Pediatric Asthma Follow-Up and Management

Subjective (S)

Chief Complaint (CC)

“Follow-up for asthma. Persistent coughing, wheezing, and shortness of breath, especially at night and with activity.”

History of Present Illness (HPI)

The patient is an 8-year-old male patient who visits the clinic with his mother for asthma follow-up. He has suffered from chronic coughing, wheezing, and chest tightness three to four days every week, with symptoms at night twice a week. Exercise, exposure to dust, and cold air provoke the symptoms. He carries an inhaler of albuterol, which he takes on demand for half relief. One emergency room visit due to wheezing happened six months ago. He is not currently taking a controller medication.

Substance / Environmental Exposure

The patient does not use tobacco, alcohol, or illicit substances. However, environmental exposure includes household carpeting and intermittent second-hand smoke exposure from neighboring apartments.

Medical History

• Diagnosed with asthma at age 5
• No other chronic medical conditions
• No prior hospital admissions related to asthma

Current Medications

• Albuterol metered-dose inhaler (SABA) PRN
• No daily controller medications

Allergies

• No known drug, food, or environmental allergies reported

Family History

• Mother with allergic rhinitis
• Father with a history of childhood asthma

Review of Systems (ROS)

• GENERAL: Denies fever, weight loss, or fatigue
• HEENT: Reports intermittent nasal congestion; denies sore throat or ear pain
• RESPIRATORY: Reports wheezing, nocturnal cough, chest tightness, and exertional dyspnea
• CARDIOVASCULAR: Denies chest pain or palpitations
• GASTROINTESTINAL: Denies nausea, vomiting, or reflux
• NEUROLOGICAL: Denies headaches, dizziness, or syncope
• SKIN: No rashes or cyanosis noted

Objective (O)

Vital Signs

• Temperature: 36.8°C
• Heart Rate: 92 bpm
• Respiratory Rate: 22 breaths/min
• Blood Pressure: 104/66 mmHg
• Oxygen Saturation: 97% on room air

Physical Examination

• General: Alert, cooperative, no acute distress
• HEENT: Pale nasal mucosa with mild turbinate edema
• Respiratory: Mild intercostal retractions; bilateral expiratory wheezes, more prominent in lower lung fields; prolonged expiratory phase
• Cardiovascular: Regular rate and rhythm; no murmurs or gallops
• Skin: Warm, well-perfused; no clubbing or cyanosis

Diagnostic Results

• Peak Expiratory Flow (PEF): 70% of predicted for age and height
• Spirometry:
  • Pre-bronchodilator: Reduced FEV₁ consistent with airflow limitation
  • Post-bronchodilator: Significant reversibility (>12% improvement), supporting asthma diagnosis

Assessment (A)

Clinical Impression

The patient presents with poorly controlled asthma, characterized by frequent daytime symptoms, nighttime awakenings, activity limitation, and reduced lung function.

Diagnostic Impression

• J45.40 - Moderate persistent asthma, uncontrolled

Global Initiative for Asthma (GINA) recommends daily controller therapy in children who have more than twice-weekly symptoms and nocturnal awakenings instead of SABA-alone therapy (Aziz et al., 2024). Due to a high risk of exacerbations, airway remodelling, and long-term pulmonary disability, the patient is dependent on rescue medication without anti-inflammatory control.

Exposure to environmental factors like dust and second-hand smoke also contributes to the persistence of the symptoms. According to the latest global recommendations, early and regular controller therapy, along with reduction of triggers and education, is the cornerstone of the successful business of optimal asthma management among pediatric patients (Plesca et al., 2024; Society & Chinese Medical Association, 2025).

Reflections

The current situation depicted in this case shows the persistent issue of under-treated children suffering from asthma, especially where controller therapy is postponed or not taken. Relapses of his symptoms notwithstanding, the patient has been using SABA-only therapy, which is currently not recommended in GINA because it correlates with a higher incidence of exacerbations and poor patient outcomes (Aziz et al., 2024). Clinically, the case highlights the value of active disease evaluation, the timely use of inhaled corticosteroids, and detailed education of the caregivers.

Ethical considerations involve making sure that the caregivers are aware of asthma as a long-term inflammatory condition instead of occasional bronchospasm. To deliver fair clinical care of asthma, it is imperative to address the environmental and social determinants of health, including not only housing conditions but also exposure to second-hand smoke. The case supports the necessity of shared decision-making, longitudinal monitoring, and guideline-adherent care in order to enhance the outcomes of asthma treatment in pediatrics on the global level.

Plan (P)

Pharmacologic Management:

• Initiate low-dose inhaled corticosteroid (ICS) therapy (e.g., budesonide) administered daily as first-line controller treatment
• Continue albuterol inhaler PRN for acute symptom relief only
• Consider step-up therapy if asthma control remains inadequate after 4-6 weeks, in line with stepwise management recommendations (Aziz et al., 2024).

Non-Pharmacologic Interventions:

• Provide a written asthma action plan tailored to symptom severity and peak flow measurements
• Counsel caregiver on trigger avoidance, including reducing dust exposure and minimizing second-hand smoke
• Encourage age-appropriate physical activity with symptom monitoring

Education and Safety:

• Demonstrate correct inhaler and spacer technique
• Educate patient and caregiver on the importance of daily controller adherence
• Review early warning signs of exacerbation and emergency response measures

Follow-Up:

• Schedule follow-up appointment in 4 weeks for reassessment
• Repeat spirometry and symptom evaluation
• Monitor growth and potential ICS side effects
• Consider referral to pediatric pulmonology if control remains suboptimal