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Hi guys. Welcome back to another episode
of the Success NP podcast. I'm your host for today, Jackie.
Today we're back in the pediatric world for the
respiratory case that starts off simple but turns out to be
anything but. You'll want to listen closely to
the clues and test your clinical reasoning as we follow this
little patient's story. Let's dive into the wheeze that
wouldn't quit. You're working in a pediatric
primary clinic. A four year old boy named Aiden
is brought in by his dad. Dad says he's been wheezing for
almost a week and it's just not getting any better.
You know, Aiden as an established patient who has a
history of mild intermittent asthma.
But this time, the usual treatments just aren't working
as expected. All right, guys, So as we all
know, a history of present illness needs to be reviewed.
Let's dive right into that with Aiden.
Aiden started with cold symptoms about 10 days ago.
Your typical runny nose, low grade fever and a mild cough
authenting the wheezing. Dad says that they use the
albuterol inhaler, which did help at first, but now Aiden is
waking up at night coughing and wheezing more frequently.
He's more tired than usual and isn't playing as much.
Dad denies any choking episodes. He denies any vomiting, any
allergies and no fever in the last few days.
But the cough that keeps lingering.
You asked about medication. He has only been on albuterol as
needed. He says no oral steroids yet and
no antibiotics. So you dive right in to your
review systems. Let's go over his symptoms or
lack thereof. No vomiting or diarrhea.
No rash. No recent travel.
No sick contacts outside of daycare.
Mild decrease in appetite. No chest pain, but he does note
that his chest feels tight. The next step is a physical
exam. So first part of a physical exam
as we all know as nurses get a set of vital signs.
His temperature is 98.9°F, heart rate is 118 beats per minute,
respiratory rate is 26, and his O2 saturation on room air is
94%. As a nurse practitioner, you
perform your physical exam and you note that he is an alert
child, but he does look tired or an auscultation of his lungs.
You hear diffuse squeezing, worse on the right side with a
prolonged expiratory phase. He does have mild retractions
but no strider, you know, clear nasal discharge, no tonsiller
enlargement and no drooling. He has a regular rate and
rhythm, and his abdomen is soft, non tender.
Her skin does not present with any rashes and looks to be
normal. But you're concerned, it's not
clear if this is a worsening asthma flare, a viral illness,
or maybe something entirely else.
So now that we have our HPI, our review of systems, our physical
exam, our wheels are turning, right.
We're thinking of differential diagnosis, right?
What could this be? So let's think it through.
One, it could be an asthma exacerbation, it could be
bronchiolitis, possibly pneumonia, or is it viral
induced wheezing? Is it a foreign body aspiration
or atypical infection? So we dig into the story a bit
more to find some more clues. We go back to that again.
We ask, Are you sure he didn't choke on anything this time?
Dad hesitate. Well, there was that Lego
incident last weekend, but I thought he just swallowed it and
passed it. Your ears perked up a week ago.
You ask Aiden to take a deep breath and cough.
It's a dry brassy cough, still wheezing, mostly on the right
though. You order a chest X-ray.
So on that chest X-ray we do see what looks like hyperinflation
on the right with a media standard shift to the left and
no infiltrate our top differential.
At this point guys, we all know what it is.
It's foreign body aspiration, so we consult pediatric pulmonology
and ENT ASAP. A bronchoscopy is performed and
sure enough, a small Lego piece is retrieved from his right main
bronchus. So did you get it right?
Our final diagnosis is an unrecognized foreign body
aspiration leading to unilateral wheezing and persistent
symptoms. Despite standard asthma therapy
post removal, Aiden's wheezing resolves completely within a few
days, and Dad is both relieved and surprised it hadn't occurred
to him that the wheezing was due to something stuck, especially
given the time frame from when he remembered Aiden playing
around with that Lego. So let's go over our teaching
points from this case study. Let's go over that.
What did we learn from Aiden? Well, for one, not all wheezing
is asthma. If the pattern doesn't follow
the usual course, expand your differential.
Foreign body aspiration can present very subtly, especially
in children who don't choke dramatically or can't explain
what happened. Unilateral wheezing,
hyperinflation, and media signal shift are the big red flags
here. And maybe not as fancy, but so
important as a thorough history. You notice how we had to go back
around that second time to ask Dad exactly when he noticed it.
Kind of more of a timeline that can make all the difference in
your differential diagnosis and ultimately, you know, expedite
treatment. All right, guys, I really hope
you enjoyed this case study. I enjoyed going through it with
you. I hope you found some value in
it. If you have a mystery of your
own that you've seen in clinical practice that you want to share
with us, please DM us on Instagram at the Success NP.
And please look at our tools that they're so valuable.
We wish we had them when we're in school, at the
successnp.etsy.com or on our website.
Until next time, stay curious and stay sharp.
Thanks for tuning into another episode of Success and P.
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Bye for now.