First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 30. 2-Year-Old Girl with Noisy Breathing

DOORWAY INFORMATION

Opening Scenario

The mother of Angelina Harvey, a 2-year-old female child, calls the office complaining that her child has noisy and strange breathing.

Examinee Tasks

1. Take a focused history.

2. Explain your clinical impression and workup plan to the mother.

3. Write the patient note after leaving the room.

Checklist/SP Sheet

Patient Description

The patient’s mother offers the history over the phone.

Notes for the SP

Show concern about your child’s health, but add that you don’t want to come to the office unless you have to because you do not have transportation.

Challenging Questions to Ask

 “Can you explain to me exactly what is going on with my child and what can be done for it?”

 “How will I be able to get a ride to the office?”

Sample Examinee Response

“It is hard for me to give you an accurate answer over the phone. I would like you to bring your child here so that I can examine her and perhaps run some tests. After that, I will be able to give you a more accurate assessment of her condition. We will arrange for the social worker to speak with you about arranging transportation to the office.”

Examinee Checklist

Building the Doctor-Patient Relationship Entrance

 Examinee introduced self by name.

 Examinee identified his/her role or position.

 Examinee correctly used patient’s name and identified caller and relationship of caller to patient.

Reflective Listening

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.

 Examinee summarized the SP’s concerns, often using the SP’s own words.

Information Gathering

□ Examinee elicited data efficiently and accurately.

Connecting with the Patient

 Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination

None.

Closure

 Examinee discussed initial diagnostic impressions.

 Examinee discussed initial management plans:

□ Follow-up tests.

 Examinee asked if the SP had any other questions or concerns.

Sample Closure

Mrs. Harvey, on the basis of the information I have gathered from you, I’m considering the possibility that your daughter might have swallowed a foreign body. However, the possibility that an infection might be causing her problem needs to be ruled out. Right now, I feel that your daughter needs emergency medical attention. Since you do not have access to transportation, I strongly suggest that you call 911 immediately and bring her to the medical center. In the meantime, I suggest that you avoid putting a finger in her mouth or performing any blind finger sweep, as doing so may cause the foreign body to become more deeply lodged if it is actually present. If you observe significant respiratory compromise or choking, perform the Heimlich maneuver by thrusting your daughter’s tummy with sudden pressure. I hope you understood what we have discussed. Do you have any questions or concerns? Okay, I will see you once you get to the hospital.

History

HPI: The source of information is the patient's mother. The mother of a 2 yo F c/o her child suddenly developing noisy breathing that is getting progressively worse. The child was playing with her toys when she developed the noisy breathing. The sound is consistent, best heard on inhalation, and similar to that of a washing machine. There is no relation to posture. It is associated with a nonproductive cough without any associated hemoptysis, tachypnea, drooling, or bluish discoloration of the skin. Her vaccinations are up to date.

ROS: Negative.

Allergies: NKDA.

Medications: None.

PMH: Uncomplicated spontaneous vaginal delivery.

PSH: None.

FH: Noncontributory.

Physical Examination

None.

Differential Diagnosis

CASE DISCUSSION

Patient Note Differential Diagnoses

There are three types of stridor: inspiratory stridor, which indicates obstruction at the level of the larynx or superior to it; expiratory stridor, which points to obstruction inferior to the larynx; and biphasic stridor, which suggests obstruction in the trachea. Stridor that presents with hoarseness suggests involvement of the vocal cords.

 Foreign body aspiration: The sudden and dramatic onset of symptoms, especially when a foreign body (usually a toy or peanuts) is in the vicinity before the patient develops symptoms, helps support this diagnosis. The patient is breathing noisily and is experiencing some shortness of breath, both of which are consistent with aspiration of a foreign body.

 Croup: Croup is common in children six months to three years of age, usually developing insidiously as a URI. The most likely culprit for croup is parainfluenza. This patient has had a low-grade fever for the past week, which is suggestive of a viral infection. Although not found in this patient, a characteristic barking cough is often present in croup.

 Epiglottitis: Occurs more frequently in children 2-6 years of age, and begins with a short prodrome. Its hallmark feature, significant drooling with symptomatic relief while bending forward, is not present in this patient. However, the patient has experienced voice hoarseness. The most common etiology of epiglottitis is Haemophilus influenzae type b, but given that this patient’s immunizations are up to date, it is unlikely that this is the cause of her disorder.

Additional Differential Diagnoses

 Laryngitis: Occurs in children older than five years of age. The absence of stridor and the presence of a hoarse voice are characteristic.

 Retropharyngeal abscess: Patients are usually younger than six years of age. They lack stridor, their voice is muffled, and drooling is often present.

 Angioedema: Can occur at any age, and may be an allergic response or hereditary (congenital). Congenital angioedema does not appear to apply to this patient, as she would likely have exhibited some manifestation of immune compromise. Onset is sudden, and the clinical features of stridor and facial edema are found. Respiration is laborious.

 Peritonsillar abscess: Typically occurs in children older than 10 years of age. Onset is gradual, with a history of a sore throat and tonsillitis. There is no stridor.

 Laryngeal papilloma: A chronic condition characterized by a hoarse voice; most commonly diagnosed in children three months to three years of age.

Diagnostic Workup

 ABG: It is essential to determine blood gas concentrations in order to indirectly assess ventilation and gaseous exchange in the lung.

 CXR—PA and lateral: It is noteworthy that the majority of foreign bodies are not visible on CXR PA plain films. Therefore, a normal radiograph cannot rule out an aspirated foreign body. However, when a foreign body obstructs the lower airway and causes air trapping, the expiratory film may sometimes reveal air trapping as a result of the ball-and-valve effect.

 XR—neck, AP and lateral: May show narrowing of the trachea (steeple sign) in croup, extrinsic pressure, or a classic swollen glottis (thumbprint sign) in epiglottitis.

 CBC with differential: To rule out or rule in an underlying infective pathology.

 Bronchoscopy: Used as a diagnostic and therapeutic modality in cases of foreign body aspiration.

 Direct laryngoscopy: Useful when differentials of laryngomalacia or laryngeal lesions such as papilloma are suspected.



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