Clinical Case 042: Cough with a significant negative
Todays case is not too tricky. The context is a recent epidemic of bronchiolitis in the Kimberley region. So lots of coughing, sick babies all over the NW.
This 3 month old girl presented to a remote nursing post (just under 1000 km away) with a one day history of cough, increasing dyspnoea and a fever. She was seen and thought to have bronchiolitis – young enough and unwell enough to need transfer to Broome.
So we saw her at 6 AM after evacuation by RFDS. And she looked sick – now hypothermic 35.0, RR = 55, grunting / subcostal recession, desaturated to 85% off of oxygen. So something is going on….
At this point I was thinking – probably bronchiolitis, looks pretty unwell. And then I put on the stethoscope – nothing, no wheeze, crackles or anything to suggest bronch. She had a flow murmur consistent with her degree of unwellness, but the chest was quiet. This is NOT bronchiolitis!
So my usual teaching to the students is to never do a CXR on a kid you think has bronchiolitis UNLESS they don’t fit or they don’t follow the bronchiolitis plan.
This kid looked sick and I was thinking sepsis – hypothermia, breathing up, clear sounding chest – maybe compensating for septic acidosis? So IV access, empirical ABs, and a saline bolus in. Septic screen – urine catch, blood cultures and consider an LP. I decided to wake up the radiographer and get a CXR
I am not to proud to say that I think my auscultation is really not that great in small infants to pick local chest signs. I think we should realise this and accept that a normal exam in no way excludes lung pathology.
If you have a piece of data that doesn’t fit with your provisional diagnosis, then DON”T ignore it. Sometimes it is a significant negative finding – a quiet chest doesn’t fit with bronchiolitis. It is human nature to try and force data to fit into our working diagnosis – a common error or bias. Ignoring a significant negative is easier than leaving out a positive finding.
Great case Casey – couple of Qs though.
(i) X-ray – do you have to wake the radiographer or can you guys do X-rays with an ‘R-exemption’ in Broome?
(ii) would ultrasound have yielded the answer? Summary of USS in pneumonia in this week’s MedScape.
I kind of like the idea of USS…but haven’t really played with it enough to be confident as rule in/rule out. Comments from any of the more experienced ED docs out there?
Next post coming your way Dr Tim – “US for pneumonia”, the recent studies say it is OK.
No, we don’t get an exemption – so we need to wake the radiographer if wewant an XR or CT, but I do it less if I have an US optionwhich I can hang my hat on until 08:00.
Casey