Jamie, 2 year old boy is brought in by his mother for a persistent cough. The cough was dry yesterday and he was started on oral antibiotics by another GP. However now the cough is moist and he is getting worse and is quite severe now. Jamie is coughing throughout the consult constantly and significantly to the point of gagging, with noisy breathing. On examination he is afebrile but tachypnoeic. He appears short of breath, and has a wheeze greater on the left on auscultation.
What is your provisional diagnoses? List 1
- Inhaled foreign body
RACGP – Good answers involved the identification of a possible inhaled foreign body and the subsequent appropriate investigation and management.
What investigations do you want to perform?
- Inspiratory and expiratory chest xray (2)
- CXR (1)
RACGP – Good answers involved the identification of a possible inhaled foreign body and the subsequent appropriate investigation and management.
What is your management of this child? List 2
- Place child upright in the position they feel most comfortable.
- Arrange for urgent removal of foreign body in the operating theatre under respiratory [or ENT] specialists
RACGP – In this case the most common error was not giving an appropriate timeline on the referral. It is important to demonstrate insight into the urgency of referrals where appropriate and furthermore identifying who the patient is being referred to. A simple answer of “refer” would not score marks.
RACGP Feedback
This case requires the assessment, investigation and management of a 2 year old boy presenting with a persistent cough that has progressed from a dry to a moist cough despite antibiotic therapy. The history describes features suggestive of an inhaled foreign body.
Good answers involved the identification of a possible inhaled foreign body and the subsequent appropriate investigation and management. This is a commonly missed diagnosis. In this case the most common error was not giving an appropriate timeline on the referral. It is important to demonstrate insight into the urgency of referrals where appropriate and furthermore identifying who the patient is being referred to. A simple answer of “refer” would not score marks. This is a key feature exam and as such requires demonstration of insight into the critical nature of the presentation.
GPCC Feedback
The “pearl” of not missing a foreign body is pretty consistent from medical school and JHO ED education. There are similar questions always involving a nasally inhaled foreign body as well. The differentiation from pneumonia is given to you by the patient being afebrile, and this cues is an example of the types of cues that you should disproportionately hang your hat on in these exams. If they give you a cue like this, then take it and commit to an answer that takes this cue into account – just think of it like you were writing the questions and what would you say as the stem.
