A three year old comes in with a complaint of coughing for 2 weeks.

Coughing is present every

night. He has also had a mild fever, but his temperature has not been measured at home. His
parents have been using a decongestant/antihistamine syrup and albuterol syrup which were left
over from a sibling. Initially the cough improved but it worsened over the next 2 days. He is
noted to have morning sneezing and nasal congestion. There are colds going around the preschool. He has had similar episodes in the past, but this episode is worse. He has no known
allergies to foods or medications.
His past history is notable for eczema and dry skin since infancy. He is otherwise healthy and he
is fully immunized. His family history is notable for a brother who has asthma. In his home
environment, there are no smokers or pets.
Exam: VS T 38.1, P 100, RR 24, BP 85/65, oxygen saturation 99% in room air. He is alert and
cooperative in minimal distress if any. His eyes are clear, nasal mucosa is boggy with clear
discharge, and his pharynx has moderate lymphoid hypertrophy. He has multiple small lymph
nodes palpable in his upper neck. His chest has an increased AP diameter and it is tympanitic
(hyperresonant) to percussion. Rhonchi and occasional wheezes are heard on auscultation, but
there are no retractions. Heart is in a regular rhythm and no murmurs are heard. His skin is dry,
but not flaky, inflamed or thickened.
He is initially felt to have moderately persistent asthma and possible asthmatic bronchitis. He is
initially treated with nebulized albuterol and nebulized corticosteroids for bronchospasm and
bronchial inflammation. He is also treated with an antihistamine at night to reduce his morning
allergy symptoms. In follow-up, his cough does not improve and he is still having fever (T
38.2C, 101.0F). A chest X-ray is obtained, but no radiographic evidence of pneumonia is present.
His cough persists, but only with exercise and drinking cold juice.
His chest now sounds clear in the office. After one week of no night cough, his nebulized
albuterol+corticosteroid is reduced to 2 times a day. His exercise induced cough gradually
resolves. His nebulized corticosteroid is replaced with nebulized cromolyn twice a day and oral
montelukast (a leukotriene inhibitor) is added. He enrolls in a soccer league and plays with
minimal coughing. His routine nebulized albuterol+cromolyn is stopped and is used only preexercise to prevent exercise induced bronchospasm. No cough is observed at night or with
exercise. He is continued on nightly antihistamines, pre-exercise albuterol+cromolyn nebs, and
once daily montelukast. He is given an asthma treatment plan which gives his parents clear
instructions on which medications to start based on his symptoms and severity.

https://www.hawaii.edu/medicine/pediatrics/pedtext/s08c02.html