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Hi guys. 
Welcome back to another episode 

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of the Success NP podcast. 
I'm your host for today, Jackie.

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Today we're back in the 
pediatric world for the 

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respiratory case that starts off
simple but turns out to be 

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anything but. 
You'll want to listen closely to

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the clues and test your clinical
reasoning as we follow this 

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little patient's story. 
Let's dive into the wheeze that 

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wouldn't quit. 
You're working in a pediatric 

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primary clinic. 
A four year old boy named Aiden 

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is brought in by his dad. 
Dad says he's been wheezing for 

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almost a week and it's just not 
getting any better. 

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You know, Aiden as an 
established patient who has a 

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history of mild intermittent 
asthma. 

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But this time, the usual 
treatments just aren't working 

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as expected. 
All right, guys, So as we all 

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know, a history of present 
illness needs to be reviewed. 

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Let's dive right into that with 
Aiden. 

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Aiden started with cold symptoms
about 10 days ago. 

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Your typical runny nose, low 
grade fever and a mild cough 

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authenting the wheezing. 
Dad says that they use the 

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albuterol inhaler, which did 
help at first, but now Aiden is 

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waking up at night coughing and 
wheezing more frequently. 

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He's more tired than usual and 
isn't playing as much. 

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Dad denies any choking episodes.
He denies any vomiting, any 

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allergies and no fever in the 
last few days. 

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But the cough that keeps 
lingering. 

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You asked about medication. 
He has only been on albuterol as

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needed. 
He says no oral steroids yet and

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no antibiotics. 
So you dive right in to your 

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review systems. 
Let's go over his symptoms or 

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lack thereof. 
No vomiting or diarrhea. 

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No rash. 
No recent travel. 

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No sick contacts outside of 
daycare. 

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Mild decrease in appetite. 
No chest pain, but he does note 

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that his chest feels tight. 
The next step is a physical 

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exam. 
So first part of a physical exam

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as we all know as nurses get a 
set of vital signs. 

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His temperature is 98.9°F, heart
rate is 118 beats per minute, 

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respiratory rate is 26, and his 
O2 saturation on room air is 

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94%. 
As a nurse practitioner, you 

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perform your physical exam and 
you note that he is an alert 

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child, but he does look tired or
an auscultation of his lungs. 

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You hear diffuse squeezing, 
worse on the right side with a 

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prolonged expiratory phase. 
He does have mild retractions 

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but no strider, you know, clear 
nasal discharge, no tonsiller 

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enlargement and no drooling. 
He has a regular rate and 

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rhythm, and his abdomen is soft,
non tender. 

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Her skin does not present with 
any rashes and looks to be 

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normal. 
But you're concerned, it's not 

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clear if this is a worsening 
asthma flare, a viral illness, 

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or maybe something entirely 
else. 

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So now that we have our HPI, our
review of systems, our physical 

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exam, our wheels are turning, 
right. 

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We're thinking of differential 
diagnosis, right? 

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What could this be? 
So let's think it through. 

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One, it could be an asthma 
exacerbation, it could be 

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bronchiolitis, possibly 
pneumonia, or is it viral 

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induced wheezing? 
Is it a foreign body aspiration 

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or atypical infection? 
So we dig into the story a bit 

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more to find some more clues. 
We go back to that again. 

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We ask, Are you sure he didn't 
choke on anything this time? 

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Dad hesitate. 
Well, there was that Lego 

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incident last weekend, but I 
thought he just swallowed it and

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passed it. 
Your ears perked up a week ago. 

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You ask Aiden to take a deep 
breath and cough. 

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It's a dry brassy cough, still 
wheezing, mostly on the right 

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though. 
You order a chest X-ray. 

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So on that chest X-ray we do see
what looks like hyperinflation 

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on the right with a media 
standard shift to the left and 

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no infiltrate our top 
differential. 

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At this point guys, we all know 
what it is. 

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It's foreign body aspiration, so
we consult pediatric pulmonology

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and ENT ASAP. 
A bronchoscopy is performed and 

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sure enough, a small Lego piece 
is retrieved from his right main

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bronchus. 
So did you get it right? 

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Our final diagnosis is an 
unrecognized foreign body 

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aspiration leading to unilateral
wheezing and persistent 

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symptoms. 
Despite standard asthma therapy 

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post removal, Aiden's wheezing 
resolves completely within a few

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days, and Dad is both relieved 
and surprised it hadn't occurred

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to him that the wheezing was due
to something stuck, especially 

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given the time frame from when 
he remembered Aiden playing 

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around with that Lego. 
So let's go over our teaching 

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points from this case study. 
Let's go over that. 

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What did we learn from Aiden? 
Well, for one, not all wheezing 

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is asthma. 
If the pattern doesn't follow 

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the usual course, expand your 
differential. 

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Foreign body aspiration can 
present very subtly, especially 

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in children who don't choke 
dramatically or can't explain 

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what happened. 
Unilateral wheezing, 

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hyperinflation, and media signal
shift are the big red flags 

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here. 
And maybe not as fancy, but so 

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important as a thorough history.
You notice how we had to go back

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around that second time to ask 
Dad exactly when he noticed it. 

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Kind of more of a timeline that 
can make all the difference in 

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your differential diagnosis and 
ultimately, you know, expedite 

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treatment. 
All right, guys, I really hope 

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you enjoyed this case study. 
I enjoyed going through it with 

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you. 
I hope you found some value in 

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00:07:32,320 --> 00:07:34,000
it. 
If you have a mystery of your 

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own that you've seen in clinical
practice that you want to share 

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00:07:35,960 --> 00:07:39,080
with us, please DM us on 
Instagram at the Success NP. 

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00:07:39,400 --> 00:07:42,480
And please look at our tools 
that they're so valuable. 

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We wish we had them when we're 
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successnp.etsy.com or on our 
website. 

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00:07:47,720 --> 00:07:49,800
Until next time, stay curious 
and stay sharp. 

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00:07:49,960 --> 00:07:52,840
Thanks for tuning into another 
episode of Success and P. 

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00:07:52,880 --> 00:07:55,960
We hope today's discussion has 
shed some light on the diverse 

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00:07:56,000 --> 00:07:59,040
career options or taught you how
to improve your clinical 

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00:07:59,040 --> 00:08:00,600
practice as a nurse 
practitioner. 

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00:08:00,960 --> 00:08:03,480
Remember, whether you're 
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pursuing advanced certification,
or exploring non traditional 

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roles, there's a wealth of 
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Until next time, take care, stay
curious, and keep advancing your

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careers as a nurse practitioner.
And just a friendly reminder, 

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the information on this podcast 
is for educational purposes 

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only. 
The information should not be 

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used and substitute for 
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The information on this podcast 

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does not represent medical or 
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Bye for now.