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Is there increased work of breathing? Approach to Syncope: Is it Cardiac or Not? Children with repeated episodes of pneumonia, poor growth, or foul-smelling stools should have a chest x-ray and sweat testing for cystic fibrosis. Special features including diurnal variability, fever, colds, relation with meals and possible foreign body aspiration, habitual vomiting, production of sputum, risk of contact with tuberculosis or HIV, smoking behaviour of parents, possible allergies, and vaccination status, should be sought. Treatment of cough is management of the underlying disorder. The legacy of this great resource continues as the Merck Manual in the US and Canada and the MSD Manual outside of North America. Lung examination focuses on presence of stridor, wheezing, crackles, rhonchi, decreased breath sounds, and signs of consolidation (eg, egophony, E to A change, dullness to percussion). Review of systems should note symptoms of possible causes, including abdominal pain (some bacterial pneumonias), weight loss or poor weight gain and foul-smelling stools (cystic fibrosis), and muscle soreness (possible association with viral illness or atypical pneumonia but usually not with bacterial pneumonia). The Merck Manual was first published in 1899 as a service to the community. Cough is a reflex that helps clear the airways of secretions, protects the airway from foreign body aspiration, and can be the manifesting symptom of a disease. Chapter 24. History •Personal data •Presentation symptom Main complain •History of present disease •Therapies , medicines •Allergic diseases •Vaccination history •Neonatal history •Pregnancy history of mother •Family history •Previous diseases / surgical operations •Developmental history •Social/ environmental history Relevant past medical history: Asthma, atopy, drug allergies (always), currently taking or recently run out of any medications, exposure to TB or other infectious diseases? He had been wheezing off and on for the past month and had visited the emergency department on one occasion. Signs of respiratory distress (eg, nasal flaring, intercostal retractions, cyanosis, grunting, stridor, marked anxiety) should be noted. Little evidence exists to support the use of cough suppressants and mucolytic agents. A barky cough suggests croup or tracheitis; it can also be characteristic of psychogenic cough or a postrespiratory tract infection cough. What type of exposure triggers the cough? Last updated on December 15, 2011 @7:34 pm, Emergency Procedures | Accessibility | Contact UBC | © Copyright The University of British Columbia, Approach to the Child with a fever and rash, Approach to Cyanotic Congenital Heart Disease in the Newborn. What colour is it? Antitussives and expectorants lack proof of effect in most cases. The cervical and supraclavicular areas should be inspected and palpated for lymphadenopathy. Fever is generally low grade (38-39°C) but can exceed 40°C. Nature of cough; How long has the child been coughing for? Click for pdf: Approach to a child with a cough. Ensure you initially keep a comfortable distance, establishing eye contact and rapportwith the family. Goldsobel AB, Chipps BE. URI-like prodrome, stridor, barky cough, high fever, respiratory distress, toxic appearance, purulent secretions, Rhinorrhea, tachypnea, wheezing, crackles, retractions, nasal flaring, possible posttussive emesis, In infants up to 24 months; most common among those 3–6 months, Sometimes nasal swab for rapid viral antigen assays or viral culture, URI-like prodrome, barky cough (worsening at night), stridor, nasal flaring, retractions, tachypnea, Sometimes anteroposterior and lateral neck x-rays, Exposure to tobacco smoke, perfume, or ambient pollutants, Abrupt onset, high fever, irritability, marked anxiety, stridor, respiratory distress, drooling, toxic appearance, If patient is stable and clinical suspicion is low, lateral neck x-ray, Otherwise, examination in operating room with direct laryngoscopy, Chest x-ray (inspiratory and expiratory views), Viral: URI prodrome, fever, wheezing, staccato-like or paroxysmal cough, possible muscle soreness or pleuritic chest pain, Possible increased work of breathing, diffuse crackles, rhonchi, or wheezing, Bacterial: Fever, ill appearance, chest pain, shortness of breath, possible stomach pain or vomiting, Signs of focal consolidation including localized crackles, rhonchi, decreased breath sounds, egophony, and dullness to percussion, Coughing at the beginning of sleep or in the morning with waking, Sometimes nasal discharge, congestion; pain on either side of the nose; pain in the forehead, upper jaw, teeth, or between the eyes; headache and sore throat, Rhinorrhea, red swollen nasal mucosa, possible fever and sore throat, shotty cervical adenopathy (many small nontender nodes), Tracheomalacia: Congenital stridor or barky cough, possible respiratory distress, TEF: History of polyhydramnios (if accompanied by esophageal atresia), cough or respiratory distress with feeding, recurrent pneumonia, Tracheomalacia: Airway fluoroscopy and/or bronchoscopy, TEF: Attempt passage of a catheter into the stomach (helps in diagnosis of TEF with esophageal atresia), Contrast swallowing study, including esophagography, Intermittent episodes of cough with exercise, allergens, weather changes, or URIs, Atypical pneumonia (mycoplasma, Chlamydia), Possible ear pain, rhinitis, and sore throat, Birth defects of the lungs (eg, congenital adenomatoid malformation), Several episodes of pneumonia in the same part of the lungs, History of meconium ileus, recurrent pneumonia or wheezing, failure to thrive, foul-smelling stools, clubbing or cyanosis of nail beds, Molecular diagnosis with direct mutation analysis, History of acute onset of cough and choking followed by a period of persistent cough, Presence of small objects or toys near child, Infants and toddlers: History of spitting up after feedings, irritability with feeding, stiffening and arching of the back (Sandifer syndrome), failure to thrive, recurrent wheezing or pneumonia (see Gastroesophageal Reflux in Infants), Older children and adolescents: Chest pain or heartburn after meals and lying down, nighttime cough, wheezing, hoarseness, halitosis, water brash, nausea, abdominal pain, regurgitation (see Gastroesophageal Reflux Disease), Sometimes upper gastrointestinal study for determination of anatomy, Trial of H2 blockers or a proton pump inhibitor, Possible esophageal pH or impedance probe study, Trial of H2 blockers or proton pump inhibitors, 1–2 weeks catarrhal phase of mild URI symptoms, progression to paroxysmal cough, difficulty eating, apneic episodes in infants, inspiratory whoop in older children, posttussive emesis, Intranasal specimen for bacterial culture and polymerase chain reaction testing, Headache, itchy eyes, sore throat, pale nasal turbinates, cobblestoning of posterior oropharynx, history of allergies, nighttime cough, Trial of antihistamine and/or intranasal corticosteroids, Possible trial of a leukotriene inhibitor, History of respiratory infection followed by a persistent, staccato cough, History of repeated upper (otitis media, sinusitis) and lower (pneumonia) respiratory tract infections, Microscopic examination of living tissue (typically from sinus or airway mucosa) for cilia abnormalities, Persistent barky cough, possibly prominent during classes and absent during play and at night, Sometimes fever, chills, night sweats, lymphadenopathy, weight loss, Sputum culture (or morning gastric aspirate culture for children < 5 years), Interferon-gamma release assay (especially if there is a history of bacille Calmette-Guérin [BCG] vaccination). Cough is a common indication of respiratory illness and is one of the more common symptoms of children seeking medical attention. The following findings are of particular concern: Clinical findings frequently indicate a specific cause (see Table: Some Causes of Cough in Children); the distinction between acute and chronic cough is particularly helpful although it is important to note that many disorders that cause chronic cough begin acutely and patients may present before 4 weeks have passed. Head and neck examination should focus on presence and amount of nasal discharge and the condition of the nasal turbinates (pale, boggy, or inflamed). Children with viral infections should receive supportive care, including oxygen and/or bronchodilators as needed. (See table Some Causes of Cough in Children. TEF = tracheoesophageal fistula; URI = upper respiratory infection. Did this help with the present episode? Cough as a manifestation of respiratory disease can range from minor upper respiratory tract infections to serious conditions such as bronchiectasis. The aetiology of coughing in children will cover a wide spectrum of respiratory disorders, … It is triggered by stimulation of airway cough receptors, either by irritants or by conditions that cause airway distortion. Acute cough is most commonly associated with the common cold, but it also can be associated with life-threatening conditions (e.g., pulmonary embolism, congestive heart failure, pneumonia). Coughing at the beginning of sleep and in the morning with waking usually indicates sinusitis; coughing in the middle of the night is more consistent with asthma. History of present illness should cover duration and quality of cough (barky, staccato, paroxysmal) and onset (sudden or indolent). In: UpToDate, Mallory GB (Ed), Hoppin AG (Ed), UpToDate, Waltham, MA, 2009. Pediatric chronic cough (ie, cough in children aged < 15 years) is defined as a daily cough lasting for > 4 weeks. The concept of cough hypersensitivity has allowed an umbrella term that explains the exquisite sensitivity of patients to external stimuli such a cold air, perfumes, smoke and bleach. Black arrows represent the afferent pathway and purple arrows represent the efferent pathway. The physician should ask about associated symptoms. A high index of suspicion for foreign body aspiration is needed if children are age 6 months to 6 years. Foreign body aspiration and diseases such as cystic fibrosis and primary ciliary dyskinesia are less common, but they can all result in persistent cough. Acute cough in children is mostly caused by upper respiratory tract infections (URTIs). In young children with sudden cough and no fever or URI symptoms, the examiner should have a high index of suspicion for foreign body aspiration. Chest radiograph can provide you with additional information, such as infiltrations/ consolidations, hyperinflation, peribronchial thickening, hyperinflation, atelectasis and chronic lung changes. (modified from Chung KF, Pavord ID.Â Prevalence, pathogenesis, and causes of chronic cough.Â Lancet.Â Apr 19Â 2008;371(9621):1364-74). Before we dive into the clinical approach to cough, let us review the respiratory physiology of cough. Cough | The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e | AccessMedicine | McGraw-Hill Medical. Learn more about our commitment to Global Medical Knowledge. 7. History of Presenting Complaint. Establish whether there was any parental illness around the time of conception that may be relevant. 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