Acute Bronchiolitis: History-Taking with Full Clinical Examination
Patient History
1-Year-Old Infant:
GP referral to Paeds ED: Bronchiolitis
Reduced fluid intake/wet nappies
ANP Assessment: POPS=3
PMH: Ex prem 32/40. Ventilated 24 hours, surfactant then extubated to air. Bilateral ear skin tags.
Phototherapy for jaundice
Home @ 2/52 age
Meds: Nil
Imms: UTD
Allergies: Nil known
Only child – mum 13/40 weeks
Parents well – mum has 2 uteruses!
Examination
Increased work of breathing (with mild recession)
Bilateral coarse crackles/wheeze consistent with Bronchiolitis
Systemically: looked well
Abdo: soft (left-sided), bloated + wind! Mild tenderness on palpation (right)
Bowel sounds heard (left)
Large mass (left-sided) – liver at 5cm, hard ++
Ears: Skin tags bilateral
Nil else found on examination
Impressions
Bronchiolitis Day 4 – reduced intake <50%
Space-occupying lesion
? Liver disease
Plan: admit to ward
Observe fluid intake ? NGT required
Maintain SaO2 above 92%
Discussed findings with senior
Cannula/Bloods & USS
Blood Results
FBC: slightly raised platelet count
U&E, Lactate: Coag, CRP, LFT all normal
Blood Results from CAU
LDH: Lactate Dehydrogenase 1865 (normally 180-430)
Ultrasound Scan
10.1cm x 9.3cm mass – under liver to umbilical area, right side of abdomen.
No renal tissue identifiable – liver, left kidney, bladder all normal.
? Mesoblastic Nephroma
? Wilms’ tumour
Considerations
Importance of top-to-toe examination
? Focused assessment by GP
Reassess
Sometimes expect the unexpected
Outcomes
Wilms’ tumour: surgery, chemo completed and now doing well
