Case by Jamal Alanni, CNH PEM Fellow

12 month old infant without significant past medical history presenting with 1 day of clear rhinorrhea and barky-like cough in setting of 10 days of decreased oral intake. They were previously breastfed but since weaning off they’ve had less oral intake and sometimes refusing bottles. Last night they took 5 oz of breastmilk through the bottle. During the past 10 days, they continued making daily diapers (4-5x), including this morning. This morning, mom heard the barky-like cough and went to check on them, where she noticed increased work of breathing, using their neck and chest muscles. They were otherwise awake, active and acting like themselves besides the trouble breathing. She called their PCP who recommended going to the ED for evaluation. Their sister had a barky cough the past weekend which self-resolved. Denies any other symptoms. 

Triage note: 

• Patient presents to ED with low temp, cold extremities, cap refill 3-4 seconds. Mom reporting runny nose starting yesterday with cough, retractions this morning. Last liquid PO last night, solid PO and wet diaper this morning. Vaccines 1 week ago 

• Runny nose, cough, congestion, croupy cough, rectal temp 34.8, mottled/cold extremities, wet diapers and good PO, moderate subcostal retractions. 

Triage Vitals: 

T 34.8C (rectal), HR 138 BP 81/48, RR 26, SpO2 93% on RA 

Given the reported history, patients overall non-emergent exam and normal mental status, decision made to start with warming , seeing how they respond, and holding off on  lab work-up. Within 30 minutes, patient temp normalized to 37.1C, HR 138, RR 26, BP 81/48. Patient received dexamethasone to treat for croup 

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