Overview
This lecture covers the structured assessment and management of a two-year-old child presenting with dry cough and wheeze, emphasizing focused history, physical examination, differential diagnosis, and outpatient management including safety netting.
Approach to Pediatric Cough and Wheeze History
- Introduce self to parents and child in an age-appropriate, reassuring manner.
- Assess the child’s stability using the pediatric assessment triangle (appearance, respiratory, circulation).
- Clarify cough onset (sudden/gradual), duration, type (wet/dry), pattern (day/night), triggers, and associated symptoms.
- Ask about exposure history (sick contacts, daycare, pets, smoking, new environments).
- Ask about wheeze onset, frequency, triggers, and relation to cough.
- Evaluate impact on eating, drinking, sleep, activity, and appetite.
- Screen for alarming symptoms (fever, rash, cyanosis, respiratory distress, vomiting, swelling, abdominal pain, ear or eye symptoms).
- Review home safety, caregiver situation, proximity to healthcare, parental understanding, and possible neglect.
Focused Pediatric Physical Examination
- Obtain consent, ensure privacy, and engage the child playfully.
- Assess general appearance, work of breathing, consciousness, and dehydration.
- Record vital signs: respiratory rate, oxygen saturation, pulse, weight, and plot on growth chart.
- Examine hands and extremities for cyanosis, clubbing, edema, and capillary refill.
- Inspect chest for deformities, retractions, trauma, and symmetry.
- Palpate chest for expansion and tracheal deviation.
- Auscultate lungs and heart for abnormal or decreased sounds.
- Examine head and neck: inspect eyes, ears, nose, and oral cavity for infection or discharge.
- Perform otoscopy for ear pathology and assess for lymphadenopathy as needed.
Differential Diagnosis and Provisional Diagnosis
- Most likely diagnosis: viral-induced wheeze.
- Other differentials: early/pre-school asthma, foreign body aspiration, croup, pertussis, pneumonia, influenza.
- Consider upper and lower respiratory tract infections (pharyngitis, rhinosinusitis, bronchitis), gastroesophageal reflux, heart disease, psychogenic cough.
Outpatient Management and Follow-Up
- Reassure parents about benign and self-limiting viral-induced airway inflammation.
- No need for cough suppressants or antibiotics unless indicated.
- Advise on non-pharmacological care: avoid smoke, triggers, keep child hydrated, encourage rest, maintain vaccinations, hand hygiene, and avoid sick contacts.
- Provide education on red flags (drowsiness, increased work of breathing, persistent fever).
- Schedule follow-up review in one week; return earlier if red flags develop.
- If symptoms persist after two weeks, consider asthma trial with salbutamol via inhaler and spacer, educate parents on use, and provide an asthma action plan.
Key Terms & Definitions
- Pediatric Assessment Triangle — Rapid evaluation tool: appearance, work of breathing, circulation.
- Safety Netting — Ensuring caregivers know when and how to seek further medical help.
- Viral-induced Wheeze — Transient airway narrowing from viral infection, common in young children.
- Red Flags — Symptoms indicating need for urgent medical review (e.g., cyanosis, drowsiness, respiratory distress).
Action Items / Next Steps
- Review RCH guidelines on viral wheeze and asthma in preschoolers.
- Practice explaining safety netting and inhaler techniques to caregivers.
- Prepare for next session: review management of wet cough, bacterial causes, and when to use antibiotics.