation syndrome

Despite the similarities in symptoms, Hyperventilation syndrome is usually triggered after strenuous activities. However, patient reports show the chronic recurrence of symptoms which is usually triggered by cold temperature. 

1. Problem list

• Frequent and recurring cough during the night triggered by cold temperature for the past few months
• Wheezing sounds are produced during coughs.
• S...