WIDI - P7) Cough, fever, and wheezing in an infant

P7) Cough, fever, and wheezing in an infant

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a pediatric patient with a cough.
Review the DDx considerations in a pediatric patient with a cough.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a pediatric patient with a cough.

History

A 5-month-old infant is brought to the ED with worsening cough, low-grade fever, and rhinorrhea over the past 2 days. He has had decreased PO intake during this time. He has since developed wheezing and difficulty breathing. Immunizations are up to date. No known sick contacts, but he attends daycare.

Physical Exam

BP: 90/55, HR 120, RR 50, Temp 38.2 C, O2 saturation 86%. General: patient appear well-developed but irritable, fever present. HEENT: nasal flaring, mild rhinorrhea. Pulmonary: tachypnea, wheezing in all lung fields, subcostal retractions. Cardiovascular: tachycardia.

Labs

WBC: 13.6. Respiratory viral panel: RSV+.

Provisional Diagnosis

Select the Dx you believe is most appropriate

Pneumonia

Pneumothorax

Bronchiolitis

This patient most likely has bronchiolitis considering the presentation (cough, fever, rhinorrhea, age of patient) and physical exam findings (diffuse wheezes, subcostal retractions).

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

The patient will require urgent workup and management.

First Imaging Study

What is the first imaging study you will order?

Chest X-ray

Chest CT

None

Findings of bronchiolitis on a chest x-ray may be nonspecific, and it is not necessary in cases of typical bronchiolitis. A chest x-ray may be useful to determine whether there is any additional consolidation or lung collapse that might require further treatment. For the purposes of this case, we will show the findings on chest x-ray.

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Chest X-ray

There is a consolidation present.

Yes

There is no focal segmental or lobar consolidation.

There is a pneumothorax present.

Yes

There is no pneumothorax.

View Report

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View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

Chest CT

Echocardiogram

None

No further imaging is needed.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Nonsevere bronchiolitis

Severe bronchiolitis

This patient has severe bronchiolitis due to the presence of persistently increased respiratory effort and hypoxemia.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

This patient will require urgent workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 5-month-old male presenting with severe bronchiolitis. They will require admission for fluid management and respiratory support with nasal suctioning and supplemental oxygen.

Lessons Learned:
- Bronchiolitis is characterized by upper respiratory symptoms leading to lower respiratory infection with inflammation, which results in wheezing and or crackles.
- Infants and children with moderate to severe respiratory distress (eg, nasal flaring, retractions, grunting, respiratory rate >70 breaths per minute, dyspnea, cyanosis), toxic appearance, poor feeding, lethargy, apnea, and/or hypoxemia usually require hospitalization for supportive care and monitoring.
- Supportive care (maintenance of adequate hydration, provision of oxygen and respiratory support as necessary, monitoring disease progression) and anticipatory guidance are the mainstays of management of severe bronchiolitis.
- Imaging is generally not indicated in cases of typical bronchiolitis. Findings on chest x-ray may include increased peribronchial thickening or atelectatic changes.

Socioeconomic Factors: Children with a lower socioeconomic status (SES) are more likely to present to the emergency department with bronchiolitis, and subsequently be admitted, when compared to the general population.

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