Is this patient stable, and can you treat them in your clinic?

The patient is relatively stable but had some manifestations of respiratory distress identified by the high respiratory rate of 52 breaths per minute and expiratory wheezing. It may be appreciated that the child is oxygenating well, given that the O2 saturation index was 96%. Nonetheless, the situation where the patient has increased respiratory effort, low oral intake, and a family history of asthma should not be taken lightly. The clinic may be able to manage the symptoms, but if they persist, progress, or fail to respond to treatment, then a higher level of care may be required.

Would you need additional testing?

Of course, further testing is needed. A chest X-ray is helpful to exclude pneumonia or other structural lung diseases. Other tests that should be carried out due to seasonality and the patient’s symptomatology include viral testing for common respiratory pathogens such as RSV (Respiratory Syncytial Virus). However, pulse oximetry should be used to measure oxygen saturation at regular intervals, especially in cases where the respiratory rate is still elevated or when the child’s condition worsens.

List 3 differentials for this patient and why.

Bronchiolitis: According to Bottau et al. (2022), this is likely given the patient’s age, recent URI symptoms, wheezing, and thick rhinorrhea. RSV usually causes bronchiolitis; it is also a possibility.

Asthma: Based on the family history of asthma and expiratory wheezing, asthma was also a reasonable possibility. Even though it is not very frequent in infants, it must not be ruled out.

Pneumonia: Fine rales may have been present, which may indicate pneumonia. The current O2 saturation is satisfactory, yet the high respiratory rate and fever speak for considering bacterial or viral pneumonia.

What is your evidence-based plan of care for this child?

Physical Care: According to Sockrider and Fussner (2020), this should involve using bronchodilators, such as albuterol, given by nebulization to curb wheezing. Ensure the patient has plenty of fluids and offers small amounts of food at shorter intervals. Monitor respiratory status closely.

Educational Needs: Teach the parents about signs symptomatic of pediatric respiratory distress, including increased work of breathing, use of accessory muscles, and cyanosis. Suggest the necessity of taking fluids and avoiding exposure to smoke.

Follow-Up: It is advised to plan a follow-up within 24-48 hours to reassess the child’s respiratory status and overall health. Include guidelines on when to rush to the doctor with breathing problems, difficulties in feeding, or signs of lethargy.

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