Annie Ramirez a nine-year-old Hispanic female has presented to your clinic with a four-day history of cough fever and increasing fatigue

Annie Ramirez a nine-year-old Hispanic female has presented to your clinic with a four-day history of cough fever and increasing fatigue

Annie Ramirez, a nine-year-old Hispanic female, has presented to your clinic with a four-day history of cough, fever and increasing fatigue. Prior to the onset of symptoms, Annie had been feeling well, attending school regularly, and participating on her competitive soccer team. Annie has a history of a peanut allergy as well as mild persistent asthma. Annie’s father reports that at baseline, Annie has a nighttime cough “maybe once a week or so” and does wheeze “if she forgets her inhaler before her soccer games.”

Over the past four days, Annie’s activity level has decreased dramatically and she feels that “it is hard to breathe” when she tries to move around. She has a persistent cough that is worse at nighttime. She has been using her inhalers according to her sick plan, but they “do not seem to be helping.” Her father reports that Annie’s fever has been as high as 102.9 °F (tympanic) and ibuprofen has been helpful to reduce her fever. She is eating, but less than normal, and her parents have been encouraging her to drink water throughout the day.

You conduct a physical exam and diagnose Annie with left lower lobe community acquired pneumonia (CAP) resulting in an acute asthma exacerbation. You administer albuterol via a nebulizer during the visit and you note that Annie has decreased working of breathing and an increased SpO2%. Your assessment is that she can be treated in the outpatient setting. What additional medications would you prescribe?

Focused Review of Systems

General: Reports fatigue; exacerbated by physical activity.

HEENT: Denies ear pain, discharge from ears, or difficulty hearing. Denies drainage or difficulty breathing through nose. Denies sore throat or difficulty swallowing. Denies neck pain or decreased range of motion.

RESP: Reports cough productive of green sputum; consistent throughout the day, but worsens at night. Shortness of breath with physical activity. Difficulty “getting the air in” even at rest. Using inhalers with minimal results.

CV: Denies heart racing.

GI: Reports a decreased appetite but drinking water throughout the day. Reports soft daily bowel movements; voiding 4-5 times daily.


  • Product of a normal pregnancy/delivery (full term infant)
  • Peanut allergy (anaphylaxis at 18 months)
  • Mild persistent asthma (diagnosed at 4yo, last required oral corticosteroids 3 years ago)
  • Denies past surgeries


  • Lives with two fathers and one 4-year-old brother
  • 3rd grade, great student, loves reading. Plays competitive soccer
  • Parents are non-smokers, no second-hand smoke exposure


  • Asmanex HFA (mometasone furoate), 100mcg/actuation: 1 puff once daily when well; 2 puffs BID when sick with respiratory symptoms
  • Ventolin HFA (albuterol sulfate), 90mcg/actuation: 2 puffs every 4-6 hours PRN for wheeze/cough; 2 puffs prior to exercise; when sick with respiratory symptoms, increase to 4 puffs every 4 hours
  • Epi-pen (epinephrine), 0.3mg: Administer in thigh for any exposure to peanuts or signs consistent with an allergic reaction; seek immediate medical attention after using. May repeat in 5-10 minutes as needed for return of symptoms.
  • Motrin (ibuprofen), 100g/5mL: 15mL every six hours as needed for fever


  • Foods: peanuts (anaphylaxis)
  • Medications: none
  • Environmental: none


Vitals: Wt-71 lbs, Ht-54.75 inches, BMI 16.7, Temp-101.3 °F (tympanic), HR-118, RR-30, SpO2-95%, BP-92/46, pain-denies

HEENT: Normocephalic; no lesions. Pupils 3 to 4 mm, and symmetrically reactive to light. TMs are flat, non-erythematous, with appropriate light reflexes bilaterally. Nares patent bilaterally. Mucus membranes are moist, good dentition, tonsils are 2+ without exudate, pharynx is non-erythematous.

Lungs: Diffuse inspiratory and expiratory wheezes, coarse crackles in the left lower lobe; no change with deep inspiration/cough. Intercostal and substernal retractions noted. Post-albuterol: Coarse crackles RLL, occasional inspiratory wheeze, resolved retractions.

Cardiovascular: Normal S1 and S2. No murmurs or abnormal heart sounds.

Abdomen: Soft, non-tender, non-distended. No hepatosplenomegaly noted.


Illustrate your understanding of Pharmacotherapeutics in this patient’s care. Please no copying and pasting but you are welcome to make your own charts or graphs if desired.

Complete an analysis for each medication and any medication you decide to prescribe including:

  • Describe the mechanism of action, side effects, caution and/or contraindications, monitoring parameters and determine if the medication is the best option for this patient
  • Common dosage, route and schedule for the medication
  • Determine cost of each medication
  • Is the medication being used reasonably in this situation (risk/benefit analysis)?
  • Would you make any changes in the use of the drug if you were the provider?

Complete an analysis of the patient including:

  • Evidence of drug effectiveness
  • Indicate potential drug interactions (drug-drug, drug-food, drug-herb, etc.)
  • Indications of possible adverse drug effects
  • Factors affecting compliance/adherence
  • What social factors must you considered for this patient?
  • What education must you provide to the patient about these medications
  • Are there special considerations for this patient population that must be considered? When would you want to see this patient again in a follow up visit?
  • Include any nonpharmacologic interventions that you feel are appropriate.



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