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Cough and you’ll miss it


­A 9-month-old boy presented to the emergency department with acute wheeze. He had a background of cleft lip repair at 4 months and was awaiting palatoplasty. He had mild eczema but had never had a previous wheezy episode, and was awaiting cardiology follow-up for a small patent ductus arteriosus (PDA). He had been at the child minder when symptoms began abruptly with no witnessed event. On assessment, the wheeze had resolved, saturations were 98% breathing air, respiratory rate was 34 breaths per minute and he was afebrile. He was discharged home with safety net advice.

He represented 2 days later with cough, wheeze and shortness of breath. On examination, he had subcostal recession and there was reduced air entry on the right. There was no wheeze, crepitations or obvious organomegaly. Oxygen saturations were 98% breathing air, respiratory rate was 38 breaths per minute and he was afebrile. Oral amoxicillin was given.


  1. Given the history what is the likely diagnosis?

    1. Bronchiolitis

    2. Congestive heart failure

    3. Foreign body aspiration

    4. Pneumonia

    5. Reactive airways disease

  2. Which investigation would be most useful at this stage?

    1. Bronchoscopy

    2. Chest X-ray

    3. CT chest

    4. Echocardiogram

    5. Point-of-care respiratory strip

  3. What is the next step in the management?

    1. Intravenous ceftriaxone/clarithromycin

    2. Intravenous diuretics

    3. Needle thoracocentesis

    4. Oral steroids and inhaled bronchodilator

    5. Rigid bronchoscopy

  4. What are the long term complications of an undiagnosed foreign body?

Questions Answers can be found on page 2.

  • paediatric
  • foreign body aspiration
  • cough
  • wheeze

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