Stage 1

You are the Doctor looking after the children’s area in Accident and Emergency. You are called urgently to see an 11 month old boy who’s parents have brought him because they were worried about his breathing.

Initial observations have been taken by the triage nurse. 

HR 130/min, RR 32/min, T 38.2 C, SaO₂ 96% in Oxygen.

Weight 9.3 Kg

The nurse has also given some paracetamol to bring down the temperature.

You obtain some basic information from the parents:

The child’s name is Jack Horner and he has been fairly well up to now apart from an episode when he was admitted for 2 days when he was 3 weeks old. The parents are unsure of the diagnosis, and they do not think that the hospital were sure either, as they were concerned he might have whooping cough or perhaps bronchiolitis. As they remember, all investigations were normal.

The parents tell you that they first noticed that he had a runny nose 2 days ago, then developed a cough. The cough has worsened and is now quite loud. They have not heard anyone ever cough like this before. Overnight he has also developed a sound when he breathes – especially when upset.

In the background, you find out that he was born at 38 weeks normally, and was discharged home the following day. His brother (age 4) has been diagnosed with asthma, and currently takes salbutamol when he needs it. His father has eczema, and his mother smokes – but never inside the house or around the children.

You decide to examine the child.

He is a well grown infant who is pink in air. He is currently asleep.

He has mild tracheal tug at rest and subtle sternal recession. Expansion looks equal.

His respiratory rate is 30/min. You listen carefully to his breathing.

https://www.youtube.com/watch?v=Qbn1Zw5CTbA

Listening to his chest there is good air entry all over.

His heart sounds and pulses are normal.

His abdomen is soft and organs are non palpable.

During the examination he wakes up and becomes agitated – he does not recognize you. At this time his breathing sound becomes much louder and you notice moderate tracheal tug and sternal recession.

https://www.youtube.com/watch?v=Gt4_79xDn6c

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