ACS Aquifer Case Study – Developmental Evaluation and Screening Pediatrics 13: 6-year-old female with chronic cough

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Pediatrics 13: 6-year-old female with chronic cough

Author(s): Leslie Fall, MD; Editor: Jonathan Gold, MD

Complete the following case studies in Aquifer and upload the student summary for each. Upload the CAT worksheet and diagnosis essay for each case.  

CHART REVIEW

HISTORY

You are working with Dr. Nancy Law in a community clinic. Today she is scheduled to see a new patient, Sunita Patel, with a report of a cough for eight weeks.

Dr. Law asks you to do a focused history and physical exam and develop a working differential before presenting Sunita’s story to her.

You begin by picking up Sunita’s chart and reviewing the nurse’s intake information:

Patient: Patel, Sunita

Patient new to practice. Recently moved to area. Old records are being faxed from prior PCP.

Age: 6 years

Chief concern: Coughing for eight weeks. No improvement and maybe worsening. Mom concerned.

Vital signs:

    • 

Temperature is 37.6 C (99.68 F)

    • Pulse is 92 beats/minute

    • Respiratory rate is 18 breaths/minute

    • Oxygen saturation is 99%

    • Weight is 22 kg (50th percentile)

    • Height is 118 cm (50-75th percentile)

Medications: None

Allergies: No medication, food, or environmental allergies

Question

After reviewing the chart, what are some of the important details that you already know about Sunita?

The suggested answer is shown below.

 

Letter Count: 119/1000

Answer Comment

Chronic cough

    • Sunita’s report of cough for eight weeks meets the definition of chronic cough (daily cough lasting > 4 weeks).

Sunita’s age

    • The causes of chronic cough in a school-aged child are different from those in infants and toddlers.

    • While many of the causes are similar, infants are more likely to have anatomic malformations (e.g., congenital vocal cord abnormalities, laryngotracheomalacia, vascular ring, laryngeal web, tracheal stenosis, or tracheoesophageal fistula) causing their cough.

    • In toddlers, a foreign body aspiration must also be considered.

New to the practice and presently on no medications

    • Because you do not have old records, you are not yet sure if Sunita’s prolonged history of cough is a new or a recurrent problem; however, the fact that she is presently on no medications suggests that this may be a new problem.

    • You notice that the family has recently moved to the area. Could this be related to her cough?

Appropriate growth parameters

    • Recognizing that you only have today’s measurements, you note that Sunita appears to be growing well.

Normal vital signs

    • Sunita’s current lack of fever, normal respiratory rate (normal range: 12–20 breaths per minute), and normal pulse oximetry reassure you that she is not in need of immediate medical intervention.

    • They also contribute to your diagnostic thinking.

TEACHING POINT

Acute versus Chronic Cough

Acute

Chronic

Duration

< 4 weeks

> 4 weeks

Etiologies

  • Acute symptoms are most commonly due to an infectious cause (viral upper respiratory infection or viral or bacterial pneumonia) or a clear precipitating event (e.g., trauma or choking).

  • Children can have 5 to 8 upper respiratory infections a year, and the cough can last on average for up to 3 weeks with 10% lasting up to 25 days.

  • Causes are many and can include infection, inflammation, and irritation, anatomic or psychogenic. Rarely the cough may be due to cardiac or gastrointestinal conditions.

  • A viral upper respiratory infection can induce airway reactivity in a healthy host for weeks; cough may persist long after other symptoms have subsided.

  • An aspirated foreign body lodged in the airway can cause recurrent and chronic cough.

References

Chang AB, Oppenheimer JJ, Irwin RS; CHEST Expert Cough Panel. Managing Chronic Cough as a Symptom in Children and Management Algorithms: CHEST Guideline and Expert Panel Report. Chest. 2020;158(1):303-329. doi:10.1016/j.chest.2020.01.042.

Traisman ES. Clinical Evaluation of Chronic Cough in Children. Pediatr Ann. 2015;44(8):303-307. doi:10.3928/00904481-20150812-03.

PRESENTING CONCERN

HISTORY
You introduce yourself to Mrs. Patel and Sunita.
TEACHING POINT

Assessment of Respiratory Distress

For patients presenting with respiratory concerns, it is important to perform an early assessment of the child’s level of respiratory distress.

    • Is the patient speaking in full sentences?

    • Does she appear short of breath when she talks?

If yes, you would need to manage her symptoms first and obtain a more detailed history later.

When you enter the room and introduce yourself to Sunita and her mother, Sunita looks up from her drawing and gives you a bright smile. You notice that Sunita appears to be a well-nourished girl who is sitting comfortably next to her mother, in no apparent distress.

You introduce yourself to Mrs. Patel and Sunita, sit down next to the little girl, and say, “Hello, Sunita!” What a terrific drawing!” She smiles and tells you it is a picture of her dog.

You then say, “I hear you have had a cough lately.”

You note that Sunita is speaking in full sentences without shortness of breath.

You turn to her mother and ask,

You ask,

Sunita tells you that running around makes her cough worse.

You ask,

TEACHING POINT

Differential of Pediatric Cough

Descriptor

Possible Etiology

Dry

  • Environmental irritant

  • Asthma

Wet/productive

  • Lower-respiratory infection

Barking

  • Croup

  • Subglottic disease

  • Foreign body

Brassy or honking

  • Habit cough

  • Tracheitis

Paroxysmal

  • Pertussis

  • Chlamydia

  • Mycoplasma

  • Foreign body

Worse at night

  • Asthma

  • Sinusitis

  • Allergic or vasomotor rhinitis (postnasal drip)

Disappears at night

  • Habit cough

Associated with gagging or choking

  • Gastroesophageal reflux disease

HISTORY

HISTORY
You learn more details about Sunita’s history.

Question

Based on what you know about Sunita, what other elements in the history would you like to specifically ask about?

Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

  • A. History of eczema

  • B. Nasal congestion

  • C. Palpitations

  • D. Presence of fever

  • E. Recent weight gain

  • F. Vomiting

Answer Comment

The correct answers are A,B, C, D, F.

The presence of fever might indicate an infectious etiology such as pneumonia or tuberculosis (D). Atopic symptoms such as nasal congestion (B), sneezing, itchy eyes and eczema (A) would point you possibly towards asthma as a cause of Sunita’s cough. As mentioned earlier, less common causes of chronic cough are cardiac and gastrointestinal conditions such as GERD. The presence of palpitations (C) or vomiting (F) might indicate the presence of these less common causes. With a more serious chronic medical condition, Sunita might have experienced weight loss; this would be a concerning sign and one that is important to explore. One would not expect weight gain (E) to be causally associated with chronic cough.

You continue your history by asking a focused review of systems and learn the following:

Constitutional: No fevers associated with the cough. No weight loss. Good appetite.

Skin: Patient has mild eczema. No new rashes associated with this cough.

Head: No headaches. More nasal congestion since moving here. Had some sneezing during the early autumn.

Throat: No sore throat. No change in Sunita’s voice. No history of choking.

Respiratory: Cough is sometimes triggered by laughing or crying. No shortness of breath. No wheezing. No chest pain.

Cardiac: No palpitations.

Gastrointestinal: No stomach aches. No vomiting or diarrhea.

TEACHING POINT

Clarifying Terminology

Wheezing

    • Most clinicians use “wheeze” to mean a high-pitched whistling sound associated with airway narrowing.

    • “Wheezing” can mean many different things to parents, including wheezing, stridor, or anything that causes noisy breathing—including simple congestion.

    • It is important to clearly define what a patient or parent means by the term “wheezing” when they use it.

Shortness of Breath

    • “Difficulty breathing,” “difficulty keeping up with playmates,” or “chest tightness” are examples of how children and/or parents may describe what clinicians term “shortness of breath.”

    • A sensation of shortness of breath would likely suggest an inflammatory cause of a cough, the most common condition being asthma. Less likely causes include congestive heart failure (e.g., cardiomyopathy).

TEACHING POINT

Review of Systems Clues for a School-age Child with Cough

In a focused review of systems in a school-age child with cough, look for:

Finding

Possible indication

Change in voice

  • Dysphonia or hoarseness may suggest laryngeal irritation due to chronic rhinitis or gastroesophageal reflux.

Chest pain

  • Probe for evidence of gastrointestinal causes of cough, not cardiac conditions; true cardiac chest pain is rare in children.

  • Alternatively, you could also ask the patient if she “ever gets a bad taste in her mouth” or “if food ever comes back up.”

  • While rare, congestive heart failure, most commonly due to infectious myocarditis, can present in school-age children with cough and wheezing and can easily be mistaken for a more common pulmonary condition, such as asthma or bronchitis.

Choking event

  • Although a foreign body aspiration is more likely in a toddler, otherwise healthy school-age children and adults are still at a small risk for aspiration pneumonia secondary to inadvertently choking on food.

  • Children with neurological impairment are at a significantly higher risk for aspiration, either from secretions (“above”) or from refluxed gastric contents (“below”).

Fever

  • Suggests an infectious etiology for cough, primarily pneumonia or upper respiratory infection.

  • Lobar pneumonia, particularly in the lower lobes, may also present with abdominal pain.

  • The presentation of bacterial pneumonia is usually acute, rather than chronic.

Headaches

  • Frontal or orbital headaches may suggest sinusitis, a common cause of persistent cough in children due to the associated post-nasal drip, which is often worse at night when the child is supine.

Sore throat

  • May suggest evidence of post-nasal drip and pharyngeal irritation due to allergies or sinusitis. (May be present in conjunction with nasal congestion, and/or a history of itchy, watery eyes.)

PAST MEDICAL, FAMILY, AND SOCIAL HISTORY

HISTORY
Mrs. Patel tells you about Sunita’s medical history.

Past medical history:

    • Born in India and moved to the U.S. when she was one year old.

    • Born full term without complications.

    • Past history significant for mild eczema and two episodes of otitis media as a toddler.

    • No history of hospitalizations, pneumonia, or wheezing.

    • Normal growth and development. Immunizations up-to-date.

    • No medication allergies.

Family History:

    • Asthma (mother and cousins).

    • No other chronic pulmonary conditions or infections.

    • No one with recurrent infections.

Social History:

    • In first grade and enjoys school.

    • Family moved to the area about three months ago. They live in a single-family home.

    • There are no smokers in the house. They have one dog. There are carpets in the bedrooms.

    • Sunita lives with her parents, 9-year-old brother, paternal grandmother.

    • Grandmother is from India and moved to the United States three months ago when they moved into the new house.

Mrs. Patel notes that there is a lot of tuberculosis in the area of India where the grandmother lived, but the grandmother recently had a negative tuberculin skin test (TST) and has not had a cough. Tuberculosis is an unlikely cause of Sunita’s cough, but placing a TST or ordering an Interferon Gamma Release Assay (IGRA) would be reasonable to consider.

TEACHING POINT

Pulmonary Tuberculosis in Children

Transmission

In the U.S., most children are infected by Mycobacterium tuberculosis in the home by someone close to them, but outbreaks in daycare centers and schools do occur.

    • The case rates for all ages are highest in urban, low-income areas and in foreign-born children, among whom more than two-thirds of reported cases in the U.S. now occur.

    • A diagnosis of tuberculosis in a young child is a public health sentinel event usually representing recent transmission.

Signs and Symptoms

The signs and symptoms of primary pulmonary tuberculosis (due to M. tuberculosis) in most children are few to none, often in sharp contrast to their degree of radiographic changes.

    • More than 50% of infants and children with radiographically evident disease have no physical findings and are discovered only by contact tracing. Hilar adenopathy is the most common radiographic abnormality.

    • Infants and toddlers are more likely to experience symptoms such as nonproductive cough, mild dyspnea, or wheezing due to bronchial compression by enlarged regional lymph nodes.

    • Infants may present with failure to thrive.

    • Severe cough and sputum production, together with systemic concerns (such as fever, night sweats, and anorexia) usually signify extrapulmonary dissemination.

Lung Findings

    • All lobar segments of the lung are at equal risk of initial infection.

    • Two or more primary foci are present in 25% of cases.

    • The hallmark of tuberculosis in the lung is a primary complex (relatively large size of the hilar lymphadenopathy compared with the relatively small size of the initial lung focus).

    • The common sequence is hilar adenopathy, focal hyperinflation, and then atelectasis, with minimal evidence of the primary lung focus itself.

    • Small local pleural effusions are common.

    • The chest x-ray findings may be confused with foreign body obstruction.

    • Small local pleural effusions are common; large effusions are rarely seen in children under 6 years.

Diagnosis

The Mantoux skin test (formerly called a “PPD” but now more correctly referred to as a “TST,” which stands for “tuberculin skin test”) is a practical tool for diagnosing TB infections in asymptomatic children. Blood based testing with Interferon-Gamma Release Assays (IGRAs) such as QuantiFERON-TB Gold may be considered in children 5 years and older. In children who have received the BCG (Bacille Calmette-Guerin) vaccine, the IGRA test is preferred because there is a lower risk of a false positive test due to the vaccine.

    • A TST test is considered positive if it is: > 5 mm in high-risk children, > 10 mm in moderate-risk children, and > 15 mm in low-risk children. See the following link for more detail on categories of risk: https://www.cdc.gov/tb/publications/factsheets/testing/skintestresults.htm.

    • In symptomatic children, a culture of the M. tuberculosis organism should be obtained from a sputum sample, or from a first morning gastric aspirate in young children.

SUMMARY STATEMENT

CLINICAL REASONING

As you complete your history and prepare to do a physical exam, you review the information from Sunita’s history and your initial impression.

Question

Based on what you know about the patient so far, write a one- to three-sentence summary statement to communicate your understanding of the patient to other providers.

Your response is recorded in your student case report.

 

Letter Count: 290/1000

Answer Comment

Sunita is a 6-year-old girl with chronic nasal congestion and a history of eczema who presents with a chronic cough that is often worse at night, with exercise, and with exposure to cold air. She has no fever, shortness of breath, or history of wheezing, but has a family history of asthma.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

Epidemiology and risk factors: Sunita is 6 years old and has a family history of asthma.

Key clinical findings about the present illness using qualifying adjectives and transformative language:

    • Chronic nasal congestion and PMH of eczema

    • Chronic (i.e > 4 weeks) of cough

    • Worsens at night, with exercise, and exposure to cold air

    • No fever, shortness of breath, or wheezing

GENERAL EXAM

PHYSICAL EXAM
Examining the posterior pharynx

You step out briefly to allow Sunita to change into a gown. You then come back into the room and wash your hands. Sunita is sitting patiently on the examination table.

General assessment: Well-nourished and in no acute respiratory distress. Dark circles under both eyes with some creases below both eyes.

Skin: Dry skin but no obvious patches of eczema.

Hands: No evidence of distal cyanosis or digital clubbing.

Nose: Transverse nasal crease. Turbinates somewhat pale and edematous. Clear nasal secretions.

No sinus tenderness when the frontal sinuses are palpated. No facial tenderness.

Posterior pharynx: Tonsils normal in size. No oral lesions. No erythema.

Focused examination of her head, eyes, and ears shows no additional abnormalities.

Cardiac: Regular, rate, and rhythm with no murmurs.

Abdomen: Benign. Soft, nontender.

Neurologic and developmental exams: Grossly normal.

TEACHING POINT

Common Terms for Physical Findings

Allergic shiners: Darkening of the lower eyelids as a result of venous stasis.

Allergic salute: A gesture that involves pushing the nose upward and backward with the hand to relieve nasal itching and obstruction. Over time, this may result in the development of a transverse nasal crease.

Dennie-Morgan lines: Infraorbital creases that appear due to intermittent edema caused by allergies.

Clubbing: Change in the appearance of the fingers so that the distal phalanx is rounded and bulbous and the angle between the nail plate and the nail fold is increased past 180 degrees. This phenomenon is suggestive of chronic hypoxia.

LUNG EXAMINATION

PHYSICAL EXAM
Listening to breath sounds

Neck: Trachea midline. No significant lymphadenopathy. No use of accessory muscles of respiration.

Lungs: No evidence of retractions or a hyperinflated thorax. No changes to percussion or E-to-A changes. Normal I:E ratio. End-expiratory wheezing. No use of accessory muscles.

Listen to Sunita’s breath sounds below.

Sunita’s breath sounds

TEACHING POINT

Significance of Findings on Lung Exam

Finding

Significance

Tracheal deviation

  • Tracheal deviation from midline may suggest a mediastinal mass, pneumothorax, or foreign body aspiration leading to lung collapse or consolidation.

Retractions

  • Caused by abnormal use of accessory muscles.

  • Appears as inward movement of the soft tissues in the intercostal, supraclavicular, or subcostal spaces during inspiration.

  • May be seen in severe obstructive airway disease in children, including asthma, bronchiolitis, and foreign body obstruction.

Use of accessory muscles of respiration

  • Inspiratory contraction of the sternocleidomastoid muscles at rest.

  • This is a sign of significant respiratory distress.

Hyperinflated thorax

  • Increased anteroposterior (AP) chest diameter, sometimes referred to as “barrel chest.”

  • This is suggestive of air-trapping due to chronic obstructive lung disease.

Increased I:E

  • “I:E” refers to the ratio of time for full inspiration to time for full expiration (normally 1:1 or 1:2).

  • In obstructive disorders, expiration is prolonged, and ratio is decreased.

Abnormal chest sounds on percussion

  • “Hyperresonance” may be heard when there is localized air trapping behind a mucus plug, foreign body, or mass.

  • “Dullness” to chest percussion may be due to lobar consolidation (e.g.pneumonia or atelectasis) or pleural effusion.

Egophony

  • This is when the patient is asked to say “ee” and the examiner hears “ay” through the stethoscope.

  • The phenomenon is suggestive of a lobar consolidation (an airless lung).

Wheezing

  • Wheezing is the sound of airflow being exhaled through narrowed airways.

  • It may be due to many different conditions, but one of the most common reasons for wheezing in children is asthma.

TEACHING POINT

Describing Breath Sounds

The description of common breath sounds varies somewhat among practitioners and there is no universally agreed-upon definition. However, there are some areas of general agreement, as follows:

Wheezing

    • The sound of airflow through narrowed airways and may be due to intraluminal obstruction (e.g., from edema, mucus, foreign object), bronchoconstriction or external compression (e.g., from lymphadenopathy, neoplasm).

    • Wheezing from asthma or other obstructive processes such as bronchiolitis is associated with obstruction in multiple small or moderate-sized airways and results in continuous, musical, high-pitched, or polyphonic sounds that are generally heard during expiration but may also be heard during inspiration.

Rhonchi

    • Like wheezing, rhonchi are also continuous rather than discontinuous sounds and tend to be low-pitched and polyphonic and may occur during either inspiration and/or expiration; they are typically thought to be due to mucus/secretions in the airways.

Crackles

    • These are discontinuous sounds and are characterized as either fine or coarse.

    • They are typically inspiratory and are generally associated with alveolar or small airway conditions such as pneumonia, pulmonary edema, and bronchiolitis, or with interstitial lung disease.

    • Crackles are sometimes are referred to as ‘rales’ in some sources.

Stridor

    • A high-pitched, hoarse noise that is the result of a partial obstruction of the extrathoracic airways such as the larynx or trachea. Typically inspiratory, but may be biphasic.

    • Stridor in children is most often due to croup, upper airway inhaled foreign body with partial obstruction, and laryngomalacia.

Dr. Law refers you to this link to review some commonly heard types of breath sounds.

DIFFERENTIAL DIAGNOSIS

CLINICAL REASONING

Question

Now that you have completed Sunita’s physical exam, you consider what information you will present to Dr. Law. Based on Sunita’s history and physical findings, what do you think are the most likely diagnoses? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

  • A. Asthma

  • B. Allergies

  • C. Atypical pneumonia

  • D. GERD

  • E. Sinusitis

  • F. Tuberculosis

Answer Comment

> The correct answers are A and B.

Asthma (A)

    • The features of Sunita’s cough as well as her past history, family history, and the finding of end-expiratory wheezing on exam all support a diagnosis of asthma.

Allergies (B)

    • Chronic nasal congestion, particularly in the context of a move to a new home, plus allergic shiners, clear nasal secretions, and edematous (“boggy”) turbinates are consistent with a diagnosis of environmental allergies.

The following are less likely:

Atypical or viral pneumonia (C)

    • Sunita’s course is prolonged relative to what you would expect for infectious pneumonia.

Sinusitis (E)

Signs and symptoms of acute bacterial sinusitis in younger children include:

    • URI symptoms with persistent illness (nasal discharge of any kind), daytime cough, or both lasting for more than 10 days but less than 30 days.

    • Worsening cough (or new onset of nasal discharge, daytime cough, or fever after initial improvement).

    • Severe symptoms (high fever and purulent nasal discharge) for at least 3 days.

Tuberculosis (F)

    • Although Sunita’s grandmother moved from an area where tuberculosis is endemic, she does not have any symptoms, and her TST was negative.

PRESENTING TO THE ATTENDING

CLINICAL REASONING

You summarize Sunita’s history, exam findings, and your differential diagnosis for Dr. Law, making sure to provide evidence to support your thought process.

“Sunita is a 6-year-old girl with eczema, who moved to the area three months ago. She is here today with a cough for two months that is worse at night, with activity, and with the colder weather. Since moving into her new house, she has also had nasal congestion. There is a family history of asthma. Her social history is pertinent for a dog in the home and carpets, but no smokers. Her grandmother recently came to live with them from India and had a normal TST.

“Her vital signs are normal. Her physical exam findings are notable for allergic shiners, clear nasal secretions, and boggy nasal turbinates but a normal oropharynx. Her lung exam is significant for diffuse, bilateral mild end-expiratory wheezing but she was not in respiratory distress and was able to speak in full sentences. She was not coughing during my exam.

“My assessment is that Sunita likely has asthma, with environmental allergies playing a role. The onset of symptoms after a move to a new environment, her history of eczema, and the family history of asthma all fit. Sunita’s symptoms worsen in response to typical asthma triggers. She has physical findings typical of allergic rhinitis as well as wheezing on exam.”

Dr. Law notes that you’ve made a compelling argument to support your assessment. She returns with you to the exam room and confirms the key elements of your history and exam.

DIAGNOSIS

CLINICAL REASONING
TEACHING POINT

Asthma

Asthma is a chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial hyper-responsiveness, and underlying inflammation.

It is the most common chronic disease in children in developed countries. Epidemiologic risk factors include sex (males have higher prevalence), race/ethnicity (higher among non-Hispanic Black children), and socioeconomic status (higher among children whose family income is below the federal poverty level).

Diagnosis requires:

    • Symptoms of recurrent airway constriction by history and exam

    • Demonstration that airway constriction is at least partially reversible

    • Exclusion of other causes of airway obstruction

Question

Which of the following tests would be most useful in establishing a diagnosis of asthma for Sunita? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

  • A. Chest x-ray

  • B. Spirometry

  • C. IgE testing for aeroallergens

  • D. Trial of albuterol

Answer Comment

> The correct answer is B.

National guidelines recommend spirometry (B) in children > age 5 to demonstrate that airway obstruction is present and at least partially reversible.

A chest x-ray (A) would help exclude other causes of wheezing, but would not be essential in establishing a diagnosis.

Allergy testing (C) might be useful in long-term management but would not be useful in making a diagnosis of asthma.

In younger children who cannot cooperate with spirometry, response to a trial of bronchodilator treatment (D) is often used in diagnosis.

CLASSIFICATION

TEACHING

Dr. Law agrees that Sunita likely has asthma. To confirm the diagnosis, she arranges for Sunita to have spirometry testing later that day and schedules a follow-up visit the next morning.

She asks you to read about asthma and to review the NHLBI Asthma Care Quick Reference. Dr. Law also mentions an additional resource from the Global Initiative for Asthma (GINA) which varies slightly compared to NHLBI for adults and children ages 6 and up. However, Dr. Law notes her institution primarily utilizes the NHLBI guidelines to initiate asthma management in pediatric patients.

TEACHING POINT

Asthma Severity and Control

The NIH asthma classification system provides a broadly accepted and consistent definition of asthma, allowing for improved communication regarding its diagnosis and management among health care providers caring for patients with this chronic condition.

During a patient’s initial presentation, the emphasis is on assessment of asthma severity, as a guide to starting therapy.

Once treatment is initiated, the emphasis changes to assessment of asthma control, as a guide to maintaining or adjusting therapy.

Assessment of severity and control varies with the age of the patient and relies primarily on consideration of asthma-related impairment:

    • Frequency of daytime symptoms

    • Frequency of nighttime awakenings related to asthma

    • Interference with activity

    • Pulmonary function (if available)

    • Use of short-acting beta2-agonist medications (SABA) (if patient is already using medications)

A primary goal in classifying severity is to determine whether a patient’s asthma is intermittent or persistent.

Asthma severity classification based on history of impairment in a school-age child:

History

Classification

Treatment

Daytime sx ≤ 2 days/week

Intermittent

Quick relief (SABA) as needed

Nighttime awakening < 2 times/month

Intermittent

Quick relief (SABA) as needed

No interference with activity

Intermittent

Quick relief (SABA) as needed

More frequent symptoms, more interference with activity

Persistent

Daily controller + quick relief as needed

Persistent asthma is further classified as mild, moderate, or severe. See the GINA Pocket Guide for Asthma Management and Prevention for additional details.

Question

Based on your reading about asthma and thinking about the history and exam findings from your time with Sunita, how would you classify her asthma? (Refer back to the GINA Pocket Guide for Asthma Management and Prevention)

The best option is indicated below. Your selections are indicated by the shaded boxes.

  • A. Intermittent

  • B. Mild persistent

  • C. Moderate persistent

  • D. Severe persistent

Answer Comment

> The correct answer is C.

Sunita has had symptoms daily and nighttime symptoms (cough) more than twice per month, with some limitations in activity (coming in from recess). Based on the daily occurrence of her symptoms, we can classify her asthma as “moderate persistent.”

TREATMENT

THERAPEUTICS

Question

Based on your classification, which of the following medications could be used in treatment?

The best options are indicated below. Your selections are indicated by the shaded boxes.

  • A. Short-acting beta2-agonist (albuterol)

  • B. Inhaled corticosteroid

  • C. Leukotriene modifier

  • D. Combined Long-acting beta2-agonist and inhaled corticosteroid (LABA-ICS)

Answer Comment

> The correct answers are A, B, C, and D.

TEACHING POINT

Types of Asthma Therapy

Quick-relief medications (short-acting beta2-agonists or SABAs) relax airway muscles to provide fast relief of symptoms. They do not provide long-term asthma control. If quick relief medications are used more than two days/week (except as needed for exercise-induced asthma), the patient may need to start or increase long-term control medications.

Long-term control medications (such as inhaled corticosteroids, which reduce inflammation) prevent symptoms. These are taken daily and do not provide quick relief of acute symptoms.

Reference: Global Initiative for Asthma (GINA)

TEACHING POINT

Anti-Inflammatory Therapy for Persistent Asthma

All patients with persistent asthma should receive daily prophylaxis with anti-inflammatory therapy such as inhaled corticosteroids. These medications are intended to prevent asthma exacerbations, thereby reducing the need for systemic steroids.

The steroid medications most commonly prescribed include beclomethasone, fluticasone, and budesonide.

Dose and Frequency

    • The micrograms of steroid medication per puff vary with each type of steroid inhaler and must be considered when prescribing.

    • Inhaled steroids require several weeks of daily use before the beneficial effects are realized.

    • Children with only seasonal symptomatology may require daily use of anti-inflammatory medications, starting several weeks before the expected antigen exposure.

Side Effects

    • Children with asthma are often undertreated, based on the misconception by parents and clinicians that long-term treatment with inhaled corticosteroids is deleterious.

    • Side effects are rare but can occur, especially when high doses are used.

    • Children receiving long-term therapy should be routinely monitored for elevation in blood pressure, serum blood sugar, growth delay, and cataract development.

TESTING

TESTING
Sunita’s PFT results

The next morning you review Sunita’s pulmonary function tests (PFTs—see image above). The results show a mild, reversible obstructive defect, consistent with the diagnosis of asthma.

TEACHING POINT

About Spirometry

How Does Spirometry Work?

Spirometry measures “active” lung volume (i.e., air volumes that a patient actively blows into the spirometer while the rate of air flow is simultaneously measured).

To obtain a volume-time spirogram, a child first breathes quietly (“tidal breaths”) into the spirometer to determine tidal volume (Vt = amount of air inhaled during a breath).

A slow and a forced vital capacity (SVC and FVC) breath is then performed to determine the maximum amount of air that can be inspired (TLC = total lung capacity) and then released when exhaling.

Next, a forced exhalation is performed to determine the rate of airflow during exhalation, which rises quickly to its maximum value immediately after exhalation is initiated.

    • As the lung volume decreases, the intrathoracic airways narrow, airway resistance increases, and the rate of air flow progressively falls.

    • The standard time for exhalation is six seconds.

    • The volume exhaled in one second (FEV1 = forced expiratory volume in one second) is obtained during this maneuver.

Requirements for Testing

    • Because it is essential to obtain maximal efforts to differentiate restrictive from obstructive disease, PFTs are performed in children who can accomplish a coordinated, forced expiratory maneuver (generally, children older than 5 years).

Measuring Reversibility

    • Measurements are obtained before and after bronchodilator use in order to determine the amount of reversible airway disease that is present.

Findings in Obstructive Lung Disease

    • Obstructive lung disease (e.g., asthma and cystic fibrosis) is characterized by a reduction in air flow and trapping of air inside the thorax behind tight, plugged airways, which lowers the FEV1.

    • Because the FEV1 is more reduced than the forced vital capacity (FVC), obstruction results in a low FEV1/FVC ratio (see BLACK arrow in the above image), the FEV1 (%), which produces the scalloped shape on the exhalation limb of the flow-volume curve (see RED arrow in the above image).

MANAGEMENT

MANAGEMENT

Sunita and her mother return that afternoon to clinic.

Dr. Law explains that Sunita’s history, exam, and PFT results all suggest a diagnosis of asthma:

“Asthma involves inflammation—or irritation and swelling—of the airways in the lungs. The inflammation can cause the airways to get tight or narrow, leading to cough, wheezing, and difficulty breathing.”

Dr. Law recommends that Sunita start treatment with a low-dose inhaled corticosteroid twice a day to keep the inflammation under control and albuterol as needed to relax the airways.

She then discusses an Asthma Action Plan for Sunita (See an example of an asthma action plan).

Because Sunita has signs and symptoms of allergies, Dr. Law also recommends starting an oral antihistamine.

She asks to see Sunita in one month but advises the family to return sooner if Sunita develops signs of respiratory distress.

TEACHING POINT

Metered-Dose Inhalers and Spacers

Metered-dose inhalers (MDIs) are portable, lightweight, and inexpensive.

The disadvantages are the high speed of medication delivery (upward of 400 miles/hour, leading to impaction of almost 99% of the medication on the back of the throat) and the need to coordinate a breath with medication delivery.

Using a spacer device (seen here with a mask attachment for infants and small children that allows for a tight seal around the nose and mouth) is the preferred way to use an MDI and optimizes drug delivery. A spacer should be used in all children (and many adults).

    • Because the medication is suspended within the spacer device, it may be inhaled either through the mouth as a single breath or with multiple tidal breaths with equal effect.

    • When used for inhaled corticosteroids, spacers also have the added benefit of preventing side effects such as dysphonia and oral thrush.

See a patient handout on using an MDI.

TEACHING POINT

Asthma Action Plan

One of the mainstays of asthma management is to educate parents and children about their asthma and to provide them with tools to manage their asthma effectively.

An “asthma action plan” provides practical and easy-to-follow instructions, based on:

    • Daily symptoms and/or

    • Peak flow readings

The plan also communicates these individualized instructions clearly to the school or daycare provider. It may be helpful to encourage parents to think of managing asthma as a “team sport.”

TEACHING POINT

Monitoring Peak Expiratory Flow

Peak expiratory flow (PEF) provides a simple, objective, and reproducible measure of the existence and severity of airflow obstruction.

PEF monitoring can be used for:

    • Short-term monitoring

    • Managing exacerbations at home and in the emergency department

    • Daily long-term monitoring of asthma-particularly in moderate to severe asthma

When used in these ways, the patient’s measured personal best is the most appropriate reference value.

Personal Best

The child’s personal best can be determined by averaging their PEF values for 14 consecutive days during a period of good control. See a table used to predict a child’s personal best PEF based on height.

PEF is designed as an ongoing tool for monitoring asthma and is not appropriate for use in diagnosis. Formal pulmonary function tests are necessary for this purpose.

Peak flow monitoring may be difficult for young children. Many clinicians rely primarily on patients’ reports of symptoms as a measure of asthma control.

ALLERGIES

CARE DISCUSSION

Dr. Law sends prescriptions for beclomethasone, albuterol, and loratadine to the pharmacy.

You ask Dr. Law about the relationship between allergies and asthma.

TEACHING POINT

Aeroallergens and Asthma

Patients with asthma often have inhalational allergies as a common trigger for their asthma.

The most common indoor aeroallergens that are responsible for sensitizing susceptible people include:

    • House dust mites

    • Animal dander

    • Cockroaches

Common outdoor aeroallergens include fungi and some grass and ragweed pollens.

The approach to the treatment of allergies in children varies somewhat among doctors and from one area of the country to the other.

Exposure Avoidance

Reducing exposure to known outdoor and indoor allergens—such as cigarette smoke or wood smoke from a stove—is a good strategy. In an individual who already demonstrates sensitivity to some environmental allergens, the risk of becoming sensitized to other environmental allergens is greater. The decision to recommend changes to the indoor environment (e.g., removing carpets or pets) should be individualized. The expense and effort involved in implementing indoor environmental allergen controls may be greater than any potential benefit.

Medication

Medications are frequently included in the management of environmental allergies.

Typical options include oral antihistamines, leukotriene receptor antagonists, and topical nasal steroids.

    • Antihistamines (H1 antagonists) are safe and effective for controlling the symptoms of sneezing, nasal pruritus, and rhinorrhea, particularly associated with intermittent or short-term seasonal allergies. Newer antihistamines are available that are significantly less sedating than the earlier antihistamines.

    • Leukotriene receptor antagonists may be useful in the treatment of both asthma and allergic rhinitis.

    • Topical nasal steroids are the most effective pharmacologic agents for the treatment of allergic rhinitis, but may not be indicated for short-term symptoms of seasonal allergies.

TEACHING POINT

Examples of Control Measures for Environmental Allergies

Animal Dander

Remove pets with fur or hair from the home, or, at a minimum, keep animals out of the patient’s bedroom and carpeted rooms within the home.

House Dust Mites

    • Encase mattresses and pillows in an allergen-impermeable cover.

    • Wash non-encased pillows, sheets, blankets, and any special stuffed animal weekly in water hotter than 130 F (54.5 C).

    • Remove all other stuffed animals from the child’s bed. Placing toys weekly in the dryer or freezer may help.

    • Remove carpet from the child’s bedroom, if possible, and damp mop wood or vinyl floor weekly.

    • If not possible, vacuum the child’s bedroom carpet twice per week with the child out of the room.

    • Reduce humidity to < 60% (ideally 30%–50%).

    • Eliminate any cockroaches.

    • Use poison bait or traps to control pests (chemical sprays may irritate asthma).

    • Do not allow food in patient’s bedroom.

    • Do not leave food or garbage exposed.

Indoor Mold

    • Fix all leaks and eliminate water sources associated with moldy growth.

    • Clean moldy surfaces.

    • The child should avoid damp rooms such as basements.

    • Dehumidify the basement to below 60% humidity, if possible.

Outdoor Mold

    • Try to keep windows closed; stay indoors when pollen and mold spore counts are highest (midday and afternoon), if possible.

Smoke, Strong Odors, and Sprays

    • Do not allow smoking in the child’s home, family vehicle, daycare center, or school.

    • Avoid strong odors, perfume, and sprays whenever possible.

References

Kliegman, RM, Stanton BF, St Geme JW, Schor, NF. Nelson’s Textbook of Pediatrics. 20th ed. Philadelphia, PA: Elsevier, 2016:11095-1115.

FOLLOW-UP

CARE DISCUSSION
Sunita’s drawing

Sunita and her family return a few weeks later.

You ask Sunita,

Mrs. Patel confirms Sunita’s coughing seems to be much better. She has been awakened at night due to her cough only once in the past few weeks. She has used her albuterol inhaler twice.

Mrs. Patel says she feels fairly confident about Sunita’s treatment plan, though somewhat concerned that her daughter might be limited by having a chronic illness.

Dr. Law explains that the goal of asthma management is to allow full participation in all activities, with no limitations—and that they will work together to adjust Sunita’s treatment as needed to make sure she can do everything she wants to do.

Given that Sunita is doing well, Dr. Law recommends continuing her current medication plan and returning for another visit in 4 weeks to assess her asthma control.

Sunita and her mother thank you for helping in her care. Sunita gives you a drawing as a parting gift.

CASE SUMMARY DOWNLOAD

FINISH CASE

Well done! You have completed the case. Click to download the case summary.

RELEASE NOTES

RELEASE NOTES

January 14, 2021

This case has been reviewed and updated by the Aquifer Pediatrics editorial course board.

LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the case, the student should be able to:

    • Perform an age-appropriate history and physical examination for a child with chronic cough.

    • Generate an age-appropriate differential diagnosis for a child with chronic cough.

    • Describe the epidemiology, pathophysiology, clinical findings, and management of important causes of chronic cough.

    • Describe physical exam maneuvers included in a complete pulmonary examination and discuss the significance of abnormal findings.

    • Summarize the epidemiology, risk factors, and diagnosis of tuberculosis in children.

    • Summarize current guidelines for the diagnosis, classification of severity, and management of asthma.

    • Discuss clinical findings and management of allergic rhinitis.

    • Discuss the association between environmental allergies and asthma.

    • Discuss how spirometry is used to measure lung function.

    • Identify a child in acute respiratory distress.

QUESTION #1

SAQ

Question

A 4-year-old male who lived internatinally presents with his mother to your general pediatrics clinic. His mother reports that he has a chronic nonproductive cough during the day and night, mild wheezing for one month and failure to gain weight (his weight has dropped from the 50th to the 10th percentile for his age). He does not have high fevers, rhinorrhea, congestion or night sweats. Which of the following are the next best diagnostic tests?

  • A. Chest x-ray and methacholine challenge
  • B. Chest x-ray and tuberculin skin test
  • C. CT of nasal sinuses
  • D. Spirometry, before and after bronchodilator therapy
  • E. None needed, patient likely has habit cough

QUESTION #2

SAQ

Question

An 11-year old boy presents to the clinic with wheezing. His mother states that in the past he has used inhaled albuterol and it has helped with wheezing and shortness of breath. His mother also reports that the patient experiences shortness of breath three times a week and is awakened at night by these symptoms once a week. What is the most appropriate outpatient therapy at this time?

  • A. A 5-day course of oral corticosteroids
  • B. High dose inhaled corticosteroids, LABA (long-acting beta agonist), and oral corticosteroids daily and albuterol rescue inhaler as needed
  • C. Low dose inhaled corticosteroids daily and albuterol rescue inhaler as needed
  • D. Medium dose inhaled corticosteroids daily and albuterol rescue inhaler as needed
  • E. A short acting beta agonist (SABA) inhaler (e.g. albuterol) to be used as needed.

QUESTION #3

SAQ

Question

A 4-year-old patient presents with several months of cough. Mom also reports a history of red skin patches, which are pruritic, and allergies to peanuts, eggs, and mangoes. Which of the following would most likely be characteristic of the cough that this patient would present with?

  • A. Barking cough
  • B. Does not awaken patient from sleep
  • C. Paroxysmal
  • D. Worse at night

QUESTION #4

SAQ

Question

A 9-year-old boy presents to your clinic with discoloration under his eyes, persistent cough, and skin rashes. He has struggled with these concerns over the past three years but recently his symptoms have gotten worse, affecting him every other day. He is afebrile. He is found to have wheezing on physical exam and increased lung volume bilaterally on chest x-ray. What would be the most appropriate treatment for him?

  • A. Long-acting inhaled beta agonist alone
  • B. Oral antibiotics
  • C. Short-acting inhaled beta agonist PRN
  • D. Short-acting inhaled beta agonist PRN with daily low-dose inhaled corticosteroid
  • E. Short-acting inhaled beta agonist PRN with daily medium-dose inhaled corticosteroid

QUESTION #5

SAQ

Question

A previously healthy 10-year-old boy comes to the clinic with a chief concern of progressive cough for three days that began gradually. His cough is described as productive with whitish sputum. His mother reports that he has been febrile up to 101.5 F daily. She thinks he is fatigued and has not eaten well in the past several days. He has no throat pain, vomiting, or diarrhea on review of systems. On exam, there is air passage throughout all lung fields, with crackles in the lower right lung field, but no other abnormal sounds. Which of the following would you likely find in your evaluation?

  • A. Alveolar consolidation in the right lower lobe on chest radiograph
  • B. Fluffy bilateral infiltrates and a large heart on chest radiograph
  • C. Hyperinflation in one lung field on chest radiograph
  • D. Positive PCR for pertussis
  • E. Response to inhaled beta-agonist

Thank you for completing Pediatrics 13: 6-year-old female with chronic cough.

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