case study: Resp

Question 1

A 9 month old girl presents with 48h of increasing wheeze and respiratory effort and a 4d history of mild runny nose and cough.
Examination shows bilateral wheeze and crackles. She has sub-costal recession, a pink throat and red ears. Resp rate 60, Sats 93% and temp 37.9o

1. diagnosis?
2. Investigations?
3. Management?

Answer 1

1. Bronchiolitis
2. Nasopharyngeal aspirate
3. No proven role for any medications
   Oxygen not yet indicated (cut-off <90-92%)
   Symptoms will peak on day 4-5
   Feeding probably best marker of severity/recovery
   Cough will persist for 1-2 weeks

Question 2

What is the most common LRTI of infants?

Answer 2

Bronchiolitis (RSV)

Question 3

Bronchiolitis sx?

Answer 3

Nasal stuffiness
tachypnoea
poor feeding

Question 4

An 18m boy presents with a 4 hour history of barking cough and noisy breathing having been well the day before
Examination shows a runny nose, loud stridor, tracheal tug sub-costal recession, well perfused peripheries and temp of 37.8o

What are the diff dx?

management?

Answer 4

1. Likely viral laryngotracheitis (croup)
2. Consider foreign body
3. Bacterial tracheitis, epiglottitis, diphtheria (all rare)

Don’t examine the throat!!
Keep calm avoid distress and anxiety (no needles)
Oral steroid (dexamethasone or ?prednisalone)
Nebulised adrenaline if severe

Question 5

Croup (LTB)

bacteria/ virus responsible?
sx?
mx?

common or rare?

Answer 5

Para’flu I

Well, Coryza++, stridor, hoarse voice, “barking” cough

Oral steroids

common

Question 6

Epiglottitis?

bacteria/ virus responsible?
sx?
mx?

common or rare?

Answer 6

H. influenzae Type B

Toxic
Stridor, drooling

Intubation and antibiotics

Rare

Question 7

Tracheitis

bacteria/ virus responsible?
sx?
mx?

common or rare?

Answer 7

Staph Aureus

Pale
Stridor, barking cough, fever, recurs despite steroids

Steroids (?IV) Fluclox +/- Cefotax (IV/Oral)

Uncommon

Question 8

A 14 month old girl presents with 12h of increasing wheeze and respiratory effort and a 3d history of runny nose and cough.
Examination shows bilateral wheeze, no creps and sub-costal recession, a pink throat and red ears. Resp rate of 60 and temperature 37.5o

1. Diagnosis and differential?
2. Other history features to help you decide?
3. Management?

Answer 8

1. Viral induced wheeze (secondary to URTI)
   ?Bronchiolitis

2.
Rapidly worse (“they were okay yesterday”)
Previous wheeze or atopy (allergies/ eczema)
FMH atopy (allergies/ eczema/ hayfever/ asthma)

3.
Salbutamol MDI via spacer (up to 10 puffs)
Consider oral prednisalone + nebuliser if severe

Question 9

How does a viral wheeze usually present

Answer 9

May follow or overlap with URTI/ LRTI

Usually viral trigger, quicker deterioration
More common in atopic families
Typically pre school
Majority of wheeze in under 5s
Simplistically
Under 18 months, most likely infection
Over 5 years, most likely asthma
Earlier the presentation the more likely to resolve

Question 10

A 3y old girl presents with a 4 day history of increasing lethargy, cough, fever and tummy pain. She has vomited x4 in the last 2 days.
Examination showed temp 39.8o, resp rate 40, nasal flaring, intercostal recession, no focal chest findings, RUQ discomfort, soft abdomen.

1. Diagnosis and differential?
2. Investigation
3. management?

Answer 10

1, LRTI/ Right lower lobe pneumonia
?UTI
?Appendicitis

2. Check saturations (Consider admission ?Threshold)
   Consider CXR to confirm clinical signs/ bloods (but won’t confirm aetiology)
   Check urine dipstix/ culture
3. Oral amoxicillin/ IV if vomiting

Question 11

Pneumonia presentation?

Answer 11

Fever (>38.5oC), SOB, cough, grunting
Wheeze makes bacterial cause less likely
Reduced or bronchial breath sounds or minimal

Question 12

pneumonia management?

Answer 12

Amoxicillin first line
Macrolide 2nd line
Broad spectrum IV for neonates/ septic patients

Question 13

pneumonia infective agents?

Answer 13

Viruses in <35% (higher in younger)

Bacteria Pneumococcus, Mycoplasma, Chlamydia