Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a junior doctor working in the emergency department, your next patient is a 3-month-old infant, Allie Andrews, brought in by her parent because of her breathing.
Please take the child's history from her parent, and perform a relevant examination.
Parent History:
You are Steven / Serena Andrews the parent of Allie Andrews (3-month-old). You have brought her to the emergency department as you are concerned about her breathing.
You've brought her in because she's just been coughing & making noises when breathing and it's gotten worse over the past 3 days. She's been breathing very fast and I could see she was struggling to breathe. She's not bringing anything up coughing. She's got a runny nose. It's not worse at a particular time of day. Measured a temperature of 38.2 °C. No blue or apnoeic episodes.
Ideas, Concerns, Expectations:
You are not sure what it is, she's sick for the first, time. It could be due to the change in the weather lately. You are concerned because the high fever is not settling.
Past Medical History:
None
Drug History:
Tried paracetamol to reduce fever.
NKDA
Family History:
None
Birth History:
Born at 34 weeks C-section due to growth plateau but normal growth since
Breathed a little fast the first day but the doctors just said it was fine (Tachypnoea of the Newborn due to C-section delivery)
Immunisation:
Up to date with vaccinations
Nutrition:
Bottle-fed every 3-4 hours - but today off his feeding, only had < half usual amount
Urinates & passes stool a little less than usual but still going
Development:
Normal growth
Reaching developmental milestones
Social History:
Household - Mum & Dad & older brother (4-year-old)
No smokers In residence
No pets
No Social Services Involvement
Examination Findings:
Appearance - Alert, Looks unwell
Breathing - Moderate intercostal, subcostal & sternal recessions & tracheal tug. good respiratory effort.
Auscultation Generalised Wheezing over the chest with associated crackles bilaterally. Good air entry.
Interpretation of Examination Findings
Differentials:
Bronchiolitis - Bronchiolitis is the most likely cause in a wheezy child in this age group in comparison to Viral-induced wheeze.
Bacterial Pneumonia - As there are chest symptoms & crackles, pneumonia is possible but would be more likely if it was localised to one area rather than globally.
Viral-Induced Wheeze - Likely older (E.g. 12 months old) and usually doesn't present with crackles.
Asthma - This may occur at any age but there is no family history or personal history of asthma and wouldn't normally have crackles on auscultation.
Foreign body aspiration - Would have been sudden, without infective symptoms & may be localised.
Croup - Usually has a characteristic barking-like cough and doesn't present with wheezing, but may present with stridor.
Investigations:
Bedside:
Observations - Monitor oxygen saturation, Respiratory rate, hydration status, heart rate
Clinical Diagnosis - This is all that is needed in typical cases.
Virology - may be used for atypical presentation and deciding whether to decide if the presentation is bacterial or viral and whether to stop anti-microbial management.
Bloods: Not needed unless atypical or severe presentation (such as this case):
If Severely unwell - ABG/VBG/CBG may be useful to assess respiratory function.
Blood Cultures - Only if atypical presentation indicates pneumonia
Full Blood Count and Routine Bloods - if Atypical presentation indicates pneumonia look for a bacterial picture (not this test is not always reliable in this age group to assess this).
Imaging:
Chest X-Ray - Only if severe, atypical and if intensive care is proposed.
Data Interpretation:
Interpretation of Chart
Management: