Patient Summary Template

Oliver Vance (DOB: 14/08/2018, MRN: 492-817-65) is a 5-year-old male with a documented history of moderate persistent asthma, mild atopic dermatitis, and allergic rhinitis. Past medical history includes two emergency department presentations for acute viral-induced wheeze (12/06/2022 and 04/11/2023), requiring short courses of oral prednisolone, with no history of ICU admissions or intubation. Past surgical history includes bilateral myringotomy and grommet insertion on 19/03/2021 for chronic otitis media with effusion; no surgical complications recorded. Immunisations are up to date per the National Immunisation Program Schedule.

Current regular medications include fluticasone propionate (Flixotide Junior®) 50 mcg INH 2 puffs BD via spacer, cetirizine (Zyrtec®) 5 mg PO OD PRN, and hydrocortisone 1% (Dermaid®) ointment TOP BD PRN to affected areas during flares. Reliever medication is salbutamol (Ventolin®) 100 mcg INH 2-6 puffs Q4H PRN via spacer. Documented allergies include amoxicillin (maculopapular rash noted on 15/09/2020) and house dust mite; no known food allergies or anaphylaxis.

Previous investigations from 10/11/2023 show FBC with Hb 124 g/L, WCC 8.2 x 10^9/L, eosinophils 0.6 x 10^9/L (elevated), and platelets 310 x 10^9/L. Total IgE on 10/11/2023 was 245 kU/L, with RAST positive for Dermatophagoides pteronyssinus (42.5 kUA/L) and negative for cat dander (< 0.10 kUA/L) and rye grass (< 0.10 kUA/L). Chest X-ray on 04/11/2023 demonstrated mild bilateral peribronchial cuffing and hyperinflation, with no focal consolidation, collapse, or pleural effusion. Spirometry attempted on 18/01/2024 was technically suboptimal due to age, but showed baseline FEV1 of 0.95 L (82% predicted) with a 14% improvement post-bronchodilator.

Management to date has comprised stepping up preventer therapy to regular inhaled corticosteroids on 18/01/2024, provision of a written Asthma Action Plan, spacer technique education with parents, and daily emollient therapy (QV® cream) for eczema maintenance. Outstanding actions include repeating spirometry in 6 months to assess objective response to regular fluticasone propionate, an audiology review scheduled for 22/05/2024 to confirm grommet extrusion and normal hearing thresholds, and routine paediatric outpatient follow-up in 3 months.