Wednesday, May 5, 2010

Asthma II

You are a pediatrics intern on your first day of clinic. Now you get third year medical students running around for you! You send a medical student to see a 2 year old who is "fussy." The medical student comes back about an hour and a half later, fumbling through pages of notes. He says this is a 2 year old with no significant past medical history and a normal birth history who presents with irritation that started about an hour ago. He was in his crib, unmonitored, when he began to cry. The parents don't know what was wrong and brought him into urgent care. The child has had a nonproductive cough.

You wonder why that history took an hour and a half to obtain. You also wonder what's on the five other scribbled pages of the medical student's notes. Oh well.

The student reports a definite wheeze, but he only heard it on the left side. There were decreased breath sounds on that side too. You're not sure why, but the medical student got chest X-rays, shown above. The right CXR is expiratory and the left CXR is inspiratory. The CXR does not improve with bronchodilators.

The med student hedges on the assessment and plan. The differential diagnosis, he says, is asthma definitely, and also...

Challenge: Your student hesitates, waiting for you to fill in the more likely diagnosis which is what?

Image shown under Fair Use.


Suheil said...

i cant really interpret the films properly, tho i think it's a foreign body obstructing the left main bronchus (knowing fully that it most commonly occludes the right main bronchus)??

Craig Chen said...

Yes!!!! exactly right
Asthma II

This is not asthma; rather it is foreign body aspiration given the demographic and unilateral physical exam findings. This foreign body is lodged in the left mainstem bronchus (foreign bodies in children can go down either bronchus). Thus, there is hyperlucency in the left lung during expiration compared to inspiration.

Source: UpToDate, image courtesy of Charles Marquette.