CASE 1 | HISTORY. verify here. 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. 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? Approach to Syncope: Is it Cardiac or Not? Grad R. Chronic cough in children. 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. Taking a history and performing a physical examination with children differs from adults and comes with a set of unique challenges. Nighttime cough can indicate postnasal drip or asthma. Introduction Cough is a common reason for pediatric outpatient visits. Please confirm that you are a health care professional. Before we dive into the clinical approach to cough, let us review the respiratory physiology of cough. Thus, adults with chronic cough now have a firm physical explanation for their symptoms … Over-the-counter antitussives, antihistamines and decongestants are as effective as placebo for acute cough … Auscultate: is air entry symmetric? All children experience head colds and many consult their doctor because of associated coughing.1 Cough with colds remedies are among the most commonly used medications in children in Western societies, despite evidence suggesting ineffectiveness of medication to treat cough as a symptom. History taking should establish the severity and time course of the cough. Cough in Children Etiology. Not only does it cause discomfort for the child, cough also elicits stress and sleepless nights for their parents. Cough | The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e | AccessMedicine | McGraw-Hill Medical. Physiology Mechanics of coughing – three phases: 1. Normal Cardiac Physiology – Transition From Fetal to Neonatal, Basic Physiology and Approach to Heart Sounds, Pharmacology of Common Agents Used in Gastrointestinal Conditions, Pediatric Gastrointestinal History Taking, Common Paediatric Skin Conditions & Birthmarks, Approach to the child with mental health concerns, Approach to a the Child with a Fever and Rash, Approach to a Routine Adolescent Interview, Sore Throat in Children – Clinical Considerations and Evaluation, Conjunctivitis: Approach to the Child with a Red Eye, Diaper Rash: Clinical Considerations and Evaluation, Evaluation of Pediatric Development (Normal), Basics to the Approach of Developmental Delay, Principles of Pharmacotherapy in Neurology, Iron-deficiency and Health Consequences in Children, Approach to Pediatric Leukemias and Lymphomas, Common Pediatric Bone Diseases-Approach to Pathological Fractures, © Copyright The University of British Columbia. General inspection for stigmata of chronic disease. Antitussives and expectorants lack proof of effect in most cases. What type of exposure triggers the cough? The pharynx should be checked for postnasal drip. Cough is a common indication of respiratory illness and is one of the more common symptoms of children seeking medical attention. 2010 Jan; 188 Suppl 1:S33-40. Ensure you initially keep a comfortable distance, establishing eye contact and rapportwith the family. HISTORY TAKING IN FEBRILEPATIENTS Using the Calgary Cambridge guide as a framework to interviewing patients. Cough in children Key concepts The cause of cough in children is often different than for adults and management reflects this The majority of children with acute cough will have a viral upper respiratory tract infection An accurate diagnosis, guided by history and examination, should be made whenever History Croup usually begins with nonspecific respiratory symptoms (ie, rhinorrhea, sore throat, cough). Can help delineate obstructive vs. restrictive lung disease, Required in the diagnosis of asthma (child must be >6yo and cooperative). It focuses on common pediatric problems, including the most pertinent topics in child healthcare with regard to both acute and chronic complaints, offering more than 30 “history stations,” each station followed by key points underpinning important points in the history. He had no fever. Before we dive into the clinical approach to cough, let us review the respiratory physiology of cough. He had been wheezing off and on for the past month and had visited the emergency department on one occasion. If foreign body aspiration is suspected, chest x-ray with inspiratory and expiratory views should be done (or in some centers a chest CT). Background Cough is a common indication of respiratory illness and is one of the more common symptoms of children seeking medical attention. The first step in the treatment of acute cough is to determine if the cause of the cough is one of these serious conditions or an acute upper respiratory infection (i.e., common cold), lower respiratory tract infection, or an exacerbation of a pr… BASIC ANATOMY AND PHYSIOLOGY To provide an accurate differential diagnosis, it is important to underst… Ask about the age/duration of onset (congenital cause). Has the child been on medication before (ex. Via the vagus nerve, impulses from the cough receptors are propagated to the cough center in the medulla and nucleus tractus solitaris. • Have you noticed any blood in your sputum? Cough can be acute (lasting less than 3 weeks), sub-acute (lasting 3–8 weeks), or chronic (lasting more than 8 weeks).  Note that these classifications are not mutually exclusive. For example, antibiotics should be given for bacterial pneumonia; bronchodilators and anti-inflammatory drugs should be given for asthma. Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. During the physical examination, you should pay attention to the following signs: Growth parameters – signs of poor growth and/or failure to thrive. Chapter 24. 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). In this guideline, only chronic cough will be discussed. In: UpToDate, Mallory GB (Ed), Hoppin AG (Ed), UpToDate, Waltham, MA, 2009. Black arrows represent the afferent pathway and purple arrows represent the efferent pathway. For children 6 months to 6 years, the parents should be asked about potential for foreign body aspiration, including older siblings or visitors with small toys, access to small objects, and consumption of small, smooth foods (eg, peanuts, grapes). Learn more about our commitment to Global Medical Knowledge. Acute cough in children is mostly caused by upper respiratory tract infections (URTIs). Examine for edema, cyanosis, clubbing of fingers/toes, and skin lesions. a. Before we dive into the clinical approach to cough, let us review the respiratory physiology of cough. If the patient is infant, ask about perinatal history (caesarean section, twins, asphyxia, maternal infection like fever or UTI at birth, prematurity and birth weight). History of present illness should cover duration and quality of cough (barky, staccato, paroxysmal) and onset (sudden or indolent). To understand the content differences in obtaining a medical history on a pediatric patient compared to an adult. All children with chronic cough require a chest x-ray. Pediatric chronic cough (ie, cough in children aged < 15 years) is defined as a daily cough lasting for > 4 weeks. Abdominal examination should focus on presence of abdominal pain, especially in the upper quadrants (indicating possible left or right lower lobe pneumonia). Each cough is elicited by the stimulation of the cough reflex arc. Cough receptors, which are afferent endings of the vagus nerve (cranial nerve X), are scattered in the airway mucosa and submucosa. Inspect chest wall for signs of hyperinflation and deformities. Establish whether there was any parental illness around the time of conception that may be relevant. Cough in the pediatric population. Coughing is an important mechanism for clearing secretions from the airways and can assist in recovery from respiratory infections. Peri-conceptual history. Failure to thrive or weight loss can occur with TB or cystic fibrosis. These guidelines incorporate the recent advances in chronic cough pathophysiology, diagnosis and treatment. A paroxysmal cough is characteristic of pertussis or certain viral pneumonias (adenovirus). Inspiratory phase: air in… Chemoreceptors are sensitive to acid, heat, and capsaicin derivatives through the activation of type 1 vanilloid receptor (TRPV1) and are located mainly in the distal airways. The link you have selected will take you to a third-party website. The cervical and supraclavicular areas should be inspected and palpated for lymphadenopathy. Grunting may be less common in older infants; however, tachypnea, retractions, and … A barky cough suggests croup or tracheitis; it can also be characteristic of psychogenic cough or a postrespiratory tract infection cough. Is there hemoptysis? For example, if allergic sinusitis is suspected and treated with an antihistamine that does not alleviate symptoms, a head CT may be necessary for further evaluation. • Do you bring anything up? Steven Todman 2,325 views. Other characteristics of the cough are helpful but less specific. 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 This site complies with the HONcode standard for trustworthy health information:   Some of these symptoms are ubiquitous (eg, runny nose, sore throat, fever); others may suggest a specific cause: headache, itchy eyes, and sore throat (postnasal drip); wheezing and cough with exertion (asthma); night sweats (tuberculosis [TB]); and spitting up, irritability, or arching of the back after feedings in infants (gastroesophageal reflux). Introduce yourself, identify your patient and gain consent to speak with them. Biomedical perspective- to understand the chronology of symptoms, analyse each symptom and review each system to localize the source of the fever. A high index of suspicion for foreign body aspiration is needed if children are age 6 months to 6 years. Head and neck examination should focus on presence and amount of nasal discharge and the condition of the nasal turbinates (pale, boggy, or inflamed). Moist cough Suggestive of LRTI, COPD exacerbation or bronchiectasis; Dry Cough Suggestive of viral illness, asthma, GI reflux, restrictive lung disease or ACE inhibitors; Long paroxysms of ‘whooping’ Suggestive of pertussis (whooping cough) Sputum Chest radiograph can provide you with additional information, such as infiltrations/ consolidations, hyperinflation, peribronchial thickening, hyperinflation, atelectasis and chronic lung changes. Management of cough in children The goal should always be to identify an underlying cause of cough in children. Nature of cough; How long has the child been coughing for? Chang AB. Paediatric history taking- Introduction Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem A large percentage of the time, you will actually be able to make a diagnosis based on the history alone The value of the history will depend on your ability to elicit relevant information lungs) when taking a medical history, a focused cardiac history is also necessary to rule-in and rule-out cardiac pathology. Is the child passively or actively exposed to smoke from tobacco, marijuana, cocaine, or wood-burning stove? Foreign body aspiration and diseases such as cystic fibrosis and primary ciliary dyskinesia are less common, but they can all result in persistent cough. Children with viral infections should receive supportive care, including oxygen and/or bronchodilators as needed. For example, antibiotics should be given for... Key Points. The physician should ask about associated symptoms. Lung. Examination of extremities should note clubbing or cyanosis of nail beds (cystic fibrosis). Bronchodilators)? Laryngotracheobronchitis – barking cough, Paroxymal – pertussis and para-pertussis, Acute upper / lower respiratory tract infection (ARI), Inhalation injury (acute exposure to smoke or volatile substances), Interstitial lung disease (i.e. 7. History of pregnancy past medical history, family history, social history). Cough When taking a history of a cough, ask the patient: • How long have you been coughing for? From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world. Chapter 24. Treatment of cough is management of the underlying disorder. * All patients require a chest x-ray when they present for the first time with chronic cough. ... History and physical in pediatric cardiology - Duration: 1:13:47. The aetiology of coughing in children will cover a wide spectrum of respiratory disorders, … A 6-month-old boy with 1-week history of dry cough that worsened at night. J Pediatr. Is there any shortness of breath (dyspnea)? Goldsobel AB, Chipps BE. Causes of cough differ depending on whether the symptoms are acute ( < 4 weeks) or chronic (> 4 weeks). Is there increased work of breathing? It is triggered by stimulation of airway cough receptors, either by irritants or by conditions that cause airway distortion. Treatment. He had also vomited 4 times in the past 24 hours but had been drinking and eating well. Note whether the child was conceived naturally or by assisted reproduction. What pets or animals did the child have contact with? 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 one of the most common complaints for which parents bring their children to a health care practitioner. A 36-year-old man comes to your office because of a persistent cough that has been bothering him for the past 3 months. The receptor locations are represented by red dots in Figure 1. The trusted provider of medical information since 1899, Nausea and Vomiting in Infants and Children, Obsessive-Compulsive Disorder (OCD) and Related Disorders in Children and Adolescents, Adolescent patients who have obsessive-compulsive disorder (OCD) are most likely to also have which of the following, Last full review/revision Jun 2020| Content last modified Jun 2020, © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA), Cystic Fibrosis: Defective Chloride Transport, © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, Musculoskeletal and Connective Tissue Disorders. Acute cough in children with upper respiratory infection symptoms and no red flag findings is usually caused by a viral infection, and testing is rarely indicated. ), For acute cough, the most common cause is, For chronic cough, the most common causes are. Children with stridor, drooling, fever, and marked anxiety need to be evaluated for epiglottitis, typically in the operating room by an ear, nose, and throat specialist prepared to immediately place an endotracheal or tracheostomy tube. History of Presenting Complaint. A cough is a forceful expulsion of air from the lungs that helps to clear secretions, foreign bodies, and irritants from the airway.It may be classified as acute (< 3 weeks), subacute (3–8 weeks), or chronic (> 8 weeks), as well as productive (with sputum/mucus expectoration) or dry.Upper respiratory tract infections (URI) and acute bronchitis are the most common causes of acute cough. Important respiratory risk factors include: Pre-existing respiratory disease (e.g. Mechanoreceptors are sensitive to touch or displacement and are located mainly in the proximal airway such as larynx and trachea. Figure 1 – Cough reflex anatomy: Red dots represent the locations of the cough receptors. 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. By conditions that cause airway distortion for foreign body aspiration is needed if children age! Because of a persistent cough that worsened at night nail beds ( cystic fibrosis, primary. Pediatrics: ACCP evidence-based clinical practice guidelines located mainly in the proximal airway such as bronchiectasis in 1899 as service! 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