Case study: How would you manage this case?
September 1, 2002 2 minutes read
When a 4-year-old girl came to the emergency department (ED) because of a persistent cough for six weeks, she already had been treated with three different courses of antibiotics for suspected sinusitis. "She had been using albuterol nebulization four times daily, including once or twice during the night, but she received only minimal relief of the cough," says Karen Huss, RN, DNSc, APRN-BC, FAAN, associate professor at Johns Hopkins University School of Nursing in Baltimore.
Here is what the history and physical examination showed:
- There was no history of fever, wheezing, or shortness of breath.
- Her father has seasonal allergies.
- The patient’s temperature was 99°F.
- The respiratory rate was 18 and not labored, but she did have frequent harsh, nonproductive cough.
- There was no sinus tenderness and no exudates seen on nasal exam.
- Ears and throat were normal, and the lungs were clear.
- A chest film was normal.
Here, Huss explains how the "stepwise" approach was used to manage this patient in the ED: An albuterol nebulizer treatment was administered, and there was improvement in the cough. She was having daily symptoms and nighttime symptoms more than one night per week. She was diagnosed with moderate persistent asthma. Budesonide repules 0.5 mg nebulized twice a day for five days were prescribed. After just three treatments, she was sleeping through the night, and albuterol treatments were gradually decreased and then stopped. The budesonide repules were decreased to once daily for five days and then stopped.
Subsequently, the girl was referred to an allergist and found to be strongly allergic by prick skin testing to house dust mites. Her family had been living in a below-ground apartment with carpets that often were damp from leaks in the foundation, conditions that are very conducive to house dust mite growth.
Fortunately, about a week before her ED visit, the family had moved to a townhouse, and her bedroom is on the second level, says Huss. "A dehumidifier was added to reduce growth of house dust mites during the more humid times of the year," she adds. "The child is doing well, and her asthma is now classified as mild intermittent."
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