Table of Contents

Aaron Preston iHuman Case Study

Aaron Preston is a 7-year-old male patient who presents to the Emergency Department at 1700 hours (5:00 PM) with his mother due to difficulty breathing. He has a known history of asthma, and the current episode of respiratory distress began after school while playing outside. The mother reports that there is smoke in their area due to wildfires, which appears to be the triggering factor for this acute asthma exacerbation. In this comprehensive guide, we’ll walk you through how to approach his case, from initial history-taking through physical examination to the final diagnosis of acute asthma exacerbation triggered by wildfire smoke exposure. You’ll learn the key clinical reasoning steps, what the iHuman grading rubric expects, and a complete step-by-step solution to help you confidently navigate this pediatric respiratory emergency simulation.

Aaron Preston iHuman Case Overview (Doorway Information)

Patient Overview: Aaron Preston is a 7-year-old male with a known history of asthma presenting with acute respiratory distress that began after school while playing outdoors. The patient was brought to the Emergency Department at 1700 hours by his mother due to difficulty breathing. Environmental factors include wildfire smoke in their area, which the mother identified as a potential trigger for the current exacerbation.

Key Background Information:

Age/Gender: 7-year-old male
Chief Complaint: Difficulty breathing
Time of Presentation: 1700 hours (5:00 PM)
Precipitating Event: Playing outside after school
Environmental Trigger: Wildfire smoke in the area
Previous Treatment: Nebulizer treatment given at home with little effect
PMH: Known asthma diagnosis
Current Medications: Albuterol and nebulizer treatments as needed
Social History: Lives with mother, father, and older sister in a pet-free and smoke-free home environment
Activities: Participates in scouts and swimming

Current Presentation: The patient appears pale with circumoral cyanosis noted, indicating respiratory compromise. Vital signs show tachycardia, tachypnea, and decreased oxygen saturation, consistent with acute asthma exacerbation.

This case represents an excellent learning opportunity for understanding pediatric asthma management, environmental triggers, and the specific challenges posed by wildfire smoke exposure in vulnerable populations.

Aaron Preston (7 y/o male) – Acute Asthma Exacerbation Assessment

CC: Difficulty breathing
MSAP: Acute asthma exacerbation triggered by wildfire smoke exposure
Environmental Trigger: Wildfire smoke in the area where patient was playing outdoors
Treatment Response: Poor response to home nebulizer treatment
History: Known asthma, active child participating in scouts and swimming
Home Environment: Pet-free and smoke-free household

History Questions:

How can I help you today?
Tell me more about the breathing difficulty Aaron is experiencing
When did this episode start and what was Aaron doing at the time?
Has Aaron had similar episodes before, and how often?
What does the breathing difficulty look like? (wheezing, coughing, shortness of breath)
What treatments have you tried at home before coming to the hospital?
How well did the home nebulizer treatment work today?
Tell me about Aaron’s asthma history – when was he first diagnosed?
What medications does Aaron typically use for his asthma?
How often does Aaron need to use his rescue inhaler?
Have you noticed any environmental triggers for Aaron’s asthma before?
Can you tell me about the air quality and smoke in your area today?
Does Aaron have any allergies to medications or environmental factors?
Has Aaron been sick recently with a cold or other respiratory illness?
What is Aaron’s normal activity level, and has this changed recently?
Tell me about Aaron’s sleep – has he been coughing or wheezing at night?
Has Aaron ever been hospitalized for asthma before?
Any family history of asthma, allergies, or respiratory conditions?
How has Aaron been eating and drinking today?
Are Aaron’s immunizations up to date?

Physical Exam:

Vitals: pulse, blood pressure, respiratory rate, temperature, oxygen saturation
General appearance: level of distress, use of accessory muscles, ability to speak
Skin: color, moisture, presence of circumoral cyanosis
HEENT: pupils, nasal flaring, throat examination
Neck: lymph nodes, use of accessory muscles
Chest wall & lungs:
- Visual inspection for retractions and respiratory effort
- Palpation for tenderness and chest wall movement
- Auscultation of all lung fields for wheezing, decreased air entry
Heart: rate, rhythm, murmurs
Abdomen: breathing pattern, use of abdominal muscles
Extremities: clubbing, edema, capillary refill
Neurologic: mental status, alertness, anxiety level

Assessment Note

A.P. is a 7-year-old male with known asthma presenting with acute respiratory distress that began after outdoor play in an area affected by wildfire smoke. The patient was brought to the ED at 1700 hours by his mother due to difficulty breathing that was poorly responsive to home nebulizer treatment. Physical examination reveals pale appearance with circumoral cyanosis, consistent with respiratory compromise. Environmental history is significant for wildfire smoke exposure, which research shows increases asthma exacerbations in pediatric populations. The patient’s current medications include albuterol and PRN nebulizer treatments, and he lives in a pet-free, smoke-free home environment.

Diagnosis: Acute Asthma Exacerbation secondary to wildfire smoke exposure

Plan:

Immediate bronchodilator therapy with albuterol
Systemic corticosteroids for inflammation control
Continuous monitoring with objective severity scoring
Patient and family education regarding environmental triggers
Discharge planning with appropriate follow-up care
Inhaled corticosteroid prescription for ongoing control

Aaron Preston SOAP Note

Patient: Aaron Preston

Subjective Data

CC: 7-year-old male presents with difficulty breathing

HPI: 7-year-old male with known asthma presents today with acute onset of respiratory distress that began after school while playing outside. The mother reports that difficulty breathing started during outdoor activities in an area with wildfire smoke. Home nebulizer treatment was administered with minimal improvement. The patient was brought to the ED at 1700 hours due to continued respiratory difficulty.

Medications: Albuterol and nebulizer treatments as needed

Allergies: No known drug allergies

PMH: Asthma diagnosis

PSH: Denies any surgical procedures

Family History: Should be assessed for asthma, allergies, and respiratory conditions

Social History:

Lives with mother, father, and older sister
Pet-free and smoke-free home environment
Activities include scouts and swimming
Environmental exposure: Wildfire smoke in area during outdoor play

Objective Data

ROS:

General: Acute respiratory distress, appears uncomfortable
Respiratory: Difficulty breathing, poor response to home nebulizer treatment
Cardiovascular: Assess for tachycardia secondary to respiratory distress
Neurologic: Assess for anxiety related to breathing difficulty

Vital Signs:

Temperature: 98.6°F
Blood Pressure: 108/60 mmHg
Heart Rate: 108 bpm (tachycardic)
Respiratory Rate: 32 breaths per minute (tachypneic)
SpO2: 94% (decreased oxygen saturation)
Pain Score: 4/10
IV Site: Right forearm

Assessment

General: 7-year-old male in mild to moderate respiratory distress, alert and responsive but uncomfortable

Skin: Clean, dry, and intact. Pale colored skin with circumoral cyanosis noted, indicating respiratory compromise

HEENT: Head shows no visible or palpable masses, depressions, or scarring

Respiratory: Expected findings include decreased air entry, possible wheezing, use of accessory muscles

Cardiovascular: Tachycardia consistent with respiratory distress and potential hypoxemia

Neurologic: Alert and oriented, anxiety related to breathing difficulty

Differential Diagnoses

Primary Diagnosis: Acute Asthma Exacerbation triggered by wildfire smoke exposure

Supporting evidence: Known asthma history, acute onset after environmental exposure, poor response to home treatment, physical findings consistent with asthma exacerbation
Wildfire smoke is a well-documented trigger for asthma exacerbations in children, with studies showing a 13% increase in emergency department visits during wildfire smoke days

Secondary Considerations:

Respiratory Tract Infection with Asthma Exacerbation

Consider due to: Common trigger for asthma in children
Arguments against: No fever, acute onset related to environmental exposure

Foreign Body Aspiration

Consider due to: Acute onset in young child
Arguments against: History of environmental trigger, known asthma history, bilateral symptoms

Pneumonia

Consider due to: Respiratory distress, hypoxemia
Arguments against: Acute onset, environmental trigger, no fever

Most Likely Diagnosis: Acute asthma exacerbation secondary to wildfire smoke exposure, evidenced by known asthma history, acute onset after environmental exposure, and physical findings consistent with bronchospasm and airway inflammation.

Plan

Immediate Management:

Severity Assessment: Use standardized scoring system (PRAM or Clinical Assessment Score) to categorize severity
Oxygen Support: Provide supplemental oxygen to maintain SpO2 >92%
Continuous Monitoring: Regular reassessment of respiratory status and response to treatment

Pharmacological Treatment:

Bronchodilator Therapy: Albuterol via MDI with spacer or nebulizer every 20 minutes for first hour, then reassess
Anti-inflammatory Therapy: Systemic corticosteroids – single-dose dexamethasone 0.3-0.6 mg/kg PO or prednisolone 1-2 mg/kg PO
Adjunct Therapy: Consider ipratropium bromide for moderate to severe exacerbations

Environmental Management:

Trigger Avoidance: Education about wildfire smoke avoidance strategies and air quality monitoring
Home Environment: Review indoor air quality maintenance during wildfire events
Activity Modifications: Guidance on outdoor activities during poor air quality days

Discharge Planning:

Controller Medication: Prescribe inhaled corticosteroid for daily use
Rescue Medication: Ensure adequate albuterol supply and proper inhaler technique
Action Plan: Provide written asthma action plan with clear instructions for exacerbation management
Environmental Monitoring: Education on using AirNow.gov and local air quality alerts

Follow-up:

Primary Care: Within 1-2 weeks for asthma control assessment
Pulmonology: Consider referral if frequent exacerbations or poor control
Return Precautions: Clear instructions for return to ED if symptoms worsen

Complete Step-by-Step Guide to Writing the Aaron Preston iHuman Case Study

Completing the Aaron Preston iHuman case requires a systematic approach that mirrors real pediatric emergency assessment. This comprehensive guide will walk you through each section of the simulation, providing specific strategies and key points to ensure you achieve the required 70% score.

Step 1: Pre-Case Preparation and Initial Approach

Before diving into the case, review the doorway information and formulate your initial clinical approach.

Key Information to Note:

7-year-old male with known asthma and acute respiratory distress
Environmental trigger: wildfire smoke exposure
Poor response to home nebulizer treatment

Initial Clinical Mindset: Approach this case with acute asthma exacerbation as the primary consideration while maintaining awareness of severity assessment and potential complications. The wildfire smoke exposure provides important context for understanding environmental triggers in pediatric asthma.

Step 2: Conducting the History of Present Illness (HPI)

The HPI is crucial for establishing severity and triggers for the asthma exacerbation:

Onset and Timing:

Key findings: Symptoms began after school during outdoor play
Duration: How long symptoms have been present
Trigger: Direct exposure to wildfire smoke

Character and Quality:

Type of breathing difficulty (wheezing, shortness of breath, cough)
Severity indicated by poor response to home treatment

Associated Symptoms:

Cough, wheezing, chest tightness
Activity tolerance and speech ability
Sleep disturbance

Previous Episodes and Treatment:

Frequency of asthma exacerbations
Current medications: Albuterol and nebulizer treatments PRN
Previous hospitalizations

Step 3: Environmental and Social History

Environmental Triggers:

Wildfire smoke exposure during outdoor play
Home environment: pet-free and smoke-free
Seasonal patterns and other known triggers

Activity Assessment:

Normal activities: scouts and swimming
Exercise tolerance and limitations
School attendance and performance

Step 4: Physical Examination Strategy

Perform a focused exam that evaluates respiratory status and severity:

Vital Signs:

Expected findings: tachycardia (HR 108), tachypnea (RR 32), hypoxemia (SpO2 94%)

General Appearance:

Key findings: pale appearance, circumoral cyanosis
Use of accessory muscles, positioning, speech pattern

Respiratory Examination:

Inspection: retractions, nasal flaring, chest wall movement
Palpation: chest expansion, tactile fremitus
Auscultation: air entry, wheezing, prolonged expiration

Step 5: Severity Assessment

Use Standardized Scoring:

Apply PRAM (Pediatric Respiratory Assessment Measure) or Clinical Assessment Score
Consider factors: oxygen saturation, air entry, wheezing, work of breathing, alertness

Classification:

Mild: SpO2 >95%, minimal work of breathing, speaks in sentences
Moderate: SpO2 90-95%, moderate work of breathing, speaks in phrases
Severe: SpO2 <90%, significant work of breathing, difficulty speaking

Step 6: Developing Differential Diagnoses

Primary Consideration: Acute Asthma Exacerbation triggered by wildfire smoke

Supporting evidence: Known asthma history, environmental trigger, physical findings
Literature support: Wildfire smoke demonstrates 13% increase in asthma exacerbations

Secondary Considerations:

Viral-induced asthma exacerbation
Pneumonia with underlying asthma
Foreign body aspiration (less likely given history)

Step 7: Management and Treatment Plan

Immediate Treatment:

Bronchodilator therapy: Albuterol via MDI with spacer
Systemic corticosteroids: Dexamethasone 0.3-0.6 mg/kg PO
Oxygen support if SpO2 <92%

Monitoring and Reassessment:

Serial severity scores every 15-20 minutes
Response to bronchodilator therapy
Consideration for additional treatments

Step 8: Environmental Education and Prevention

Wildfire Smoke Management:

Air quality monitoring using AirNow.gov
Indoor air quality maintenance strategies
Activity modifications during poor air quality

Long-term Asthma Control:

Inhaled corticosteroid therapy
Written asthma action plan
Regular follow-up care

Step 9: Disposition and Discharge Planning

Discharge Criteria:

SpO2 >92% on room air, minimal work of breathing, good response to bronchodilators
Adequate home support and understanding

Discharge Medications:

Inhaled corticosteroid for controller therapy
Albuterol rescue inhaler with spacer
Consider short course of oral steroids if needed

Step 10: Documentation and Submission Tips

Key Documentation Elements:

Clear description of environmental trigger
Objective severity assessment
Response to treatment
Discharge planning and education

Final Submission Checklist:

✓ Complete environmental history including wildfire exposure
✓ Appropriate physical exam with severity assessment
✓ Correct primary diagnosis of asthma exacerbation
✓ Evidence-based treatment plan
✓ Environmental education and prevention strategies
✓ Appropriate disposition and follow-up planning

Aaron Preston iHuman Case Summary

Grading Criteria:

The Aaron Preston iHuman case evaluates your ability to diagnose and manage pediatric asthma exacerbations with environmental triggers. Here’s what you need to focus on to maximize your score:

(1) History Taking (Major Points): You must ask targeted questions about asthma symptoms and environmental triggers. Essential questions include: onset of breathing difficulty, environmental exposures (especially wildfire smoke), previous asthma episodes, current medications, response to home treatments, and family history. Don’t miss asking about: specific environmental triggers, home environment (pet-free, smoke-free), activity level, and previous hospitalizations.

(2) Physical Examination (High Weight): Focus your exam on respiratory assessment and severity scoring. Must-do components: vital signs (noting tachypnea, tachycardia, hypoxemia), respiratory examination including inspection for retractions and cyanosis, auscultation for wheezing and air entry. Pro tip: The rubric awards points for using standardized severity assessment tools like PRAM.

(3) Environmental Assessment (Critical for Scoring): You must identify wildfire smoke as the environmental trigger and discuss its impact on asthma exacerbations. Scoring secret: The rubric rewards students who can clearly connect environmental exposures to asthma symptoms and provide appropriate education.

(4) Final Diagnosis & MSAP: You must correctly identify acute asthma exacerbation triggered by wildfire smoke as your primary diagnosis. Justification should cite: environmental trigger, known asthma history, physical findings, and poor response to home treatment.

(5) Management Plan (Heavily Weighted): The rubric expects evidence-based treatment including bronchodilator therapy, systemic corticosteroids, and appropriate monitoring. High-scoring responses mention: inhaled corticosteroid prescription for ongoing control, environmental trigger avoidance education, and appropriate follow-up planning.

(6) Environmental Education: Demonstrate understanding of wildfire smoke impacts and provide practical strategies for air quality monitoring and exposure reduction. Bonus points for: discussing air quality resources, indoor air management, and activity modifications during poor air quality days.

Example of a High-Scoring Clinical Summary

Patient Summary – Aaron Preston

Situation: 7-year-old male with known asthma presenting with acute respiratory distress following wildfire smoke exposure during outdoor play.

Background: Patient has established asthma diagnosis with current medications including albuterol and PRN nebulizer treatments. Lives in appropriate home environment (pet-free, smoke-free) and maintains active lifestyle with scouts and swimming. Current episode triggered by wildfire smoke exposure, which research demonstrates increases pediatric asthma exacerbations by 13%.

Assessment: Physical examination notable for pale appearance with circumoral cyanosis, tachypnea (RR 32), tachycardia (HR 108), and hypoxemia (SpO2 94%). Poor response to home nebulizer treatment indicates moderate severity exacerbation.

Primary Diagnosis: Acute Asthma Exacerbation secondary to wildfire smoke exposure

Recommendation:

Immediate bronchodilator therapy with albuterol via MDI and spacer
Systemic corticosteroids with single-dose dexamethasone 0.3-0.6 mg/kg PO
Continuous monitoring with standardized severity scoring
Inhaled corticosteroid prescription for ongoing controller therapy
Environmental education regarding wildfire smoke monitoring and avoidance strategies
Appropriate follow-up with primary care within 1-2 weeks

Patient Education Provided: Explained wildfire smoke as environmental trigger, provided resources for air quality monitoring (AirNow.gov), discussed indoor air quality maintenance during wildfire events, provided written asthma action plan with clear instructions for future exacerbations, and emphasized importance of controller medication adherence for prevention.

Conclusion

By following this comprehensive approach to the Aaron Preston case, you’ll demonstrate the clinical reasoning skills that iHuman evaluates for pediatric respiratory emergencies. Success in pediatric asthma cases requires systematic thinking: gather detailed environmental and symptom history, perform focused respiratory examination with severity assessment, consider appropriate differentials, and develop evidence-based treatment plans. The key unique aspect of this case is recognizing wildfire smoke as an important environmental trigger and providing appropriate education for future prevention. With this guide, you’re well-prepared to excel in this challenging but essential pediatric case simulation.

Frequently Asked Questions

Q1: What is the correct diagnosis for Aaron Preston’s breathing difficulty?

Aaron Preston’s primary diagnosis is acute asthma exacerbation triggered by wildfire smoke exposure. The key distinguishing features include known asthma history, acute onset following environmental exposure, poor response to home nebulizer treatment, and physical findings consistent with respiratory compromise including circumoral cyanosis and decreased oxygen saturation. Research supports wildfire smoke as a significant trigger for pediatric asthma exacerbations, with studies showing a 13% increase in emergency department visits during wildfire smoke exposure days.

Q2: What are the critical history questions I need to ask to score well?

Essential history elements include asking about the onset and timing of breathing difficulty, specific environmental exposures (especially wildfire smoke), previous asthma episodes and their frequency, current medications and their effectiveness, response to home treatments, and family history of asthma or allergies, home environment factors, activity level and limitations. Many students miss points by not exploring the environmental component thoroughly or failing to ask about the patient’s usual asthma control and previous hospitalizations.

Q3: How do I assess the severity of Aaron’s asthma exacerbation?

Use standardized assessment tools like PRAM (Pediatric Respiratory Assessment Measure) or Clinical Assessment Score that consider oxygen saturation, air entry, wheezing, work of breathing, and alertness. Key indicators of severity include: SpO2 94% (indicating moderate hypoxemia), tachypnea (RR 32), tachycardia (HR 108), pale appearance with circumoral cyanosis, and poor response to home nebulizer treatment. This presentation suggests moderate severity requiring immediate bronchodilator and anti-inflammatory therapy.

Q4: What management interventions should I include for this asthma exacerbation?

Comprehensive management should include: immediate bronchodilator therapy with albuterol via MDI and spacer, systemic corticosteroids (dexamethasone 0.3-0.6 mg/kg PO or prednisolone), continuous monitoring with objective severity assessments, supplemental oxygen if needed to maintain SpO2 >92%, discharge planning with inhaled corticosteroid prescription for controller therapy, environmental education about wildfire smoke monitoring and avoidance strategies using resources like AirNow.gov, and written asthma action plan with clear instructions for future exacerbations. Students often forget the importance of environmental education and long-term prevention strategies, which are crucial components for comprehensive pediatric asthma care.