You are working in the paediatric department in ED when the paramedics bring in a 13 week old baby boy with his mother.

There has been a history of persistent coughing and an episode of apnoea lasting a few seconds when the patient turned a blue colour.

On further questioning he has been coughing for 16 days, has been to see the GP 2 times and been to the ED once 10 days ago. The coughing has persisted despite a course of erythromycin started by the GP after a normal CXR performed 7 days ago.

He has been feeding around 60% to normal, exclusively breast fed. Tonight after a feeding episode he continued to cough for several minutes before becoming apnoeic for around 10 seconds and mother noticed a blue tinge to lips. He has been back to his normal self since then but generally has been more lethargic the last week. Mother has not noticed any fever. He has had only 1 wet nappy today.

He was born prematurely at 33 weeks and was discharged after 1 week.

On examination he appears alert but a little tired. Sats are 96% on room air, HR 180/min, PP 45/min, CRT <2 seconds and temperature 37.7°C. He has coughed frequently in ED. Heart sounds are normal with good pulses and respiratory auscultation reveals normal air entry with no crepitations or wheeze.

QUESTIONS

Answer one question before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. The first part of teaching will be spent discussing this case:

  1. What is the differential diagnosis with this child and state the 2 most likely diagnoses?

  2. What further questions would you like to ask the mother to help with the diagnosis?

  3. What investigations would you request in this patient and how would they help you differentiate the cause?

  4. What risk factors are present in this patient that may prompt you to admit the patient and state any other risk factors that could influence your decision?

A VBG is performed:

 
  • pH 7.28

  • pCO2 7.01

  • pO2 5.41

  • BE -3.5

  • HCO3 23.6

  • Glucose 6.1

  • Lactate 2.1

5. What does this blood gas show and how will it influence your management?

6. What treatments could you commence in ED and where should this patient be referred?

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