Hot Seat #156: 6 yo with cough

Posted on: September 7, 2020, by :

Nate Jones, MD with Joelle Simpson, MD, MPH

Date: September 10, 2020

CC: Referred in by pediatrician for likely asthma exacerbation

HPI: Patient is a 6 year old F with h/o asthma and eczema who is referred into the ED by his pediatrician with complaints of fever, cough, myalgias and trouble breathing. The patient presents with the nanny who reports that symptoms started 2 days ago with cough. Over the past 2 days patient has worsened with increased shortness of breath, requiring albuterol roughly every 4-6 hours with minimal improvement of symptoms. Patient otherwise having a mild decrease in PO intake without a decrease in UOP. Both father and mother work for the State Dept and alternating being home versus the office and deny any known COVID exposure. No recent travel. Immunizations UTD.

Patient brought in as presumed PUI into a private room with neg pressure.

ROS: CONSTITUTIONAL: + Fever,
SKIN: Denies rash or hives
EYES: Denies redness, discharge, or swelling
RESPIRATORY: + Cough, SOB, DOE. Denies stridor
CV: Denies edema
GI: Denies diarrhea, nausea, vomiting, abdominal pain
NEURO:  Denies AMS or decreased tone  

Birth Hx: Full born NSVD without complications   

PMHx: Asthma, Eczema, Allergic rhinitis

PSHX: None

SHx: Patient lives at home with father and mother, largely under the care of nanny

FHx: Father- Asthma and Eczema, Mother-Asthma

Meds: Albuterol PRN

PE: T 36.9  HR165 BP112/64 RR 40 SpO2 93% on RA

GEN: Appears sitting upright and appears to be uncomfortable 

HEENT: Normocephalic. PERRL. EOMI. Conjunctiva clear. Nares patent. Moist oral mucosa. Mild pharyngeal erythema.
Neck: Supple, + Cervical  lymphadenopathy
Resp: Mild diffuse exp wheeze with crackles at the bases bilaterally
CV: Tachycardic, Normal S1, S2. No murmur appreciated.
GI: Abd soft NT/ND

Integumentary: Warm, scattered hyperpigmented patches localized to the antecubital
MSK: Full range of motion, Normal strength, No edema
Neuro: Alert

The patient is given a round of albuterol and dexamethasone. Repeat vital signs: T 37.8 HR155 BP 110/65 RR 35 SpO2 92%RA. Patient reports no improvement with breathing. Repeat exam immediately after round demonstrates persistent exp wheeze and crackles at the bases.

You decide to give a second round of albuterol.  During that time the mother of the patient calls for an update and expresses concern. She describes that the child usually grabs mail from their box and helps them open their envelopes. Yesterday, there was a small package that looked like spam mail with a sample packet that she thought was fragrance sachet. Today, other governmental colleagues at her office report similar packages and it is being investigated. Mom is concerned and says she is leaving the office to come be with the patient – she has a mild cough but otherwise feels well.

Labs are pending. CXR demonstrates widening of the mediastinum with bilateral infiltrates and pleural effusions.

You consider that it may not be wise to have the mother come to the hospital because of her infectious risk to other is she has the same illness.

The nanny inquiries about why additional tests are being done as. well as the working diagnosis.

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2 thoughts on “Hot Seat #156: 6 yo with cough


  1. Wow! Quite the case with so many complex issues. While patient care ought to come first, this demonstrates the epitome of the complexity of our field. In general, we often focus on treatment first, diagnostics second, then legal/ethical issues . I thought to get CXR first from the perspective of COVID-19 and minimizing aerosol generating procedures for our radiology techs. Though starting with albuterol was fine, quickly the needed diagnostics and the story from mother required changing the flow and further, her impending arrival required engaging various leaders to ensure we create the safest environment for our other patients in the ED.

    The irony/disconnect of how things come together in a written case (like our board review questions) vs. in real-time where we actually will contact multiple people to ensure the right thing is done for the patient, the ED and the hospital even.

    While the differential can be broad, at this point, the key piece becomes ensuring safety and thus engaging ID, legal, security, triage all at once will be the first step to protect as many people as possible.


  2. Thank you Pavan for pointing out the complexities we intended by writing this case. I also agree that we are fortunate in real life to take advantage of the resources around us to help with patient care and ethical decision making. We do have a tool box of sorts — and quite a few resources at our disposal for “disasters” to guide decisions. That being said, none of it is easy. However as PEM docs, Nate and I wanted to be sure that we were aware of the SYSTEM we function in and all the moving parts that support us — as you mention – security, legal, ethics, admin on call, charge MD, charge RN, Dept of Health. Central to this case is also the importance of communication. In disasters or high threat events– risk communication is extremely important. What is communicated (or not communicated) can derail efforts significantly.

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