Emma Jhonson
Dr Fransiska Hutahaean
87 George Town Road
NEWNHAM, TAS 7248
03-11-1995
Dr B Townsend
Emergency Department Royal Children’s Hospital
HOBART, TAS
Dear Dr Townsend,
I am referring Emma Johnson, 11 years old. She presented first on 24-07-1995 with viral upper respiratory infection and the possibility of asthma for which she was treated with analgesic and more fluid intake.
Three weeks later she presented again with the major complaint of persistent nocturnal cough. On examination there was basal wheeze on chest auscultation and her PEFR was 230 l/m. I assessed her as having probable asthma and prescribed Ventolin puffer 2 puffs three times daily.
A 2 - month review of her condition revealed well-controlled asthma after I commenced her on Becotide 200 mg 2 puffs three times daily and continued Ventolin as required. She has a family history of asthma and no allergies. Today she presented with a 48-hour history of worsening shortness of breath, wheezing, runny nose, fever and loss of appetite. Further investigations have shown there was obvious difficulty in breathing which confirmed by using of accessory muscles. Chest auscultation revealed widespread wheeze and PEFR resulted in 140 l/m. I diagnosed severe asthma triggered by viral upper respiratory infection.
I would appreciate your further assessment and management of this patient’s condition.
Yours sincerely,
Dr Fransiska Hutahaean
http://adrive.com/public/70705c0d5b483a7cbaf4bd64e32e1f59660ffd9e34d7adefda83a7acfe77df47.html
General Practitioner
Correction by Kay
