Assessment and Management of Bronchiolitis in an 18-Month-Old Male

The case involves an 18-month-old male child with complaints of shortness of breath, fever, and productive cough for the last two days. Other noted signs include a runny nose and reduced appetite levels. Immunizations are up to date, and the growth and development of the child are well within the expected age range: Assessment and Management of Bronchiolitis in an 18-Month-Old Male.

Physical examination findings are as follows: fever at 102°F, rapid breathing, SaO₂ of 92%, erythema in the throat area, wheezing, and lung crackles. The risk factors include exposure to secondhand smoke and contact with other sick children in the daycare. A specific rapid RSV antigen test was proven positive. With these findings, the first diagnosis is viral bronchiolitis.

History of Present Illness (HPI)

An 18-month-old male presents with a clinical history of dyspnoea, productive cough, and fever for the last two days and worsening. His caregiver also experienced nasal drip and reduced meal consumption linked to him. Breathlessness commenced as a recent symptom and has been continuous without relief of oxygen shortage known to the patient. The cough is productive, not very severe, and contains yellowish phlegm.

The fever was reported two days back, and it was 102°F. The child’s caregiver reports that no vomiting, diarrhea, or rash has been observed. There has been no similar previous incidence, no history of allergies, or any other related chronic diseases.

The child is regularly exposed to secondhand smoke within the home environment and has been interacting with other children at daycare recently, some of whom had flu-like illnesses. He has no local or international travel history in the last two weeks. Immunizations are current, and there are no signs of developmental delays for a child of the same age.

Diagnosis, Differentials, and Coding

The primary diagnosis is acute viral bronchiolitis, ICD-10 J21.0, based on clinical features of wheezing, crackles, tachypnea, and hypoxemia (SaO₂ 92%) associated with a positive RSV antigen test. Bronchiolitis is the most common cause of lower respiratory tract infections in infants and young children, and RSV causes it throughout the fall and winter months. Inflammation and mucus production lead to airway obstruction, hence symptoms of respiratory distress as seen in the patient (Justice & Le, 2022).

Differential Diagnoses

1. Influenza (ICD-10 J11.1): Influenza shares overlapping symptoms with bronchiolitis, including fever, cough, and fatigue (Boktor & Hafner, 2022). However, the lack of systemic symptoms, such as body aches, a negative influenza test, and a prominent presentation of wheezing and crackles, makes influenza less likely.
2. Group A Streptococcal Pharyngitis (ICD-10 J02.0): Pharyngeal erythema may be concerning for streptococcal pharyngitis. However, the absence of hallmark signs, such as tonsillar exudates, cervical lymphadenopathy, or sore throat history, helps rule this out (Luo et al., 2019).
3. Asthma Exacerbation (ICD-10 J45.901): Wheezing is one of the typical findings in asthma; however, the age of the patient, the acute presentation, and the positive RSV antigen test point toward viral bronchiolitis rather than asthma, as indicated by Ramsahai et al. (2019).

A systematic assessment of these differentials and the clinical findings confirms the diagnosis of bronchiolitis as the first order.

Treatment and Medications

Management of bronchiolitis is primarily supportive since most viral infections are self-limiting and do not need antiviral medications. Suggested treatment may include:

• Normal Saline Nebulization: Administered every 4–6 hours to relieve nasal congestion and improve airway clearance.
• Acetaminophen: 15 mg/kg every 4–6 hours as needed for fever; maximum daily dose, 75 mg/kg. Parents and caregivers should be counseled about side effects, including GI upset and risks related to overdosing (Justice & Le, 2022).

Management Plan

The management plan focuses on maintaining adequate hydration, monitoring respiration status, and avoiding irritants like passive smoking. The caregivers need to be educated on symptom management and prevention measures. Specific actions include managing oral fluids to prevent dehydration, monitoring for signs of respiratory distress, including grunting or nasal flaring, and preventing secondhand smoke through counseling and smoking cessation resources.

Social determinants of health (SDOH) are also tackled by offering education on decreasing exposure to environmental triggers and ensuring access to high-quality childcare. Preventive measures against RSV include hand hygiene promotion and limiting exposure during peak seasons (Hahn, 2021).

Patient Education

Caregivers were told to watch for signs of the baby worsening: increasing effort to breathe, turning blue, or decreased fluid intake. Education on the typical course of bronchiolitis was given; it typically peaks between days one through three to five and resolves in two weeks. Prevention guidance, including education on RSV, handwashing, and avoiding crowded areas, was also emphasized. Instructions were given to continue the prescribed medication and look out for any signs/symptoms that may predispose to complications (Justice & Le, 2022).

Follow-Up

Follow-up is recommended in 5–7 days to reevaluate respiratory status and assure resolution of symptoms. In the case of severe respiratory distress, the parents were advised to put the child under immediate medical attention for signs including apnea, cyanosis, or unresponsiveness.

References

Boktor, S. W., & Hafner, J. W. (2022). Influenza. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29083802/

Hahn, R. A. (2021). What is a social determinant of health? Back to basics. Journal of Public Health Research, 10(4). https://doi.org/10.4081/jphr.2021.2324

Justice, N. A., & Le, J. K. (2022). Bronchiolitis. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/28722988/

Luo, R., Sickler, J., Vahidnia, F., Lee, Y.-C., Frogner, B., & Thompson, M. (2019). Diagnosis and management of group a streptococcal pharyngitis in the United States, 2011–2015. BMC Infectious Diseases, 19(1). https://doi.org/10.1186/s12879-019-3835-4

Ramsahai, J. M., Hansbro, P. M., & Wark, P. A. B. (2019). Mechanisms and management of asthma exacerbations. American Journal of Respiratory and Critical Care Medicine, 199(4), 423–432. https://doi.org/10.1164/rccm.201810-1931ci

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The patient is an 18 months old male presenting with a 2 day history of a shortness of breath, fever, and productive cough. Additional symptoms includes rhinorrhea, and decreased appetite. Immunization are up to date; developmental milestones present and appropriate for age.

Physical finding includes: Temp 102F, tachypnea, and SaO2 92%, erythema in pharynx, pulmonary wheezing and crackles. Risk factor includes exposure to second hand smoke and other sick children at daycare.

Test: Positive for RSV Antigen

Diagnosis

• Bronchiolitis

1). Clearly written HPI statement including all 8 aspects and pertinent information related to chief complaint. Includes pertinent positives and negatives. 10 points

2). Diagnosis, Differentials, and Coding: What were the key clinical presentations in this patient that led you to choose these differentials; then how did you rule them out to reach your primary diagnosis? Includes ICD coding for each diagnosis. 10 points

Assessment and Management of Bronchiolitis in an 18-Month-Old Male

Differential diagnoses

1. Influenza
2. Pharyngitis, Group A Streptococcal
3. Bronchiolitis (viral) (Correct diagnosis)

3). Medications prescribed are appropriate, evidenced based, and full prescription is included and dosing correct. Includes side effect. Full patient education information is included. 10 points

4). Management Plan: Clearly written plan covering all critical components for patient’s final diagnosis .List each SDOH and specific to this patient. SDOH and Health promotion/anticipatory guidance is addressed. 20 points

5 Patient Education: Comprehensive patient education is included related to current health visit and recommended health screenings. 10 points

6). Follow up instructions: are complete and include time to next visit and specific symptoms to prompt a return visit sooner.10 points

7). Scholarly References and Clinical Practice Guidelines: The assignment includes a minimum of 3 scholarly references that are not older than 5 years. Clinical practice guidelines are included if applicable.  5 points