The School - Aged Child
Case 4.3 Cough and Diffi culty Breathing
102 The School-Aged Child
HEENT : History of watery eyes, sneezing, and clear rhinorrhea, especially in the spring. Her mother also complains that “ when she gets a cold, it lasts longer than normal. ”
Skin : She does not have any rashes or skin lesions.
OBJECTIVE
General: Emily is alert, well hydrated, active, and cooperative.
Vital s igns: Temperature 38 ° , pulse 72, and respirations 28 per minute with a blood pressure of 100/52 in the left arm. The O2 saturation is 94%, and weight is 25 kg.
Skin: No lesions, rashes, or scars; and the patient is not cyanotic.
HEENT : Normocephalic with no evidence of trauma or lesions. Eyes show no signs of drainage;
sclera white, with pink conjunctiva. Otoscopic examination reveals tympanic membranes gray bilater- ally with positive light refl ex and normal pinnae. The nose has clear rhinorrhea; no nasal polyps with pink turbinates. Examination of the throat shows a cobblestone appearance in the posterior pharynx, uvula midline, tonsils size 0/4 with no exudate or erythema, moist mucous membranes; and the trachea is midline.
Respiratory: Bilateral inspiratory and expiratory wheezing; mild intercostal retractions; mild short- ness of breath; no rales, crackles or nasal fl aring.
Cardiovascular: No murmur; normal S1/S2; 2 + brachial and femoral pulses; no cyanosis, clubbing, or edema noted.
Lymphatic: There is no lymphadenopathy on examination.
Abdomen: Soft, nontender abdomen; nondistended; + bowel sounds; no hepatosplenomegaly during palpation.
Genitourinary: Normal female genitalia.
Neurological: Grossly intact.
CRITICAL THINKING
What diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Oxygen saturation ___Chest X - ray
___Nasal pharyngeal culture
What is the most likely differential diagnosis and why?
___Foreign body aspiration ___Bronchiolitis
___Asthma ___GERD
What is the plan of treatment?
What is the plan for follow - up care?
Are any referrals needed at this time?
Are there any standardized guidelines that you should use to assess or treat this case?
Cough and Diffi culty Breathing 103
RESOLUTION
Diagnostic t ests: The nasal pharyngeal culture was positive for respiratory syncytial virus (RSV).
Oxygen saturation is 94%, which is an indication of poor exchange of oxygenation. Chest x - ray was negative for pneumonia; and there is no peribronchial cuffi ng, which is more often seen in bronchi- olitis. There was no mediastinal shift or collapsed lung seen with foreign body aspiration.
What is the most likely differential diagnosis and why?
Asthma:
Asthma is the most prevalent chronic illness facing American children today. The diagnosis of asthma is based on the exclusion of alternative diagnoses, as well as the history of recurrent and transient obstructive symptoms, the patient ’ s subjective experience of symptoms, and objective clinical mani- festations. These criteria will vary among patients and in the same patient over time. The important signs and symptoms needed to diagnose asthma include (1) recurrent wheeze, (2) improvement of symptoms after treatment with a bronchodilator, (3) recurrent cough or shortness of breath (4) impaired peak fl ow performance when compared to the expected value based on height and age, and (5) exclusion of alternative differential diagnoses.
A differential diagnosis still requires consideration in any patient who is wheezing, including one with a known diagnosis of asthma and a history of exacerbations. Several conditions may lead to a presentation similar to acute asthma. Some of these include congestive heart failure, vocal cord dys- function, gastroesophageal refl ux, acute bronchitis or bronchiolitis, pulmonary emboli, or the pres- ence of a foreign body.
After the diagnosis of asthma has been made, the severity of the patient ’ s asthma can be classifi ed, based in part on the frequency of symptoms, fi ndings on physical exam, and severity of exacerba- tions. Severity ranges from intermittent to severe persistent, depending on the frequency of asthma symptoms, nighttime symptoms, and impairment of lung function. Accurate classifi cation of asthma severity is critical because treatment goals and pharmacological management are based on the indi- vidual ’ s asthma classifi cation. Because individuals may manifest different symptoms over time, periodic reevaluation, repeat classifi cation of severity, and adjustment of the patient ’ s care plan are necessary.
Information gathered during the initial asthma assessment will serve as baseline data, by deter- mining the patient ’ s respiratory status and the severity of the current exacerbation. After an inter- vention is implemented, repeat assessments are recommended. These serial assessments can be compared against the baseline data so that trends in the patient ’ s response to treatment can be revealed.
Next, the health care provider can assess the severity of the current exacerbation through auscultation of the lung fi elds, noting the movement of air and presence of abnormal breath sounds. Medicinal treatment should be started as soon as the diagnosis of asthma exacerbation is confi rmed.
What is the plan for follow - up care?
Patients should not leave the health care setting without receiving educational information, a written care plan, a follow - up appointment to take place within 3 days of the exacerbation, and a clear under- standing of how to contact the provider should their condition deteriorate. It is recommended that children who have experienced an exacerbation should follow up with their health care provider 2 – 3 days after the acute episode to (1) monitor the response to treatment, (2) encourage continued patient compliance with their medication regimen, (3) prevent a relapse in symptoms, and (4) provide an educational review of information discussed during previous visits.
Are any referrals needed at this time?
No. The provider should consider a referral to a pulmonologist, allergist, or EENT if symptoms cannot be managed using standard approaches or if the provider thinks that there may be additional factors that complicate the case.
104 The School-Aged Child
Are there any standardized guidelines that you should use to assess or treat this case?
The following approach to acute asthma treatment is based on the fi ndings of the National Heart, Lung, and Blood Institute Expert Report Panel (2007). This information is meant to serve as a guide to exacerbation treatment. Strict adherence to general guidelines should never supersede individual response to therapy, which is monitored through patient report of symptoms, continuous skilled assessment, and accurate data collection. Adjustments may need to be made initially and ongoing during treatment depending on the patient ’ s prior exacerbation history, present respiratory abilities, and response to treatment. The lowest and simplest dosing regimen that effectively controls the individual ’ s acute asthma should be selected to encourage patient compliance.
An asthma exacerbation should be treated with an early intensifi cation of an inhaled beta 2 - agonist and the administration of oxygen and an oral or systemic steroid when medically necessary. The inhaled beta 2 - agonists, known as quick - relief or rescue medications, should be given to all patients regardless of the severity of their exacerbation. Exacerbation therapy should begin with up to 3 treat- ments of a short - acting beta 2 - agonist, given at 20 - minute intervals over an hour. The minimum dose should be 2.5 mg, or 0.15 mg/kg of body weight. The alternative is to give 2 – 6 puffs of albuterol, 90 mcg/puff by metered dose inhaler (MDI) with a spacer attachment. However, if no improvement is demonstrated after the initial treatment, the exacerbation severity can be classifi ed as moderate or severe; and a steroid should be given in conjunction with the bronchodilator. The recommended child dose for an oral steroid such as prednisolone is a loading dose of 2 mg/kg of body weight, followed by 2 mg/kg of body weight divided twice a day (maximum dose of 60 mg/day). Additionally, an inhaled beta 2 - agonist should be given every 4 hours as needed for wheezing.
After the treatment goals have been met, the patient can continue therapy and monitoring inde- pendently at home with a short - term intensifi cation of their treatment. For most patients, this means an increase in the frequency of beta 2 - agonist use and the addition of a systemic steroid.
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