Wheezy Child – OSCE Case

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Introduction

A 7-year-old boy is brought to the GP by his mother due to a wheeze. Work through the case to reach a diagnosis.

UK Medical Licensing Assessment (UKMLA)

This clinical case maps to the following UKMLA presentations:

  • Wheeze
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History

Presenting complaint

“It’s my son, Elliot, I’ve noticed a wheeze sometimes, and it’s worrying me.”

History of presenting complaint

When did you first notice the wheeze?

β€œ6 months ago”

When does Elliott wheeze?

β€œMainly when playing sports, but also sometimes in the mornings”

Has the wheeze been getting worse over time?

β€œIt occurs more regularly with exercise now”

Have you noticed any other triggers for the wheeze?

β€œHe seems more wheezy after he plays with his neighbour’s cat”

Have you tried any medications for the wheeze yet?

β€œNo”

When did you first notice the cough?

β€œ6 months ago”

When does Elliott cough?

β€œHe always coughs in the mornings and often before bedtime too”

Does he bring up any phlegm with the cough?

β€œYes”

What colour is the phlegm?

β€œUsually it is colourless, but sometimes it is yellow-green when he has a cold”

Have you ever noticed blood in the phlegm?

β€œNever”

When was the last time he was tested for COVID-19?

β€œHe does twice-weekly lateral flow tests for school- they are always negative”

Shortness of breath?

β€œHe’s increasingly short of breath when playing sports now”

Chest pain?

β€œOnly when he feels very wheezy after playing sports”

Fever?

β€œOnly when he has a cold”

Night sweats?

β€œNo”

Family history of asthma?

β€œHis father had childhood asthma”

Any A&E attendances for the wheeze?

β€œNo”

For more information, see the Geeky Medics guide to respiratory history taking.


Clinical examination

Examination findings

Respiratory examination:

  • Mild expiratory wheeze bilaterally
  • No intercostal recession nor tracheal tug
  • RR 24
  • Sats 99% on room air

Cardiovascular examination:

  • HS I + II + 0
  • HR 80
  • CRT 2 seconds

Patient’s elbow

An image of the patient’s anterior elbow crease is shown below:

The patient's anterior elbow crease
Figure 1. The patient’s anterior elbow crease.1Β 

Suggestive of atopic dermatitis

  • Dry and erythematous skin
  • Lichenification
  • Areas of skin thinning (possibly secondary to steroid overuse)


Investigations

Measuring the peak expiratory flow rate (PEFR) is the first-line investigation as it is easy to perform during the initial consultation. Patients can also be given a peak flow meter to measure their PEFR at home.

Peak flow readings

The patient’s first week of peak flow readings are shown below:

The measurements show diurnal variability, defined as a mean intra-day variation of peak expiratory flow rate >20%. In this graph, the mean intra-day variation is approximately 70%.


Diagnosis

Those in bold are the most likely, but a range of other potential differentials are shown using the VINDICATE acronym:

  • Vascular –
  • Inflammatory & infectious – asthma, series of lower respiratory tract infections
  • Neoplastic
  • Degenerative
  • Idiopathic – gastro-oesophageal reflux disease, vocal cord dysfunction
  • Congenital – cystic fibrosis, tracheomalacia
  • Autoimmune – children’s interstitial lung disease
  • Traumatic – inhaled foreign body
  • Endocrine

Asthma is the most likely diagnosis. This is because asthma typically presents with wheeze/dyspnoea/cough, which are worse in the mornings and evenings, and can be triggered by exertion. Also, diurnal variation in peak expiratory flow rate is diagnostic for asthma.


Management

An inhaled corticosteroid, such as beclometasone dipropionate (Clenil) 100mcg BD, would be an appropriate initial preventer regime for a 7-year-old boy.


Complications


Editor

Dr Jess Speller


References

  1. James Heilman, MD. Atopy. License: [CC BY-SA]
  2. British Thoracic Society.Β BTS/SIGN Guideline for the management of asthma. Published in 2019. Available from: [LINK].

 

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