A Child with Cough and Fever

Student Presentation
A CHILD WITH COUGH
AND FEVER
-Sarah Bouka & Anjala Nizam-

Contents
1. Case
2. History Taking
3. Physical Examination
4. Investigations
5. Differential Diagnosis
6. Management
7. References

Case
History taken from: Mother of the child
A 2 year old girl presents with fever and
cough that started 3 days ago that is
progressively worsening. She was given
paracetamol which reduced the fever. She
also had diarrhea for 2 days.

History Taking
1- History Of Present Illness

● Chief complaint
She has a cough and a fever.
● Onset
It started 4 days ago with a runny nose. The fever and cough started 3 days ago.
● Constant/intermittent
She has had a fever and cough the whole time.
● Precipitating factors
None.
● Progression
The fever has gotten worse, and she has been coughing more since it started.
1- History Of Present Illness

● Previous episodes
She is sick pretty often – she gets everything her brother brings home from daycare, poor thing. The
last time she had a cough was about 3 months ago. But she didn't have this high of a fever then.
● Relieving factors
I gave her panadol, which lowered the fever.
● Aggravating factors
None.
● Productive/non productive cough
When she coughs phlegm comes out.
● Sputum (color, amount, blood)
She coughs up green-colored slime. Not much though, and there is no blood in it.
History Of Present Illness1- History Of Present Illness

● Associated symptoms
She also has diarrhea.
● Onset and frequency
She has had it for 2 days. She has had 4–5 poopy diapers every day.
● Color
Normal color.
● Consistency
It looks watery.
● Blood/mucus in stool
No.
History Of Present Illness1- History Of Present Illness

History Taking
2-Review of systems

• Fever (how high, how was it measured)
I just measured 39.8°C with the ear thermometer.
• Ear pulling
No.
• Nausea/vomiting
No.
• Eye/Ear discharge
No.
• Rash
No.
• Crying/irritable
She seems really miserable
2-Review of Systems

● Shortness of breath (dyspnea)
She is breathing faster than usual.
● Drooling/difficulty swallowing (dysphagia) or speaking
No. She has not been drooling and her voice sounds normal to me.
● Bluish discoloration around the lips or mouth (Circumoral cyanosis)
No. serious lung or heart problem, such as cyanotic congenital heart disease.
● Noisy breathing
No.
● Retractions below or between ribs when breathing
No.
● Urinary problems
No.
● Sleep problems
She is not sleeping well because she is really uncomfortable.
● Seizure
No.
2-Review of Systems

● Activity (playful)
She is really not her normal, playful self at all.
● Lethargic/sleepy
No, nothing like that. She just seems really unhappy.
● Dry mouth, sunken eyes, fluid intake (dehydration)
She seems like she has a dry mouth, and she is drinking less than normal.
● Amount of wet diapers/24 hrs
I can't really tell because of the diarrhea.
● Recent travel
No.
2-Review of Systems

History Taking
3-Past Medical History, Family History,
Social History

● Past medical history
She had jaundice for the first week after she was born. She was treated with a blue
light.
● Past surgical history
None.
● Previous hospitalizations
None.
● Prenatal history
Normal.
3-Past Medical History, Family History, Social History

● Allergies
None.
● Medications
None.
● Ill contacts
Her big brother goes to daycare and has been sick for the last 4 days. He has a runny nose
and cough, too, but no fever.
● Family history
None.

● Birth history
She was born vaginally at 37 weeks, but there were no problems whatsoever. (early
term)
● Immunizations
All of her immunizations are up-to-date.
● Growth and development
Everything has been normal at the well-child visits so far.
● Daycare
I stay home with her, and her brother goes to daycare.

● Eating habits and appetite
She usually eats everything I give her, including meat, vegetables, fruits, and bread. But
she doesn't really want to eat right now.
● Last checkup
We had a checkup 1 month ago and everything was fine.

Introduction
• Wash your hands
• Introduce yourself to both the
parents and the child
• Explain what the respiratory
examination will involve
• Gain consent from the
parents/carers and/or child
before proceeding.
WHO steps for hand washing
Physical Examination

General Inspection
Patient
• Sick/well looking
• Level of consciousness
• Color- (pallor/cyanosis)
• Ability to speak
• Signs of respiratory distress
• Stridor/Wheeze/Grunting/Rattling
• Stature
• Appear a healthy weight
• Dysmorphic features
Cyanosis
Hands of a 2-year-old child showing
intense pallor (Hb 3.6g/dL)

General Inspection
Surroundings
• Mobility aids
• Feeding tubes (NG/NJ/Gastrostomy)
• Oxygen saturation monitor or
oxygen cylinder
• Tracheostomy
• Sputum pot
• Inhalers
Tracheostomy
Inhaler
Oxygen cylinder

Vital Signs
Age Approximate Weight
(Kg)
Respiration:
Breaths/Min
Heart Rate: Beats/Min
Term 3.5kg 25-60 110-170
3 Month 6kg 25-55 105-165
6 Month 8kg 25-55 105-165
1 yr 10kg 20-40 85-150
2 yr 13kg 20-40 85-150
4 yr 15kg 20-40 85-150
6 yr 20kg 16-34 70-135
8 yr 25kg 16-34 70-135
10 yr 30kg 16-34 70-135
RCHM 2017

Fever
• The differential diagnosis
includes: infection (most
common), malignancies,
autoimmune, neurologic, genetic,
and iatrogenic causes.
• A child has a fever when his or
her Axillary/Tympanic
temperature is:
• Mild/low grade fever: 37.8 °C – 38.5 °C
• High grade fever: > 38.5 °C (101.3 °F)
• Very high fever: 41 °C

Cough
• Duration: acute (< 2 weeks),
subacute (2-4 weeks), chronic (>
4 weeks)
• Severity: interferes with
sleeping, feeding & speaking
• Painful cough: lesions related to
pleura & ribs
• Timing: Seasonal, At night time
• Quality: moist/wet/productive
OR dry
• Characteristic : barky cough,
staccato cough, paroxysmal
cough,
Young children with sudden cough and no fever or URI symptoms- suspicion for foreign body aspiration

Coughs according to duration
Acute cough(<2 weeks)
Classical recognizable cough
Acute upper / lower
respiratory tract infection (ARI)
Foreign body aspiration
Asthma
Inhalation injury
Embolism hemorrhage
Subacute cough
(2-4 weeks)
Post viral cough
Acute bronchitis
Chronic cough (> 4 weeks)
Non-specific cough
Subacute bronchitis
Interstitial lung disease
Cardiac
Bronchiectasis or recurrent
pneumonia
Aspiration
Chronic infections

Sputum
• Nature- Purulent,
Mucoid, Frothy
• Quantity- Scanty/
Copious
• Color- Blood Stained,
Greenish, Yellowish
• Smell- Fetid (Lung
abscess, cystic fibrosis,
bronchiectasis)
Cough

Hands- Inspection
• Peripheral cyanosis – hypoxia,
hypothermia
• Finger clubbing –
bronchiectasis, cystic fibrosis,
primary ciliary dyskinesia
• Eczema – increased likelihood
of asthma and hay fever (atopy)
• Tremor – beta 2 agonist use
(e.g. salbutamol)
• Pulse- Radial (rate & rhythm)
Peripheral cyanosis
Finger clubbing
Radial Pulse
Eczema

Face- Inspection
Eyes: Pallor & jaundice
Nose: nasal flaring/grunting, foreign body, nasal
polyp, deviated septum, discharge, color of mucosa.
Nasal polyp
Central & peripheral
cyanosis

Tonsillar hypertrophy
Hearing aids
Tympanic Membrane
(Acute Otitis Media)
Face- Inspection

Neck- Inspection
• Inspect tracheal position
• Palpate the cervical and
supraclavicular lymph nodes
• Lymphadenopathy
• Cystic Hygroma
Cystic Hygroma

General signs of increased work of breathing
•Tracheal tug
•Use of accessory muscles
•Supraclavicular recession
•Suprasternal recession
•Intercostal recession
•Subcostal recession
•Nasal flaring
•Grunting
•Head Bobbing
•Abdominal breathing
Chest- Inspection
Tachypnea, Retractions, Grunting and Nasal flaring.

Chest- Inspection
• Asymmetry of chest wall movement
• Harrison’s sulcus
• Chest hyper-expansion (barrel chest)
• Pectus excavatum (hollow chest)
and pectus carinatum (Pigeon chest)
• Others: Rachitic rosary, shield shaped
chest
• Respiratory Rate
• Scars- Sternotomy, Left Thoracotomy,
Right Thoracotomy

Position of trachea
Assess chest expansion
Tactile vocal fremitus
Palpate the apex beat
Chest- Palpation

Chest- Percussion
• Perform percussion gently, comparing one side to the other.
• Percussion is often not performed on younger children
• Types of percussion note
• Resonant
• Dullness
• Stony dullness
• Hyper-resonance

Areas of percussion & auscultation

Chest Auscultation
• Auscultate each side of the chest in
a symmetrical pattern, comparing side to side
• Character of air entry: Normal, equal, reduced
• Character of breath sounds: Vesicular &
Bronchial
• Character of expiratory & inspiratory phase
• Presence of added sounds: Wheezes, Crackles,
Stridor, Pleural rub
• Vocal resonance
• Transmitted sounds
Stridor
https://hawaiicopd.org/media/lung-sounds/
Wheeze

Back
• Inspect for:
• Kyphosis/Scoliosis
• Scars
• Position of scapula
• Palpation: Chest expansion, Tactile
fremitus
• Percuss + Auscultate

Conclusion
• Thank the child and/or parents
• Explain your findings to the parents
and/or child
• Ask if the parents and/or child have
any questions
• Wash your hands

• CBC with differential
• Electrolytes, glucose
Pulse oximetry
Arterial blood gas analysis
Respiratory viral panel
Investigations

Mantoux Testing (Tuberculin Skin Test)
Chest X-ray of child with RSV
(Bronchiolitis)
Pulmonary Function Test
Bronchoscopy
Investigations

This is the most likely cause of this child's cough and fever. Acute
bronchitis is oftentimes preceded by an upper respiratory infection,
which this child had.
1. Acute bronchitis:
Differential Diagnosis

Although acute bronchitis is the most likely cause of this otherwise
healthy child's cough and fever, her increased respiratory rate,
prolonged high fever, and poor fluid intake should raise concern for
pneumonia. An x-ray and CBC would allow this diagnosis to be
ruled out.
2. Pneumonia:

While this patient has a history of diarrhea and fever, she has no
nausea or vomiting. This child has signs of volume depletion (e.g.,
dry mouth and decreased fluid intake) and should be monitored
and treated for this if necessary.
3. Viral gastroenteritis:

Other differential diagnoses to consider
● Croup
● Bacterial gastroenteritis
● Influenza
● Sepsis

Management
Treatment of acute bronchitis is typically divided into two
categories:
-antibiotic therapy.
-symptom management.

Management
Treatment of acute bronchitis is typically divided into two
categories:
-antibiotic therapy. X
-symptom management. rest+ antipyretic +treat dehydration

Methods for Managing Patient Expectations
for Medication to Treat Acute Bronchitis
Symptoms
● Define the diagnosis as a “chest cold” or “viral upper respiratory
infection”
● Set realistic expectations for symptom duration (about three weeks)
● Explain that antibiotics do not significantly reduce the duration of
symptoms, and that they may cause adverse effects and lead to antibiotic
resistance
● Consider delayed “pocket” prescription or “wait-and-see” prescription*

References
“Case 7: Toddler with a Cough and Fever.” – Knowledge for Medical Students and Physicians, 26 Mar. 2018,
www.amboss.com/us/knowledge/Case_7:_Toddler_with_a_cough_and_fever.
Albert, Ross H. “Diagnosis and Treatment of Acute Bronchitis.” American Family Physician, 1 Dec. 2010,
www.aafp.org/afp/2010/1201/p1345.html.
“Respiratory Medicine.” Handbook of Paediatrics, by Dr. Ian Balfour-Lynn, 2nd ed., Oxford University Press, 2013.
Gould, MD, Jane M. “Fever in the Infant and Toddler Differential Diagnoses.” Fever in the Infant and Toddler
Differential Diagnoses, 3 May 2020, emedicine.medscape.com/article/1834870-differential.
Grad R. Chronic cough in children. In: UpToDate, Mallory GB (Ed), Hoppin AG (Ed), UpToDate, Waltham, MA,
2009
K.W. Tong, Calvin. “ Approach to a Child with a Cough.” Learn Pediatrics, 16 Dec. 2011,
learn.pediatrics.ubc.ca/body-systems/respiratory-system/approach-to-a-child-with-a-cough/.

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