Case 7: Toddler with a cough and fever

Opening scenario

The mother of Virginia Jameson, a 2-year-old girl; , consults you because her child has a cough and a fever.

Vital signs

Not available.

Examinee tasks

• Take a focused history.
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

For telephone cases, you can complete the focused history as you normally would, but you will not conduct a physical examination and can leave this section of the patient note blank.

Patient instructions

• You are very anxious and concerned about your daughter. You become even more anxious when the examinee uses medical terminology.
• You are unaware of the meanings of medical terms (e.g., chest x-ray) and ask for clarification if the examinee uses them.
• Use the checklists below for history, communication, and interpersonal skills.

Challenge: When the examinee suggests that you come to the hospital, say, “I don't have time to come to the hospital! I have to pick up my son from daycare.”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• She has a cough and a fever.
• Onset
• It started 4 days ago with a runny nose. The fever and cough started 3 days ago.
• Constant/intermittent
• She has had a fever and cough the whole time.
• Precipitating events
• None.
• Progression
• The fever has gotten worse, and she has been coughing more since it started.
• Previous episodes
• She is sick pretty often – she gets everything her brother brings home from daycare, poor thing. The last time she had a cough was about 3 months ago. But she didn't have this high of a fever then.
• Alleviating factors
• I gave her Tylenol^®, which lowered the fever.
• Aggravating factors
• None.
• Associated symptoms
• She also has diarrhea.
  • Onset and frequency
  • She has had it for 2 days. She has had 4–5 poopy diapers every day.
  • Color
  • Normal color.
  • Consistency
  • It looks watery.
  • Blood in stool
  • No.

Review of systems specific to cough in an infant or toddler

• Fever (how high, how was it measured)
• I just measured 103.6°F (39.8°C) with the ear thermometer.
• Ear pulling
• No.
• Nausea/vomiting
• No.
• Eye discharge
• No.
• Ear discharge
• No.
• Rash
• No.
• Crying/irritable
• She seems really miserable.
• Sputum (color, amount, blood)
• She coughs up green-colored slime.; Not much though, and there is no blood in it.
• Shortness of breath
• She is breathing faster than usual.
  • Drooling/difficulty swallowing or speaking
  • No. She has not been drooling and her voice sounds normal to me.
  • Bluish discoloration around the lips or mouth
  • No.
  • Noisy breathing
  • No.
  • Retractions below or between ribs when breathing
  • No.
• Urinary problems
• No.
• Sleep problems
• She is not sleeping well because she is really uncomfortable.
• Seizure
• No.
• Activity (playful)
• She is really not her normal, playful self at all.
  • Lethargic/sleepy
  • No, nothing like that. She just seems really unhappy.
• Dry mouth, sunken eyes, fluid intake (dehydration)
• She seems like she has a dry mouth; , and she is drinking less than normal.
• Amount of wet diapers/24 hrs
• I can't really tell because of the diarrhea.
• Recent travel
• No.

Asking about bluish discoloration around the lips or mouth is an important question for pediatric patients with respiratory symptoms. Cyanosis could indicate emergency assistance is required (i.e., the caregiver should be advised to call 911)!

Past medical history, family history, social history

• Past medical history
• She had jaundice for the first week after she was born. She was treated with a blue light.
• Past surgical history
• None.
• Previous hospitalizations
• None.
• Prenatal history
• Normal.
• Allergies
• None.
• Medications
• None.
• Ill contacts
• Her big brother goes to daycare and has been sick for the last 4 days; . He has a runny nose and cough, too, but no fever.
• Family history
• None.
• Birth history
• She was born vaginally at 37 weeks, but there were no problems whatsoever.
• Immunizations
• All of her immunizations are up-to-date.
• Growth and development
• Everything has been normal at the well-child visits so far.
• Daycare
• I stay home with Virginia, and her brother goes to daycare.
• Eating habits and appetite
• She usually eats everything I give her, including meat, vegetables, fruits, and bread. But she doesn't really want to eat right now.
• Last checkup
• We had a checkup 1 month ago and everything was fine.

Not available in telephone cases.

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's and the caregiver's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt patient or caregiver).
• Examinee showed interest in the patient and the caregiver as persons (i.e., appeared caring and showed respect).
• Examinee demonstrated ability to support the patient's and the caregiver's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient or caregiver.
• Examinee explained management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated caregiver's agreement with next diagnostic steps.
• Examinee asked about concerns and/or questions.

Counseling and challenge

• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Ms. Jameson, I understand your feeling of responsibility for your son. At the same time, from what you have told me so far, I am concerned that your daughter may have a serious infection that requires treatment. Her rapid breathing, high fever over several days, and the impression you have that she is not drinking enough all indicate to me that she needs to be examined by a physician. Is there anyone else who could pick up your son, or would you like me to put you in contact with our social worker, who could arrange some temporary care for him?”

Patient note

Differential diagnoses

1. Acute bronchitis: This is the most likely cause of this child's cough and fever. Acute bronchitis is oftentimes preceded by an upper respiratory infection, which this child had. Acute bronchitis is viral in > 90% of cases and as such does not usually require antibiotic treatment. Adenovirus in particular is known for causing both respiratory and gastroenterological symptoms, which would be consistent with this patient's symptoms.
2. Pneumonia: Although acute bronchitis is the most likely cause of this otherwise healthy child's cough and fever, her increased respiratory rate, prolonged high fever, and poor fluid intake should raise concern for pneumonia. Although viral pneumonia is the most common type in this age group, bacterial pneumonia can occur as well. An x-ray and CBC would allow this diagnosis to be ruled out. Pneumonia in children can also manifest with diarrhea.
3. Viral gastroenteritis: While this patient has a history of diarrhea and fever, she has no nausea or vomiting. Although she might suffer from an associated gastroenteritis, it is more likely here that her gastrointestinal symptoms are related in some way to her respiratory infection. This child has signs of volume depletion (e.g., dry mouth and decreased fluid intake) and should be monitored and treated for this if necessary.

Diagnostic studies

• Physical examination: Always note physical examination as part of the workup in a telephone case.
• Pulse oximetry: to determine the degree of respiratory distress
• Arterial blood gas analysis: to determine if any acid-base disturbances are present, either because of the patient's diarrhea, her respiratory symptoms, or both
• CBC with differential: A WBC count can help determine if an infection is bacterial or viral. Hematocrit is typically elevated in cases of dehydration.
• Electrolytes, glucose: The child has watery diarrhea. She has lost electrolytes and may be dehydrated or hypoglycemic.
• Respiratory viral panel: detects common viruses that can cause respiratory tract infections
• CXR: to rule out pneumonia

In telephone cases, physical examination is not possible. Leave the “physical examination” section blank in your patient notes but add the physical exam to your diagnostic studies.

Other differential diagnoses to consider

• Croup
• Bacterial gastroenteritis
• Influenza
• Sepsis
• See also cough and diarrhea.