A&e Case Summary

Student name: Yoshana Muruganand Patient’s R/N: HTJ1024621
Student ID: 00000026024 Date of admission: 12/1/2021

Patient’s initials: ARA Date of clerking: 12/1/2021
ARA ,4 years old Malay boy was brough to the emergency department due to rapid breathing which started at night.
The boy had cough and runny nose for 3 days with greenish sputum production. He also had fever for a day with 2
episodes of vomiting. His mom told that his oral intake has been reduced and he became less active. He started going
to school since a week ago. His mom denied any episodes of diarrhea and any Covid-19 or sick contact. His
immunization is up to age and this is his 3rd hospitalization. His 1st admission was at birth for jaundice and his 2 nd
admission was at 2 years old for Viral gastroenteritis. He has no history of eczema. He is sensitive to cold
environment which causes runny nose.
He was alert, conscious and tachypneic at the time of admission. His peripheries were warm with good pulse volume.
Capillary refill was within 2 sec. Vital signs: pulse rate: 157 beats/minute; respiratory rate: 37 breaths/minute; Spo2:
94-95% at the time of admission. There was no enlarged tonsil during throat examination. During auscultation of the
lungs, there was generalized rhonchi and crepitation was heard over the left lower zone of his lung. Air entry was tight
bilaterally. Cardiovascular examination revealed dual rhythm and no murmur. His abdomen was soft and non-tender.
 Provisional diagnosis- Asthma

 Differential diagnosis- Viral Pneumonia, Asthma, Influenza
 Investigation- Chest Xray- hyperinflated lungs and haziness over the right side
 Final diagnosis- Preschool wheeze with multi triggers
 Management- MDI Salbutamol 6 puffs burst, waiting for admission.
Learning issue:
1) Critical thinking, problem solving and research: Preschool Wheeze Vs Asthma?
The pathology and natural progression of wheezing illnesses in pre-school children is variable and not fully
understood. The term asthma is not used to describe a wheezing illness in pre-schoolers as there is insufficient
evidence that the pathophysiology is similar to that of asthma in older children and adults. The type of wheeze a child
experiences can change over time. Pre-schoolers commonly experience wheeze during discrete time periods, often in
association with clinical evidence of a viral infection (such as rhinovirus, RSV, coronavirus, human metapneumovirus,
parainfluenza virus and adenovirus) with symptoms absent between episodes. Repeated episodes tend to occur
seasonally, and it usually declines over time disappearing by six years of age. This is known as an episodic viral
wheeze. Less commonly, a pre-school child can experience a multi-trigger wheeze. In such cases symptoms also occur
between acute exacerbations. Viral infection is a common trigger, but other triggers include tobacco smoke, allergen
exposure, mist, crying, laughter and exercise. Risk factors for a future diagnosis of asthma include: 1) onset of wheeze
over the age of 18 months, 2) personal history of atopy e.g. eczema, 3) maternal asthma. Several clinical predictive
indices for future risk of asthma have been developed based on combinations of the presence of atopic manifestations,
indirect evidence of airway inflammation such as peripheral blood eosinophil count, and severity of pre-school
wheeze.2 The ability of these tools to identify those who will develop asthma is poor (positive predictive value (PPV)
ranging from 44 to 54%). However, the absence of known risk factors can be useful to reassure parents of a lower risk
of future asthma.
2) Clinical Skills: Assessment in Preschool wheeze patient?
The purpose of assessment (history taking and physical examination) is to: • confirm a wheezing disorder • identify
symptom pattern, severity and possible trigger factors • look for features suggestive of an alternative diagnosis or
associated condition. Studies have shown while physicians can accurately identify wheeze, parents may not be able to
do so. Ideally, the presence of a wheeze should be confirmed by a clinician.
History should include specific information on: • the wheeze, other noises and features of respiratory distress • family
history (including mother and sibling/s) of asthma and atopy • smoking status of household members.
All health professionals have a role in advocating for their patients by advising parents about the increased risk of
wheezing associated with parental smoking.
The child should be assessed within the time frame recommended by the triage category. General appearance, mental
state and level of respiratory distress are the most important markers of illness severity. Signs of respiratory distress in
pre-school children include accessory muscle use, abdominal breathing, intercostal recession, subcoastal recession and
tracheal tug.

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Student name: Yoshana Muruganand Patient’s R/N: HTJ1024621

Student ID: 00000026024 Date of admission: 12/1/2021

 Provisional diagnosis- Asthma

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