A.K. is a 9-year-old boy who presents to an urban ED with cough and trouble breathing typical of his usual asthma exacerbation. This episode began 2 days ago and has been accompanied by a runny nose and a low-grade fever without any other symptoms. Several family members are also ill with upper respiratory infections. His mother has been treating him with albuterol by a nebulizer every 4 hours, but he has become more short of breath this evening prior to coming to the ED. Past medical history is notable for asthma/RAD since infancy, with multiple prior hospitalizations. Other problems on review of systems include eczema and environmental allergies. Multiple family members also have asthma. On social history, his mother mentions that he is in second grade but has missed at least 10 days of school this year due to his asthma. In the past, his primary care has been inconsistent, although recently the family obtained health insurance and he has been assigned to a new provider. His only current medication is albuterol. In the past, he was prescribed inhaled fluticasone, but the prescription ran out and the family has not followed up for a refill. On physical examination, he appears in moderate respiratory distress, with suprasternal and intercostal retractions. His vital signs include a temperature of 100.1°F, a respiratory rate of 40 breaths per minute, heart rate of 120 beats per minute, and pulse oximetry of 95% on room air. Lung exam is notable for diffuse symmetrical wheezes, a prolonged expiratory phase, and diminished aeration. His nasal mucosa is erythematous with boggy turbinates and clear mucus. His skin is dry with excoriation over the flexor creases. The remainder of the examination is unremarkable. What is your initial treatment plan, medications, testing, and follow up?

Charlie is a 4-year-old patient diagnosed with mild asthma 2 years ago.   He was initially started on Flovent 44 mcg/puff 1 puff BID and albuterol MDI 2-4 puffs q 4-6 hours PRN upon diagnosis.   His parents stopped his Flovent ~ 3 months ago because he hadn’t had any “attacks” in over 6 months. He has not been to the ER or been on steroids since he was last seen nor was he waking at night but mom reports that he was using his albuterol about once a day for symptoms (before soccer practice). Approximately one week ago, he started to develop URI symptoms, cough, chest pain, SOB and wheezing that have worsened over the past few days and his albuterol use has increased to 2-3x/day. Last night, he required more frequent albuterol use (every 3-4 hours). Upon physical examination, you note subcostal and intercostal retractions and diffuse expiratory wheezing throughout all lung fields without crackles or stridor. His oxygen saturation is 92% on room air. He was given one albuterol nebulizer treatment with minimal improvement. After a second albuterol treatment, his oxygen saturation increased to 94-95%, he no longer had retractions, but you continue to auscultate mild wheezing throughout all lung fields. Which of the following is the most appropriate treatment regimen for Charlie at this time?

A 12 yo male is brought to the office because of recurrent episodes of epistaxis during the past two months.  He has no history of bruising or unexplained bleeding.  While he is in the exam room, an episode of epistaxis occurs.  On physical examination, anterior bleeding is visible within the Kiesselbach plexus.  Which of the following is the most appropriate initial step in management?

Lab tests recommended for an 8 yo female who has a BMI > 95th percentile include all of the below except:

Findings on an infant exam concerning for craniosynostosis include:

The most appropriate treatment for uncomplicated acute otitis externa with an intact TM is:

When evaluating a 12 month old for communication skills, one milestone that should be met is:  

Which immunizations would you order for a 4 month old male who is in your office for a routine well child check.  The infant received the recommended immunizations at 2 months of age and received his first Hepatitis B vaccine at birth?  

When instructing a school age child and their parent about the significance of peak expiratory flow readings, you should teach them that, when the reading is in the yellow zone, this means that the asthma control is what?

A 2-month-old infant is brought to clinic with a stuffy, runny nose of 3 days’ duration. The infant is afebrile and has no cough or respiratory difficulty but is not nursing or sleeping well. The tympanic membranes are within normal limits. What advice would the FNP give?