31. Resident-attending in the ED: Shortness of breath
Resident: Good afternoon Dr. Reynolds, I’m worried about a patient I’ve just seen.
Attending: Tell me about it.
Resident: It’s a 5-year-old boy with no previous medical history, except for bronchiolitis and just one episode of bronchospasm 2 years ago. He has come in with shortness of breath which started this morning, cough and hoarseness since 2 days ago and low-grade fever for about a week. On pulmonary auscultation he has diffuse hypoventilation and his O2 sat is 92%. I’ve started him on bronchospasm treatment with nebulised salbutamol and ipratropium bromide and oral methylprednisolone. The treatment finished half an hour ago and it seems he’s not responding well. He still has shortness of breath and hypoventilation and he needs low flow oxygen.
Attending: Have you thought about other differential diagnosis apart from bronchospasm and laryngitis?
Resident: I’ve ruled out diabetic ketoacidosis with a blood glucose level and I was planning on asking for a chest X-ray to discard pneumonia or other pulmonary causes.
Attending: Perfect, keep me updated and if he worsens I’ll take a look at him.
Resident: Dr. Reynolds, we have the X-ray result; it appears he has a mediastinal mass.
Attending: Oh! This is some bad news. Let’s take a look at the X-ray and the boy. We should call in the pediatric oncologist and inform his family. He’ll need to be admitted for further evaluation and treatment. For the moment, please inform his parents he needs an IV line and a blood test. Let me know when the oncologist arrives.
(The oncologist arrives and he informs the parents with Dr. Reynolds and the resident).
Attending: Good afternoon. I’m Dr. Reynolds, Dr. Mathews’ colleague, who has attended you, and this is Dr. Brown, pediatric oncologist. We asked her to come to see your son because of the findings on the chest X-ray. There is a mass inside his chest which is probably compressing his airway and causing the obstruction. This is why he isn’t responding to bronchospasm treatment. We think the mass could be a tumour.
Mother: Oh my god, I don’t know what to say. So what do we do now? What is the treatment?
Oncologist: First of all, we need to treat the symptoms, so he’ll need to be hospitalised with oxygen and initial treatment with intravenous steroids, which can reduce the mass. He’ll now be seen by the cardiologist to discard cardiac involvement and we’ll order an abdominal US. We’ll also perform a CT scan to determine the exact location and extension, although he may need other diagnostic imaging on the following days. Then, we’ll need to confirm the type of tumour to decide the specific line of treatment, since there are different tumours that can present this way. For this, we’ll need a biopsy, if he has peripheral lymphadenopathies, that will do. Once we have the diagnostic confirmation we’ll start him on chemotherapy. I know this a lot of sudden information. You can ask all the questions you like right now and we can discuss further doubts during these days.
Mother: How much time will he be hospitalised? What is the prognosis?
Oncologist: He may need to be admitted to the PICU for continuous monitoring during the first days. When his clinical situation improves, he’ll stay in our ward for some other days. Both parents can stay with him the whole time. If everything goes as expected, he will be able to receive outpatient treatment. As for the prognosis, I’m sorry I can’t give you an answer right now until we have more results. But the whole team will be in constant contact with you.
Mother: OK, thank you very much for your time. Please let us know when you have more information.
Attending: Let the boy stay in the position he prefers because his trouble breathing may worsen if he lays down.
Diffuse hypoventilation: hipoventilación difusa.
O2 sat: saturación de oxígeno.
Ipratropium bromide: bromuro de ipratropio.
Low flow oxygen: oxígeno de bajo flujo (p. ej., cánulas nasales).
Mediastinal mass: masa mediastínica.
Airway: vía aérea.
Cardiac involvement: afectación cardíaca.
Diagnostic imaging: diagnóstico por imagen.
Line of treatment: línea de tratamiento.
Peripheral lymphadenopathies: linfadenopatías periféricas.
Outpatient treatment: tratamiento ambulatorio.
Lays down (to lay down): tumbarse.