A 6-year-old girl is brought to the clinic due to a prolonged cough. The patient started having rhinorrhea 6 weeks ago. A week later, she developed a cough with occasional expectoration of whitish sputum; the rhinorrhea resolved at that time. For the past 5 weeks, the patient's cough has continued throughout the day and night, occasionally awakening her and with no improvement. Her father tried using a humidifier, with no relief of her symptoms. The patient has been afebrile and has had no vomiting, abdominal pain, diarrhea, or sick contacts. She takes no daily medications. Immunizations are up to date. The patient's mother has atopic dermatitis. Height and weight are at the 25th percentile. Temperature is 36.7 C (98 F) and respirations are 24/min. The patient is awake, alert, and playing. Tympanic membranes are normal. The tonsils are normal, the mucous membranes are moist, and the lips are pink. Cardiac examination has a normal rate and rhythm. The lungs are clear to auscultation bilaterally; no retractions or use of accessory chest muscles are present. Which of the following is the best next step in evaluation of this patient?

Question

A 6-year-old girl is brought to the clinic due to a prolonged cough.  The patient started having rhinorrhea 6 weeks ago.  A week later, she developed a cough with occasional expectoration of whitish sputum; the rhinorrhea resolved at that time.  For the past 5 weeks, the patient's cough has continued throughout the day and night, occasionally awakening her and with no improvement.  Her father tried using a humidifier, with no relief of her symptoms.  The patient has been afebrile and has had no vomiting, abdominal pain, diarrhea, or sick contacts.  She takes no daily medications.  Immunizations are up to date.  The patient's mother has atopic dermatitis.  Height and weight are at the 25th percentile.  Temperature is 36.7 C (98 F) and respirations are 24/min.  The patient is awake, alert, and playing.  Tympanic membranes are normal.  The tonsils are normal, the mucous membranes are moist, and the lips are pink.  Cardiac examination has a normal rate and rhythm.  The lungs are clear to auscultation bilaterally; no retractions or use of accessory chest muscles are present.  Which of the following is the best next step in evaluation of this patient?

Quizplus · Accepted Answer

Explanation: Chronic cough in children is defined as a cough lasting >4 weeks. Initial evaluation includes a detailed history and thorough physical examination to potentially identify a specific underlying cause. For example, poor growth may suggest a chronic illness (eg, cystic fibrosis [CF]) or peripheral edema may suggest cardiovascular disease. In the absence of specific historical (eg, concomitant upper respiratory symptoms) or examination findings, initial evaluation begins with spirometry. Spirometry is a simple pulmonary function test that can be performed in a cooperative child to detect obstructive airway disease (eg, asthma). Cough due to asthma may be associated with wheezing, shortness of breath, or a history of atopy, as in this child with a family history of atopic dermatitis. However, isolated chronic cough with a normal lung examination may be the sole finding in asthma. Chest x-ray is also recommended for the evaluation of chronic cough. It may be helpful in identifying abnormalities such as mediastinal widening (eg, chronic infection, neoplasm), hyperinflation (eg, foreign body aspiration), or cardiac defects. (Choice A) CT scan of the chest in children is typically reserved to evaluate abnormal findings (eg, mass) found on less-invasive imaging (eg, x-ray) due to radiation exposure. This child warrants imaging if spirometry is normal, but x-ray is indicated first. (Choice B) Pertussis can present with a chronic cough following the paroxysmal stage and classically presents with a "whoop" in children age <10. Vaccinated children are less likely to develop pertussis and typically have a less severe illness. Pertussis testing could be considered if spirometry and imaging are normal. (Choice D) Sputum culture is obtained for patients with suspected active tuberculosis (TB). Although TB causes chronic cough, this patient has no risk factors (eg, high-risk travel, known contacts with TB) or other symptoms (eg, fever, weight loss) of TB. (Choice E) Sweat chloride testing is used in evaluation of CF. CF typically presents with failure to thrive, recurrent pulmonary infections, and pancreatic insufficiency (ie, steatorrhea). None of these symptoms are present in this patient. Educational objective: Chronic cough (>4 weeks) without specific historical or examination findings warrants spirometry testing to identify underlying obstructive lung disease (eg, asthma). References: Guidelines for evaluating chronic cough in pediatrics: ACCP evidence-based clinical practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/16428719)

A 6-Year-Old Girl Is Brought to the Clinic Due to a Prolonged