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Routine tests may include a CBC; sedimentation rate; smear and culture of material from the nose, throat, and sputum; x-ray of the chest and sinuses; and, in adults, an EKG. In adults also it might be wise to order a chemistry panel, thyroid profile, and VDRL test, depending on the clinical picture. Direct laryngoscopy can now be done in the office with the fiberoptic laryngoscope. In addition, fiberoptic bronchoscopy may be valuable. A Tensilon test may need to be done. An ear, nose, and throat specialist should be consulted before ordering expensive diagnostic tests. If there are neurologic signs, a neurologist should be consulted.
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
The CBC, sedimentation rate, chest x-ray, EKG, sputum analysis and culture, and pulmonary function testing will usually assist with the clinical diagnosis. Bronchoscopy may be needed also, especially when there is hemoptysis .
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?
Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?
Then examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note burns or signs of trauma, such as ecchymoses and lacerations.
Source: Handbook of Signs & Symptoms (Third Edition), 2006
If the patient isn’t in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma or changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or any respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?
Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?
Examine the patient’s nose and mouth for congestion, drainage, or signs of infection, such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 599.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rubs. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds.)
Source: Handbook of Signs & Symptoms (Third Edition), 2006
When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?
Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?
Then examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note any burns or signs of trauma, such as ecchymoses and lacerations.
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
If the patient isn’t in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma and recent changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or any respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?
Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?
Examine the patient’s nose and mouth for congestion, drainage, or signs of infection such as halitosis. If he produces sputum, obtain a specimen for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 766.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rub. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds. See also Differential diagnosis: Wheezing, pages 826 and 827.)
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
A. Focused physical examination (PE)
1. The PE should include vital signs, notably temperature and respiratory rate, and pulse, with emphasis on general appearance and examination of the head and neck, including ears, nose, and throat.
2. Signs of respiratory distress may be present, including dyspnea, tachypnea, chest retractions, nasal flaring, and stridor. If cyanosis is present, this is an ominous sign (2,4) (Chapter 8.2).
B. Additional physical examination may reveal:
1. A toxic-appearing child with high fever, drooling, severe respiratory distress, and preference for a sitting and forward-leaning position (1,4)
2. Varying degrees of anxiety, which will increase during examination, cause a worsening of stridor (1,4)
A. The best test is a lateral neck x-ray study to assist with a diagnosis that is mostly made on clinical grounds. Films of the larynx and trachea in anteroposterior and lateral neck views may show narrowing of the trachea or extrinsic pressure on the tracheobronchial airway. Acutely, lateral neck radiographs showing the classic swollen glottis described by some as a thumbprint, assist with the diagnosis of acute supraglottitis and eminent respiratory collapse. Chest x-ray studies are of little value. Films showing hyperinflation or bronchial thickening may help to make a diagnosis of asthma rather than stridor. Additionally, foreign body aspiration or mass will be elucidated in x-ray studies (2).
B. Tomograms or computed tomography (CT) of the neck may provide additional information, especially in chronic stridor (2).
C. Blood tests (e.g., complete blood count) can be useful in the acutely ill patient, especially if viral or bacterial infection is suspected.
D. With suspicion that the stridor is a result of a laryngomalacia or laryngeal lesions such as papilloma, direct laryngoscopy is the test of choice for accurate diagnosis. Direct observation via fiberoptic bronchoscope positioned in the pharynx would provide diagnostic views of the larynx (2,4).
In making the diagnosis of stridor, two key elements exist: acute onset in a toxic-appearing patient, versus chronic stridor in a relatively stable patient.
A. Acute stridor
1. The most likely cause of acute stridor in the febrile child with the additional features of barking cough and antecedent coryza is laryngotracheobronchitis or croup. Acute stridor is a non–life-threatening condition accounting for 90% of stridor cases. Classically, it improves with exposure to moist air. It has a viral cause, usually from one of the following: respiratory syncytial virus, rhinovirus, adenovirus, parainfluenza virus, and influenza virus. Generally, this diagnosis is made on clinical grounds (1). The child is less ill and, although often febrile, not toxic appearing. The entire illness usually abates in 5 days. Hospitalization, unlike with epiglottitis, is rarely needed (2).
2. In the toxic patient with fever, respiratory distress, sore throat, or drooling, especially in the younger age group, consider epiglottitis—a medical emergency. As use of the Haemophilus influenzae vaccine has increased in recent years, acute epiglottis is becoming increasingly rare. H. influenzae is the most common bacterial cause of stridor, although streptococcus, staphylococcus and viral agents are also possible causes.
3. The patient with a history of suspected foreign body aspiration will have similar symptoms without fever. Foreign body aspiration is common in the 1- to 2-year age groups, although it does occur in adults. It can be a cause of chronic stridor (3).
4. Additionally, an acute allergic reaction can cause stridor. The history should herald a possible offending agent and, although respiratory collapse may be eminent, the patient will not be toxic, as no infectious agent is involved.
5. Trauma can also cause laryngeal damage; however, the history will assist with this diagnosis.
B. Chronic stridor. For the most part, these causes of stridor occur in early childhood. With the exception of laryngeal papillomas, tumors, and subglottic stenosis after instrumentation as in intubation (there is a congenital form also), foreign body aspiration with partial obstruction and hysterical stridor can occur at any age. Laryngomalacia and laryngeal lesions are caused by webs, hemangiomas, and cysts; they are usually identified early in life (1–3).
References
1. Pryor MP. Noisy breathing in children. Postgrad Med 1997;101:103–112.
2. Behrman RE, Kliegman RM, Arvin AM. Nelson textbook of pediatrics. Philadelphia: WB Saunders, 1996:241, 1173, 1198, 1238.
3. Behrman RE, Vaughan VC. Nelson textbook of pediatrics. Philadelphia: WB Saunders, 1983:1031–1032, 1076–1077.
4. Tintinalli JE, Ruiz E, Krome RL. Emergency medicine: a comprehensive study guide. New York: McGraw-Hill, 1996:247–251.
5. Campbell AGM, MacIntosh N. Textbook of pediatrics. London: Pearson Ltd., 1998:
508–513, 563.
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
A. Vital signs. A full set of vital signs is essential to the assessment of the wheezing patient. The respiratory rate and the pulse are a more objective, and often more accurate, assessment of the severity of wheezing than the auditory volume of the wheezing itself. Fever suggests a concurrent respiratory infection. Hypotension is an ominous sign that points to a decompensating patient.
B. Lung examination. During auscultation, note the location, intensity, and duration of wheezing. Wheezing caused by asthma, chronic obstructive pulmonary disease (COPD), or interstitial disease should be diffuse and symmetric and present during expiration. The expiratory phase will be prolonged. Focal obstruction (e.g., tumors and foreign bodies) can give asymmetric findings and inspiratory wheezing. Mucus plugging will change with cough. Rhonchi and crackles suggest a concurrent infectious process. Percussion and egophony can be present with consolidation.
A. Pulmonary function. A peak flow meter is a valuable initial assessment of airway obstruction and can be done quickly and cheaply in the office. It is also an excellent measure of progression of disease or success of treatment. Pulse oximeter is another quick, noninvasive office technique to assess the severity of both chronic disease and acute respiratory distress. Full spirometry, although not available in all primary care offices, gives additional diagnostic information that can differentiate among asthma, COPD, and fixed airway obstruction.
B. Chest x-ray study. Plain chest films will identify consolidation, masses, mediastinal shifts, and hyperaeration.
C. Clinical laboratory tests. A complete blood count may demonstrate signs of an acute bacterial infection. Polycythemia is a sign of chronic hypoxia (Chapter 16.5). Eosinophilia can indicate asthma or allergic disease (Chapter 16.2). Angiotensin-converting enzyme levels are elevated in sarcoidosis. A tuberculin skin test should be considered in all patients with wheezing or chronic cough.
The history and physical examination are the key elements to an acute diagnosis. A consistent exposure or reaction history, coupled with an elevated serum IgE or eosinophilia, indicates allergic disease. Wheezing in the setting of acute bronchitis or sinusitis is not true asthma and the patient can be reassured that this is not the beginning of a chronic disease. Inspiratory wheezing, or stridor, indicates upper airway obstruction or psychogenic wheezing. A normal, or nearly normal, peak flow is reassurance that good air exchange is occurring, regardless of the loudness of the wheezing. The pulse oximetry will differentiate between severe obstruction and poor cooperation with the peak flow testing. When confusion still exists, spirometry will clarify the diagnosis in most cases. The diagnosis and treatment of most cases of wheezing is within the scope of practice of the primary care physician.
References
1. Pryor MP. Noisy breathing in children. Postgrad Med 1997;101:103–111.
2. Martinati LC, Boner AL. Clinical diagnosis of wheezing in early childhood. Allergy 1995;50:701–710.
3. Meslier N, Charbonneau G, Racineux JL. Wheezes. Eur Respir J 1995;8:1942–1948.
4. Goldman J. All that wheezes is not asthma. Practitioner 1997;241:35–38.
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
A wheeze is a continuous musical sound produced by vibration of airway walls when they are near closure. A wheeze consisting of a single musical note indicates small airways disease, usually asthma. Polyphonic wheezes (multiple musical notes) are produced by dynamic compression of large central airways.
Stridor signifies central airway obstruction, and is an ominous portent of impending complete airway closure. Causes such as an aspirated foreign body or bronchogenic cancer should be suspected when the onset of wheezing is sudden and focal, allergic markers and specific triggers are absent, and response to bronchodilator is poor. A history of aspiration, or smoking and clubbing are also helpful.
Nocturnal wheezing could be the result of congestive heart failure (paroxysmal nocturnal dyspnea) or gastric aspiration with reflux.
Dyspnea on exertion correlates with an FEV1 below 50% predicted, and dyspnea at rest with FEV1 below 25% predicted. Forced expiratory time (FET) is measured by ausculting over the trachea, and timing until airflow is no longer heard. FET of 9 seconds predicts an FEV1/FVC ratio of 70%. Stridor indicates that the airway diameter is less than 5 mm.
Source: Field Guide to Bedside Diagnosis, 2007
When the patient is awake, perform a complete respiratory assessment, followed by an examination of his head, nose, and throat. If you detect stertorous respirations while the patient is sleeping, observe his breathing pattern for 3 to 4 minutes. Do noisy respirations cease when he turns on his side and recur when he assumes a supine position? Watch for periods of apnea and note their length.
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note any burns or signs of trauma, such as ecchymoses and lacerations.
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Examine the patient’s nose and mouth for congestion, drainage, or signs of infection, such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 655.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rubs. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds, pages 720 and 721.)
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
If you detect stertorous respirations while the patient is sleeping, observe his breathing pattern for 3 to 4 minutes. Do noisy respirations cease when he turns on his side and recur when he assumes a supine position? Watch carefully for periods of apnea and note their length.
If the patient isn't in severe respiratory distress, begin with the history. Question the patient about his snoring habits. Is his partner frequently awakened by his snoring? Does the snoring improve if the patient sleeps with the window open? Does he talk in his sleep or sleepwalk? Ask about signs of sleep deprivation, such as personality changes, headaches, daytime somnolence, or decreased mental acuity.
Perform the physical examination by first assessing the patient's level of consciousness and his orientation to time, place, and person. Observe spontaneous movements, and test muscle strength and deep tendon reflexes. Next, inspect the chest for deformities or abnormal movements such as intercostal retractions. Inspect the extremities for cyanosis and digital clubbing.
Now, palpate for expansion and diaphragmatic tactile fremitus, and percuss for hyperresonance or dullness. Auscultate for diminished, absent, or adventitious breath sounds and for abnormal or distant heart sounds. Do you note peripheral edema? Finally, examine the abdomen for distention, tenderness, or masses.
Source: Nursing: Interpreting Signs and Symptoms, 2007
When the patient's condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?
Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or cough?
Then examine the patient's mouth for excessive secretions, foreign matter, inflammation, andswelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient's chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note burns or signs of trauma, such as ecchymoses and lacerations.
Source: Nursing: Interpreting Signs and Symptoms, 2007
If the patient isn't in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma or changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?
Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?
Examine the patient's nose and mouth for congestion, drainage, or signs of infection, such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect the patient's chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 597.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rubs. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds,
Source: Nursing: Interpreting Signs and Symptoms, 2007
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
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Medical Articles:
Wheezing - Case 1-1: 8-Month-Old Girl:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
Temperature (T), 38.3°C; respiration rate (RR), 60/min; heart rate (HR), 110 bpm; blood pressure (BP),
110/55 mm Hg; and pulse oximetry (SpO
2), 100% in room air
Height, 25th percentile; weight, 25th percentile; head circumference, 25th
percentile
Initial examination revealed a well-nourished, acyanotic infant in moderate
respiratory distress. Physical examination was remarkable for purulent
rhinorrhea and buccal mucosal thrush. Moderate intercostal and subcostal
retractions were present. There was fair lung aeration with diffuse expiratory
wheezing. No murmurs or gallops were heard on cardiac examination, and femoral
pulses were palpable. No hepatomegaly or splenomegaly was present.
IV. Diagnostic Studies
Laboratory analysis revealed 14,600 white blood cells (WBCs)/mm3, with 38% segmented neutrophils, 53% lymphocytes, and no band forms. The
hemoglobin was 11.0 g/dL, and there were 580,000 platelets/mm
3. Electrolytes, blood urea nitrogen, and creatinine were normal. Polymerase
chain reaction performed on nasopharyngeal aspirate was negative for
Bordetella pertussis. Antigens of adenovirus; influenza A and B viruses; parainfluenza virus types 1,
2, and 3; and respiratory syncytial virus (RSV) were not detected by
immunofluorescence of nasopharyngeal washings. However, RSV subsequently grew
in viral culture of the nasopharyngeal aspirate. Blood and urine cultures were
negative.
Wheezing - Case 1-3: 5-Week-Old Boy:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
T, 38.5°C; HR, 180 bpm; RR, 70/min.; BP, 62/40 mm Hg; SpO2, 96% in room air
Length, 25th percentile; weight, 50th percentile
The infant was ill-appearing and in moderate respiratory distress. His anterior
fontanelle was open and flat. There was no conjunctival injection or discharge.
There was intermittent grunting and nasal flaring. Moderate intercostal and
subcostal retractions were present. Breath sounds were diminished throughout
the left chest. The right lung was clear to auscultation. There was no
wheezing. The heart sounds were normal. The liver was palpable 1 cm below the
right costal margin. The spleen was not palpable. The Moro reflex, grasp, tone,
and reflexes were normal. There were no rashes or petechiae.
IV. Diagnostic Studies
Arterial blood gas revealed the following: pH, 7.40; carbon dioxide tension
(PaCO
2), 40 mm Hg; oxygen tension (PaO2), 214 mm Hg; and bicarbonate, 26 mEq/L. The complete blood count demonstrated
37,900 WBCs/mm
3, including 3% band forms, 67% segmented neutrophils, and 30% lymphocytes. The
platelet count was 520,000/mm
3, and hemoglobin was 9.4 g/dL. Serum electrolytes, blood urea nitrogen, and
creatinine were normal. There were no WBCs, protein, or nitrites on
urinanalysis. A blood culture was obtained. Lumbar puncture was not performed
due to the patient
's respiratory distress. Chest radiography demonstrated left lower lobe
consolidation with an associated pleural effusion causing rightward shift of
the mediastinal structures (Fig. 1-4).
Wheezing - Case 1-4: 15-Month-Old Girl:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
T, 37.4°C; RR, 44/min; HR, 110 bpm; BP, 103/65 mm Hg; SpO2, 96% in room air
Weight, 16.5 kg (10th percentile); height, 105 cm (25th percentile)
Physical examination revealed a thin child in mild respiratory distress. There
was no conjunctival infection. The sinuses demonstrated symmetric
transillumination. The oropharynx was clear. There was no cervical
lymphadenopathy. There were mild intercostal retractions with good aeration and
mild diffuse wheezing. Breath sounds were slightly diminished in the right
lower lobe. The cardiac examination was normal. There were no rashes or skin
lesions. The remainder of the examination, including the neurologic
examination, was normal.
IV. Diagnostic Studies
Her WBC count was 18,300 mm3, with 9% band forms, 78% segmented neutrophils, and 13% lymphocytes. Her
hemoglobin and platelet counts were normal. A blood culture was obtained and
subsequently was found to be negative. Chest radiography revealed a right
middle lobe density. There was no hyperinflation or peribronchial thickening.
Wheezing - Case 1-5: 5-Week-Old Boy:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
T, 37.7°C; RR, 60/min; BP, 78/37 mm Hg; HR 160 bpm; SpO2, 88% in room air
Weight, 3.0 kg (less than 5th percentile); length, 49 cm (less than 5th
percentile)
Physical examination revealed a cyanotic infant in moderate respiratory
distress. The anterior fontanelle was open and flat. There was no conjunctival
injection. There were no oral mucosal ulcerations. Capillary refill was brisk.
The heart sounds were normal. Femoral pulses were palpable. There were
intercostal retractions. Rales and wheezes were present diffusely. The liver
edge was palpable 3 cm below the right costal margin. The remainder of the
examination was normal.
IV. Diagnostic Studies
Laboratory analysis revealed 10,200 WBCs/mm3, with 76% segmented neutrophils, 19% lymphocytes, and 3% monocytes. The
hemoglobin was 13.0 g/dL, and there were 350,000 platelets/mm
3. Hepatic function panel was as follows: total bilirubin, 0.3 mg/dL; alanine
aminotransferase, 32 U/L; aspartate aminotransferase, 66 U/L. The prothrombin
and partial thromboplastin times and fibrinogen split products were normal.
Blood cultures were obtained. Chest radiography revealed diffuse interstitial
pulmonary edema but a normal cardiothymic silhouette.
Wheezing - Case 1-6: 4-Month-Old Boy:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
T, 37.0°C; RR, 76/min; HR, 120 bpm; BP, 102/72 mm Hg; SpO2, 93% with 3 L O2/min by nasal cannula
Weight, 10th to 25th percentile; length, 10th percentile; head circumference,
10th percentile
He was awake and alert. The anterior fontanelle was open and flat. He had
flaring of the alae nasi. There were moderate intercostal, subcostal, and
supraclavicular retractions. Scattered rhonchi were present, with diminished
breath sounds at the bases bilaterally. There was no focal wheezing. The heart
sounds were normal. The spleen was palpable just below the left costal margin.
The remainder of the examination was normal.
IV. Diagnostic Studies
The WBC count was 10,200/mm3, with 15% band forms, 68% segmented neutrophils, and 12% lymphocytes. The
hemoglobin was 10.3 g/dL, and the platelet count was 277,000/mm
3. Arterial blood gas analysis revealed the following: pH, 7.42; PaCO2, 30 mm Hg; and PaO2, 90 mm Hg. Hepatic function panel revealed a total bilirubin of 0.3 mg/dL;
alanine aminotransferase, 55 U/L; aspartate aminotransferase, 82 U/L, and
lactate dehydrogenase, 3,280 U/L. No antigens to respiratory syncytial virus;
parainfluenza types 1, 2, and 3; influenza A and B; or adenovirus were detected
by immunofluorescence of nasopharyngeal aspirate. Serum immunoglobulin (Ig)
results were as follows: IgA, 24 mg/dL (normal range, 27 to 73 mg/dL); IgM, 528
mg/dL (normal range, 37 to 124); and IgG, 650 mg/dL (normal range, 292 to 816
mg/dL).
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