Pineda, Immah Marie R.

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PED2 PAPER CASE

CASE: A previously healthy 3 year old child was brought to you for evaluation and management. Chief
complaint is a recurrent cough for the last 2 months. There was no fever noted, no weight loss and no
other associated signs and symptoms. Birth history is noncontributory, as well as developmental and
nutritional history.

IMMUNIZATION HISTORY
Completed primary immunizations and he received boosters as well. Environmental history: The patient
lives in a 2 bedroom condominium. It is fully carpeted. He has no pets. His father is a smoker.
Nutritional history: He eats a well balanced diet. He has an allergy to peanuts. Past Medical history: No
confinements since birth. He had 1 emergency room visit due to a peanut allergy described as macular
rashes. Review of systems were unremarkable except for a history of persistent rhinitis associated with
sneezing and itchy water eyes when he wakes up in the morning.

Physical Exam:
General appearance: Patient is active, playful and neatly dressed. He is noted to have intermittent dry
cough after running around the clinic.
Weight : 14 kgs Height : 94 cm
Vital signs: HR 105/min
Respiratory rate: 30 /min BP 90/60
Focused Physical Exam on the respiratory system:
Nose: pale and boggy turbinates, no septal deviation, minimal clear discharge
Mouth and pharynx: No cavities, complete primary teeth, tongue is midline, tonsils are not enlarged
Neck: supple, no masses, cervical nodes noted at 0.5 cm
Thorax and Lungs:
Inspection: Symmetrical, no masses, no deformities
Palpation: Symmetrical expansion during inspiration and expiration
Auscultation: Wheezing noted over bilateral lung fields, polyphonic, occasional crackles noted also
over both lungs fields

Question 1: What are the questions that you will ask to evaluate the cause of the
recurrent cough?

First, I will ask the onset of the cough by asking the parents, “When did the coughing
start?”, this is to know how long the patient is suffering from the condition. Then important
questions like, “How frequent does it appear within the day?” and “What time of the day does
the cough usually appear or aggravate?” will be asked, because some diagnosis of cough
occurs at different times of the day, for example, asthma is worse at night affecting sleep, while
habit cough has a diurnal variation that usually disappears with sleep. Knowing about the
characteristic of the cough is also important; “Is the cough dry or wet?” - this is because dry
cough is seen in patients with bronchial asthma, while wet, productive cough is usually a
characteristic of foreign body aspirations, bronchiolitis or pneumonia; “Does the cough have a
specific quality like brassy or barking?” - as seen in cases of croup, tracheomalacia or tracheitis;
“Is it paroxysmal (coughing that has an increasing severity or frequency)?” - as seen in cases of
foreign body aspiration, pertussis, or infection to mycoplasma or chlamydia. “Does the patient
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perform throat clearing?” - as seen in post-nasal drip. These specific details are important to
pinpoint the etiology of the cough. It is also important to know what triggers or aggravates the
cough, “Are there any activities that are accompanied by the cough like feeding, sleeping,
playing, or doing school works?”, this is important to understand the cause and the impact of the
symptom to the patient’s functionality in activities of daily living. It is also important to know what
activities and modalities relieve the cough. It can assist in the diagnosis and can also affect the
management of the patient. Not only the patient information is important in this case, but also
information from the people that the patient spends time with most of the time. We can rule out
conditions that have genetic predisposition by asking if there is any history of asthma, TB,
pneumonia, and other respiratory conditions in the family. Infectious causes may also be ruled
out by asking if there are any household members with the same symptoms. And since there is
a pandemic that is present nowadays, it is also an important consideration. Parents should be
asked if there was any exposure to probable or confirmed COVID-19 patients within the
members of the household for the past 2 weeks to know if the child has a possible exposure to
COVID-19 infection.

Question 2: What are the questions that you would like to ask to arrive at a probable
diagnosis of asthma?

Several important questions are needed to ask to support the diagnosis of asthma,
starting with the presence or absence of accompanied symptoms such as wheezing, shortness
of breath, and chest tightness. It is also important to ask the parents about triggers by asking
“Are there any triggers like cold air, exercise, exposure to certain irritants, strong odor, food,
cigarette smoke, drugs or any chemicals?”. Presence of triggers will support the diagnosis of
bronchial asthma. It is also important to ask the patterns of symptom occurrence by asking the
parent, “Does the patient experience symptoms when laughing, crying, running, or needs to
stop when playing?”. Asthma also has a nocturnal pattern of symptoms, therefore, it is important
to ask the following: “Are the symptoms worse at night?”, “Does the child wake up due to
coughing, wheezing or difficulty breathing?”. This condition is also commonly associated with
atopy and allergic rhinitis, that is why it is important to ask the parent if the patient has allergies
or any history of allergic rhinitis or eczema. It is also important to rule out other conditions by
asking the parents whether the patient shows other symptoms like fever, flu-like symptoms,
presence of stridor, sudden weight loss, and other symptoms that will point to an alternative
diagnosis. And since studies show that asthma has a genetic predisposition,1 asking about any
family history of asthma, hay fever, eczema, allergies or any breathing problems is necessary in
the consideration of the disease. Lastly, since this condition is diagnosed clinically, it is important
to know the response of the patient’s symptoms in the occurrence that medications were given
as a remedy, the parents should be asked the following questions: “Have you tried giving
medications? If yes, what is it and did the patient’s symptoms relieve?”

Question 3: Provide at least 3 differential diagnoses in a child with a probable diagnosis

of B. asthma and describe in your own words how you would rule in or out the clinical
diagnosis based on history taking.
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Differential diagnosis:
● Foreign body aspiration
● Acute bronchiolitis
● Pneumonia

In determining the primary diagnosis of the patient, it is important to determine first the
different systems that may have contributed to the patient’s symptoms. The chief complaint of
the patient is recurrent coughing for approximately 2 months duration which may have
originated from a specific system in the body. It may come from the gastrointestinal system, as
seen in cases of gastroesophageal reflux. However, no mention of coughing associated with
feeding, therefore this system is less likely. Nervous system can also cause recurrent coughing
when the cough center in the medulla oblongata of the brainstem is affected, but the patient
appears to be alert and active and no mention of accompanied neurological symptoms and any
history of recent head injury, therefore, this system is less likely. More commonly, the
cardiovascular system may also cause coughing in children as seen in conditions such as
congenital heart disease and congestive heart failure, but the patient’s only complaint is
coughing, and no mention of symptoms that may point to a cardiac origin like cyanosis,
tachycardia, or tachypnea. Therefore, the most basic organ system that may be involved in this
case is the respiratory system.
After determining the system involved in the case, three diagnoses were determined and
were clinically ruled out because it may confuse the diagnosis of bronchial asthma. First is
foreign body aspiration. This is a condition that occurs when an object or a foreign body (most
common are food) gets dislodged in the respiratory tract, more commonly in the right-side
airways because the right mainstem bronchi is more vertical than the left. Children are at high
risk for aspirations because they tend to put small objects in their mouth and that they aren't
able to chew their food adequately because their molars are not yet developed. Commonly,
parents tend to not notice that the child aspirated something because most of the time the child
is asymptomatic at onset especially if the size of the particle is too small to cause obstruction in
the upper airways which typically manifests with coughing and choking at onset. It is commonly
detected only several weeks after when the child already manifests with coughing or pneumonia
symptoms that do not respond to antibiotics. In relation to the case, a previously healthy child
who presented with recurrent coughing may be suspected of having foreign body aspirations.
However, this will be ruled out if the parent reported in the history taking absence of
accompanied sputum production (wet cough) and recurrent episodes of pneumonia symptoms
in the past.
Next condition that needs to be ruled out is acute bronchiolitis. This is a condition that
involves acute inflammation of the bronchioles which is typically induced by a virus, most
commonly, respiratory syncytial virus (RSV). It is typically accompanied with edema, increased
mucus production and bronchospasm. This diagnosis was considered in the differential because
it has the same pathophysiology with bronchial asthma. Bronchiolitis typically manifests with
harsh, moist coughs that vary from mild to severe. It is likely because the patient’s cough was
preceded by episodes of rhinitis associated with sneezing which are the typical presenting signs
and course of bronchiolitis. However, bronchiolitis is typically associated with fever since it has a
viral origin. In the case of the patient, it was mentioned in the history that no fever was noted
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and it is also important to consider that the immunization of the patient was complete with
boosters, which makes him/her less likely to have an infection. More importantly, as the name
implies, acute bronchiolitis has a short duration of symptom progression which typically occurs
within 7 days or 1 week that can either progress into complete recovery or an acute respiratory
failure in severe cases. In the patient history, it was mentioned that the symptom was
intermittent and has been recurrent for 2 months duration.
Last condition to consider is pneumonia. This is a condition that is associated with
airway obstruction from swelling, abnormal secretions and cellular debris. It is usually a result of
viral or bacterial infection, hypersensitivity reactions, aspiration, or sometimes, drug-induced.
Coughing combined with rhinitis is a typical precipitating manifestation of pneumonia, that is
why this diagnosis was considered in the patient's case. However, because the majority of
pneumonia cases in childhood are a result of viral infection, it is frequently accompanied with
fever as its presenting symptom. And just like in the case of bronchiolitis, it was ruled out
because the patient has no fever, and complete immunization was reported in the history.
The primary diagnosis in this case is bronchial asthma as suggested by the recurrent
non-productive dry cough of the patient that occurred after playing around. Combinations of
coughing, wheezing and shortness of breath have been shown to increase the probability of
bronchial asthma as diagnosis.1 This is because this condition involves narrowing of airways as
a result of inflammation, mucus production, hypersensitivity reaction, and bronchospasm. It is
usually triggered by various factors like infection, presence of irritants, and allergies which in this
case, supported by the patient’s allergy to peanuts indicating atopic dermatitis and history of
allergic rhinitis which together forms the atopic triad in conjunction with bronchial asthma.

Question 4: What tests will you do to determine if the child has asthma or not and
provide expected results if you are highly considering B. asthma?

● Therapeutic trial with low dose inhaled corticosteroids (ICS)

○ As-needed short-acting beta2-agonist (SABA) and low dose ICS were used as a
trial of treatment for at least 2-3 months to guide the diagnosis of asthma.1
Response to the medication is evaluated by control of symptoms at both daytime
and night-time, as well as the frequency of wheezing episodes and
exacerbations. Marked improvement of symptoms upon providing treatment and
deterioration of symptoms upon ceasing the treatment supports the diagnosis of
asthma.1
● Chest X-ray
○ Radiography is not really routine in bronchial asthma and is often used to exclude
differentials1 such as structural abnormalities, infectious causes, and foreign body
that may manifest with wheezing or coughing which can confuse the diagnosis of
asthma. In this case, x-ray will be recommended to rule out the 3 differentials
mentioned above.
● Test for allergic sensitization (Skin prick test/Allergen-specific immunoglobulin E)
○ Skin prick testing or allergen-specific immunoglobulin E is used to assess
sensitization to allergens which as mentioned above, most children with asthma
have. However, negative results with sensitization doesn’t necessarily rule out
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the diagnosis of asthma, but it can be a good predictor in the development of
asthma.1 Since an allergic reaction to peanuts were mentioned in the history, this
test will still be included in the work up to know other allergens that the patient
may be allergic to and can trigger an asthma attack.
● Exhaled nitric oxide
○ This test is not widely used in children because of its limited availability,
therefore, this will not be included in the patient’s work-up. However, for the sake
of completion of information, when this test is available, elevated exhaled FeNO
is seen in children with recurrent cough and wheezing as a result of inflammation
in the airways. This is usually an adjunct to diagnose asthma and to monitor the
patient's response to medications given.

Question 5: The patient had a previous chest x-ray and the mother shows the film to you.
Please provide your description of the chest x-ray and correlate it with your diagnosis.

● Widening of intercostal space (red), narrow cardiac silhouette (green), and flattening of
the hemidiaphragm (black) are indicative of hyperinflation as seen in most cases of
bronchial asthma2 due to the trapping of air as a result of narrowing of the airways.
● Bronchial thickening with paucity of lung markings (blue) and hilar enlargement (yellow)
is seen when inflammation is present in the airways3 which is one of the the mechanisms
behind airway narrowing in bronchial asthma.

Question 6: Provide your management of this patient for this consultation based on your
diagnosis.

Because the patient has intermittent, dry cough upon running around and auscultation
showed wheezing, indicating an active asthma attack, inhaled short acting beta2-agonist (SABA)
will be given for relief of symptoms. This will be recommended as the initial management plan of
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the patient and response to it will be monitored for a month. If an average use of more than
twice a week for over a month in order to achieve symptomatic relief was reported, the patient
will be started with a trial of controller medication.1 Regular, daily low dose of inhaled
corticosteroid (ICS) will be recommended and will be given for at least 3 months to establish its
effectiveness in controlling the patient’s asthma. If the diagnosis of asthma is established and
the patient responds well with the trial period of controller treatment, regular controlled ICS will
be prescribed as maintenance medication for the patient.1
Assessment of symptom control and presence of side effects will be done every visit,
including measurement of the patient's height annually, since one of the side effects of steroids
is retarded growth. The response to this therapy will be regularly assessed every 3-6 months. If
after 3 months, the initial therapy of low dose ICS fails to control the symptoms or if
exacerbation occurs, assessment on inhaler technique, adherence to prescribed dose, or
encounter with risk factors will be done to know the cause of uncontrolled symptoms. If all these
were considered yet the symptoms are still uncontrolled, doubling the initial dose of ICS may be
the best option which will be reassessed after 3 months.1

Question 7: Provide an asthma action plan in case the child will have an asthma
exacerbation.

RECOGNIZE Acute or subacute increase in symptoms such as wheezing, shortness of breath, and coughing (especially
at night)

ASSESS ● Alterations in the level of consciousness and/or activity (lethargic or with decreased exercise
tolerance)
● Impairments in daily activities (e.g. feeding)
● Alternative diagnosis
● Need for hospitalization:
○ In acute distress
○ Unrelieved symptoms or progressively shorter periods of relief after inhaling bronchodilators
○ Repeated inhaled bronchodilators is required over several hours

Severity Symptoms (Any of the Reliever medication Immediate medical

following is present) attention if:

MILD / ● Breathless, agitated Salbutamol 100 mcg 2 puffs ● Lack of response to

MODERATE ● Pulse rate of at least 180 (inhaler) salbutamol over 1-2 hrs
bpm or less ● Signs of severe
(Start ● O2 sat of 92% or greater Repeat every 20 exacerbation
treatment) minutes for the first ● Increased respiratory rate
hour, if needed. ● Decreased O2 sat

(Continue ● Symptoms recur within 3-4 Extra 100 mcg 2-3 ● Worsening or failure to
treatment if hours Salbutamol puffs/hr respond to 10 puffs over
needed) 3-4 hours
Prednisolone 2 mg/kg oral
(max: 30
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mg)

SEVERE / LIFE ● Unable to speak or drink

THREATENING ● Bluish discoloration of the
body and mucosa Immediate medical attention needed!!
(Immediate ● Confusion or drowsiness
medical ● Respiration of >40/min While waiting:
attention ● O2 saturation of less than ● Give salbutamol, 100 mcg x 6 puffs (inhaler). Repeat every 20
needed) 92% minutes
● Silent chest on auscultation ● Provide oxygen (if available) and maintain O2 sat at 94-98%
● Pulse rate of more than 180 ● Give prednisolone 2 mg/km (max 30 mg) orally.

Emergency contact details:

St. Luke's Medical Center – Quezon City (Emergency Department)
Address: 279 E Rodriguez Sr. Ave, Quezon City, 1112 Metro Manila
Phone: (02) 8723 0101
Hours: Open 24 hours

**All information in this asthma action plan is based on the Global Initiative for Asthma (GINA), 2021. 1

Question 8: Provide a short asthma education for parents.

Asthma is a disorder that involves narrowing of the airways in the lungs as a result of several
triggers such as infections, allergies, cigarette smoke, exercise and many others, which may
cause symptoms of dry, recurrent cough, wheezing, and/or shortness of breath. Therefore, to
control these factors and allow symptom control, parents must know the following:
● Eliminate the exposure of the child to cigarette smoke by preventing smoking at areas
that their children use such as in their homes, school or even inside the car. It is also
encouraged that parents or caregivers quit smoking in order to totally remove the chance
of the child to be exposed.
● Regular exercise and physical activity is encouraged because it improves
cardiopulmonary fitness and has been proven to provide benefits in asthma control. To
prevent exercise-induced bronchoconstriction, the following may be done:
○ Warm-up and breathing exercises before physical activity or play
○ Inhaled SABA and/or low dose ICS taken before play
● Immunization must always be completed and updated, including booster shots to
decrease the risk of acquiring infection that may trigger asthma symptoms.
● Encourage children to consume a diet rich in fruit and vegetables for its general health
benefits.
● Indoor and outdoor allergens and triggers such as dust, insects, or pests can be
controlled by maintaining a clean and conducive environment for the child to live in.
Avoiding pets or limiting the child's exposure to pets can also help in controlling the
symptoms and preventing exacerbations
● Proper inhaler technique should also be practiced and the parents should monitor and
correct the patient's usage. Proper technique is shown in the picture below:
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Photo taken from: https://www.fairview.org/patient-education/86587

● In the event that exacerbation occurs, the parents or caregivers may refer to the asthma
exacerbation action plan above.
● Regular check-up should be done every 3-6 months, to assess the child’s status and
response to reliever and/or controller medications
● Any questions and/or concerns, contact your pediatrician.

(Attached on the last page is an example of the asthma education flyer that will be given
to the parents and caregivers)

Bibliography:
[1] 2021 GINA Main Report - Global Initiative for Asthma [Internet]. GINA. 2021 [cited
2021Oct29]. Available from: https://ginasthma.org/gina-reports/
[2] Weerakkody Y. Asthma: Radiology Reference Article [Internet]. Radiopaedia Blog RSS.
[cited 2021Oct29]. Available from:
https://radiopaedia.org/articles/asthma-1#:~:text=Radiographic features,-Plain
radiograph&text=Plain chest radiographs can be,of cases with asthma 1)
[3] Dimango EA, Lubetsky H, Austin JHM. Assessment of Bronchial Wall Thickening on
Posteroanterior Chest Radiographs in Acute Asthma. Journal of Asthma. 2002;39(3):255–61.
Pineda, Immah Marie R.
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