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PE28.1-5 | Allergy and Asthma — Assignment
CLINICAL SCENARIO
You will analyse a clinical scenario of a child with persistent asthma and allergic rhinitis, classify disease severity using GINA and ARIA criteria, interpret pulmonary function test results, construct a stepwise management plan, and counsel the parent on inhaler technique and trigger avoidance. This task develops the clinical reasoning skills required to individualise asthma management in paediatric practice.
Instructions
- Read the clinical scenario below carefully. 2. Complete each section of the structured write-up using current GINA (Global Initiative for Asthma) and ARIA (Allergic Rhinitis and its Impact on Asthma) evidence-based guidelines. 3. Dose all medications in mg/kg with the child's weight specified. 4. Use subheadings matching the scaffolding sections provided. 5. Word limit: 900–1200 words (excluding references). 6. Submit individually; your work will be reviewed by two peers using the rubric below.
Clinical Scenario: Arjun, an 8-year-old boy (weight 24 kg) from Chennai, is brought by his mother with a 2-year history of recurrent wheeze, nocturnal cough (3–4 nights/week), and daytime breathlessness that limits his ability to play cricket. He has had 3 hospital visits for acute wheeze over 18 months. He also has chronic nasal blockage, sneezing, and clear rhinorrhoea every day for the past 6 months, worse on waking. Skin-prick tests are positive for house dust mite and cat dander. On examination: RR 22/min, mild wheeze on forced expiration, no distress at rest. Spirometry: FEV1 72% predicted, FVC 88% predicted, FEV1/FVC 0.75; post-salbutamol FEV1 84% predicted (improvement = 16.7%). He is currently using salbutamol MDI 2 puffs on demand (daily) with no controller.
Length: 900–1200 words (excluding references). Include at least 3 referenced sources (Ghai Essential Pediatrics, IAP asthma guidelines, GINA 2024 report).
What to Submit
1. Disease Classification
Guidance: Classify Arjun's asthma severity using GINA criteria (intermittent / mild persistent / moderate persistent / severe persistent). Justify using daytime symptom frequency, nocturnal frequency, activity limitation, and lung function data. Then classify his allergic rhinitis using ARIA (intermittent vs persistent; mild vs moderate-severe). State all criteria used.
2. Spirometry Interpretation
Guidance: Interpret the spirometry result: is the pattern obstructive, restrictive, or mixed? Calculate the percentage improvement in FEV1 post-bronchodilator and state whether reversibility is significant (≥12% threshold). Explain what this tells you about the diagnosis and severity.
3. Stepwise Management Plan
Guidance: Prescribe a complete GINA stepwise treatment plan for Arjun: (a) state the GINA step; (b) name the controller medication with dose in mcg/kg or mg/kg/day; (c) prescribe the rescue medication with dose in mg/kg; (d) address the allergic rhinitis pharmacotherapy (ARIA step — INCS and antihistamine with weight-based doses where applicable); (e) state criteria for stepping up or stepping down. All doses must be weight-referenced.
4. Inhaler Technique Counselling
Guidance: Write out the step-by-step instructions you would give Arjun's mother for correct pMDI + spacer use, including the number of puffs, correct driving technique, and frequency of spacer cleaning. State specifically why the spacer is necessary for this age group and what error to avoid (blow-by technique).
5. Trigger Avoidance and Environmental Control
Guidance: Based on Arjun's sensitisation profile (house dust mite + cat dander), describe three specific, practical, evidence-based environmental control measures the family can implement at home. Explain the rationale for each measure and its expected benefit on symptom burden.
6. Follow-Up and Monitoring Plan
Guidance: State when you would review Arjun, what you would assess at follow-up (symptom control, spirometry, growth monitoring on ICS, technique check), and what criteria would trigger a step-up or referral to a paediatric pulmonologist or allergist.
Grading Rubric — Allergy and Asthma Case Writeup Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Disease Classification Accuracy (GINA + ARIA criteria correctly applied and justified) | 20 pts | Correct GINA severity class with all four criteria stated; correct ARIA category (persistent/moderate-severe) with both frequency and severity axes addressed; evidence cited. |
| Spirometry Interpretation (pattern, reversibility calculation, clinical significance) | 15 pts | Obstructive pattern correctly identified; reversibility calculated accurately as 16.7% (above ≥12% threshold); clinical implication for asthma diagnosis stated with reference to the 12% and optionally 200 mL absolute criteria. |
| Management Plan Completeness and Accuracy (GINA step, correct weight-based dosing, AR pharmacotherapy) | 25 pts | Correct GINA step identified (Step 2–3); ICS dose stated in mcg/day with weight context; rescue salbutamol 0.15 mg/kg stated; INCS named with daily administration; second-generation antihistamine weight-dosed; LABA monotherapy explicitly avoided if mentioned; step-up/step-down criteria stated. |
| Inhaler Technique Counselling (pMDI + spacer steps, rationale, avoidance of blow-by) | 15 pts | Correct step-by-step pMDI + spacer technique described (shake → actuate 1 puff into spacer → 3–5 tidal breaths); age-appropriate rationale for spacer; blow-by explicitly identified as incorrect with explanation of why (50–80% drug loss). |
| Environmental Control and Trigger Avoidance (evidence-based, practical, specific to sensitisation profile) | 15 pts | Three specific evidence-based measures tailored to house dust mite and cat dander sensitisation (e.g. allergen-proof mattress/pillow covers, washing bedding at ≥60°C weekly, removing carpets/soft furnishings, HEPA air filtration, pet removal/bedroom exclusion, humidity control); mechanism/benefit stated for each. |
| Follow-Up Plan and Clinical Reasoning Quality (monitoring parameters, step-up criteria, referral triggers) | 10 pts | Specific follow-up timeline (4–6 weeks initial, then 3-monthly once controlled); monitoring includes symptom control score (CACT/ACQ), spirometry interval, growth monitoring on ICS; step-up criteria explicitly stated (any exacerbation, ≥3 SABA/week, nocturnal symptoms); referral criteria (Step 4+, diagnostic uncertainty, biologic therapy consideration) stated. |
PEER REVIEW
Review your peer's case writeup using the six-criterion rubric. For each criterion: (1) assign a score with justification citing specific text from the writeup; (2) identify one specific strength; (3) identify one specific improvement. Check: Are all doses weight-based (mg/kg)? Is LABA monotherapy correctly avoided? Is ARIA classification applied correctly using both frequency and severity axes? Is blow-by explicitly condemned in the inhaler counselling? Is the reversibility threshold ≥12% (not ≥20%)? Provide constructive, evidence-based feedback — cite Ghai or GINA where relevant. Total score: 100 points.