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Ward Round Preparation - Clerking & Examination Guide

BED 13 - FAIHA HUMAIRA, 5 months - Bronchiolitis

History to Clerk

• Noisy breathing (onset, duration, constant or episodic?)
• Recession/chest wall retraction (subcostal, intercostal, suprasternal?)
• Cough (onset, character - dry/wet, worse at night?)
• Rapid breathing (duration)
• Vomiting (after feeds? amount? any blood?)

• Duration of symptoms - classic 2-7 day course
• Preceding URTI (runny nose, nasal congestion) - typically starts 2-3 days before lower respiratory symptoms
• Fever (how high, how long, any rigors?)
• Feeding history - breastfed or formula? Volume intake vs normal? Number of wet diapers (assess hydration)
• Any apnoeic episodes (critical in infants <2 months, premature babies)
• Contact with sick person (viral spread - RSV, rhinovirus, hMPV, parainfluenza)

• Gestational age at birth (prematurity = higher risk of severe disease)
• Birth weight
• Any NICU admission, oxygen, ventilation at birth

• Prior episodes of wheeze/bronchiolitis
• Congenital heart disease (CHD is a major risk factor for severe RSV)
• Chronic lung disease / BPD
• Immunodeficiency

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Examination

• Temperature
• Heart rate
• Respiratory rate (tachypnoea >60/min in infants is significant; normal <50 for this age)
• SpO2 (target ≥92-94%; <92% = admission criteria)
• Weight (for drug dosing, compare to growth chart)

• Inspection: Chest shape (hyperinflation = barrel chest), recession (subcostal, intercostal, suprasternal, tracheal tug), nasal flaring, head bobbing, grunting, use of accessory muscles
• Percussion: Hyperresonance (air trapping)
• Auscultation:
  • Fine end-expiratory crackles (hallmark of bronchiolitis)
  • Wheeze (expiratory > inspiratory)
  • Reduced air entry (suggests severe obstruction or consolidation)
  • Symmetry of air entry

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Severity Assessment (Bronchiolitis)

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Key Investigations

• Nasopharyngeal swab for respiratory virus panel (RSV, hMPV, rhinovirus, parainfluenza, influenza, coronavirus, adenovirus)
• SpO2 monitoring - continuous
• FBC (if fever and concern for secondary bacterial infection)
• CXR only if: uncertain diagnosis, severe disease, or not improving (classic finding = hyperinflation ± patchy atelectasis)
• Blood gas if severe/impending respiratory failure
• U&E if IV fluids needed

Management Principles

• Supportive - mainstay of treatment; no drug shortens illness course
• O2 if SpO2 <92% (via nasal prongs, target ≥94%)
• Feeding support - NG feeds if oral intake <50-75% normal
• IV fluids if significant recession, RR >60-70, aspiration risk
• Nasal suctioning - temporary relief only
• Bronchodilator trial acceptable if moderate-severe distress (salbutamol/adrenaline nebulisation) - continue only if clear clinical response
• Steroids - NOT routinely recommended
• Antibiotics - NOT routine; only if confirmed bacterial co-infection (positive culture, consolidation on CXR, AOM)
• Palivizumab - post-discharge prophylaxis if high-risk (CHD, prematurity, CLD)

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BED 14 - MUHAMMAD IMAN, 2y5m - URTI, Multi-trigger Wheeze, Bronchopneumonia

History to Clerk

• Fever (duration, peak temperature, pattern, response to antipyretics?)
• Cough (wet or dry, productive, paroxysmal, at night?)
• Rapid breathing (onset relative to fever?)
• Wheeze episodes (this episode vs past episodes - what triggers? viral URTI? cold air? exercise? allergen?)

• URTI symptoms: runny nose, nasal congestion, sore throat - how long?
• Did wheeze follow the URTI? (classic multi-trigger wheeze pattern)
• Fever duration, any chills/rigors
• Feeding/drinking - reduced intake?
• Any apnoea, cyanosis?

• Age of first wheeze episode
• Number of episodes per year
• Triggers: viral URTI (most common at this age), cold weather, exercise, smoke, allergens, emotion
• Any interval symptoms (wheeze/cough between episodes)? - if yes, suggests persistent asthma rather than episodic viral wheeze
• Previous hospitalisations for wheeze
• Previous medications: salbutamol, ICS, LTRA (montelukast)?

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Examination

• Temperature (fever supports infective trigger)
• RR (tachypnoea for age: >40/min in 2y = abnormal)
• SpO2
• Heart rate (tachycardia from fever, hypoxia, or salbutamol)

• Inspection: Recession (subcostal, intercostal), nasal flaring, accessory muscle use, chest symmetry
• Auscultation:
  • Wheeze - expiratory, bilateral, widespread (bronchospasm)
  • Crackles - if present + consolidation = bronchopneumonia
  • Reduced air entry (severe bronchospasm or consolidation)
  • Area of bronchial breathing (consolidation)

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Key Investigations

• CXR - bronchopneumonia: patchy bilateral infiltrates; lobar consolidation suggests bacteria
• FBC + CRP - elevated WBC/CRP suggests bacterial component
• Nasopharyngeal swab - viral panel
• Viral PCR (rhinovirus most common trigger for multi-trigger wheeze at this age)
• Blood culture if high fever and ill-appearing
• SpO2 monitoring
• Procalcitonin if available

Management Principles

• Bronchodilator: Salbutamol MDI via spacer (2.5 mg neb or 6-10 puffs MDI) - repeat PRN; hourly in severe wheeze
• Steroids: Oral prednisolone 1-2 mg/kg/day (max 40 mg) x 3-5 days for wheeze exacerbation
• Antibiotics: Amoxicillin-clavulanate OR amoxicillin first-line for bronchopneumonia in this age (cover Strep pneumoniae, H. influenzae); co-amoxiclav if atypical cover needed
• Antipyretics: Paracetamol/ibuprofen for fever
• O2 if SpO2 <92%
• Consider LTRA (montelukast) for multi-trigger wheeze prevention (controversial but widely used)
• Discharge criteria: SpO2 stable ≥94%, feeding well, parental education on spacer technique

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BED 15 - NUR AIN NADEERA, 6y1m - Mild Persistent Bronchial Asthma, Eczema - Moderate AEBA secondary to URTI

History to Clerk

• Rapid breathing - when started? At rest or only with activity?
• Cough (nocturnal? worse with exercise? productive?)
• Nasal congestion (URTI trigger)
• Any wheeze noticed by parents?

• Trigger (URTI symptoms precede this episode?)
• How quickly did it progress?
• Response to reliever (salbutamol) at home - how many puffs? How often?
• Last dose of ICS (compliance with preventer therapy?)
• Any previous similar severe episodes, A&E visits, hospitalisation, ICU admission?

• Current step of treatment (ICS dose, LABA, LTRA?)
• Last spirometry / peak flow reading
• Frequency of reliever use per week (marker of control)
• Night symptoms, exercise limitation
• School attendance affected?
• GP visits for asthma in past year?

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Examination

• RR - Moderate exacerbation: RR 30-50/min for this age
• SpO2 - target ≥92% room air; SpO2 <92% = severe
• Heart rate
• Pulsus paradoxus (>10 mmHg = moderate-severe)
• PEFR (if cooperative): compare to personal best/predicted

• Inspection: Use of accessory muscles (SCM, scalenes), intercostal/subcostal recession, nasal flaring, prolonged expiration
• Auscultation:
  • Bilateral rhonchi (wheeze) - as documented
  • Air entry - good bilaterally as noted (reassuring - severe asthma may have "silent chest")
  • No creps - distinguishes from pneumonia, rules out consolidation
• Percussion: Hyperresonance (air trapping)

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Key Investigations

• SpO2 - continuous monitoring
• PEFR - % predicted (mild >75%, moderate 40-75%, severe <40%)
• CXR if: first episode, uncertain diagnosis, suspected pneumothorax, not responding to treatment
• FBC - eosinophilia supports atopy; raised WBC if bacterial secondary infection
• CRP / procalcitonin if bacterial URTI suspected
• Nasal swab for viral panel
• Total IgE, specific IgE (RAST) / skin prick test - for outpatient allergy workup

Management - Moderate AEBA (GINA-guided)

1. Salbutamol nebulised 2.5-5 mg (or 6-10 puffs MDI via spacer) every 20 min x3 in first hour, then 1-4 hourly - assess response
2. Ipratropium bromide 250 mcg nebulised every 20 min x3 (adds to bronchodilation in moderate exacerbation)
3. Systemic corticosteroids: Oral prednisolone 1-2 mg/kg/day (max 40 mg) x 3-5 days - start EARLY
4. O2 if SpO2 <94%
5. Magnesium sulphate IV 25-75 mg/kg (max 2g) if severe/not responding

• Review ICS compliance
• Step-up to medium-dose ICS or add LTRA
• Eczema: emollient intensification, topical corticosteroids, avoid triggers

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BED 16 - NIK MUHAMMAD NAQI, 4 months - RSV Pneumonia with Secondary Bacterial Infection

History to Clerk

• Cough (onset, character, paroxysmal?)
• Fever (duration, peak, response to antipyretics?)
• Rapid breathing (onset, worsening?)

• Any preceding URTI in baby or household contacts
• Feeding difficulty (volume, frequency, any pauses for breath during feeds?)
• Wet diapers (hydration)
• Apnoeic episodes (CRITICAL question for <6 months - RSV commonly causes apnoea in young infants)
• Any cyanotic episodes
• Contact with sick individuals (siblings, daycare)
• RSV season context (typically Nov-April in temperate regions)

• Gestational age (prematurity → BPD → severe RSV risk)
• NICU admission
• Any congenital heart disease workup

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Examination

• Temperature (fever in RSV pneumonia may indicate secondary bacterial co-infection)
• RR - normal for 4 months: <50/min; tachypnoea >50-60/min abnormal
• SpO2 - critical parameter; target ≥94%
• Heart rate
• Blood pressure
• Weight and head circumference (plot on growth chart)

• Inspection:
  • Recession - subcostal, intercostal, suprasternal, tracheal tug
  • Nasal flaring
  • Head bobbing (use of SCM = severe distress in infants)
  • Grunting (expiratory grunt = PEEP equivalent, sign of severe disease)
  • Chest asymmetry (effusion?)
• Percussion:
  • Dullness (consolidation)
  • Hyperresonance (air trapping)
• Auscultation:
  • Crackles (fine/coarse) - hallmark of pneumonia
  • Wheeze if bronchiolitis component
  • Bronchial breathing (consolidation)
  • Reduced air entry (effusion or severe consolidation)
  • Symmetry of air entry

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Severity Assessment - WHO Pneumonia Severity in Infants

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Key Investigations

• CXR - RSV bronchopneumonia: bilateral patchy infiltrates, hyperinflation, peribronchial thickening; bacterial consolidation may show lobar/segmental pattern
• FBC - raised WBC/neutrophilia suggests secondary bacterial infection
• CRP / procalcitonin - elevated in bacterial infection
• Blood culture - BEFORE starting antibiotics (identify bacterial co-pathogen)
• Nasopharyngeal swab / aspirate for RSV Ag (rapid antigen test or PCR), full respiratory viral panel
• U&E - assess for SIADH (hyponatraemia common in RSV pneumonia)
• Blood gas if SpO2 poor or work of breathing severe (monitor for respiratory failure)
• NPA for RSV PCR - gold standard

Management

• O2 via nasal prongs if SpO2 <92-94% (target 94-98%)
• Nasal suctioning
• Feeding support - NG feeds if not tolerating orally
• IV fluids if RR high or aspiration risk; restrict to 2/3 maintenance if SIADH suspected (check Na+)
• Humidified air/O2

• IV ampicillin + gentamicin OR IV co-amoxiclav for this age group
• Consider IV ceftriaxone if S. pneumoniae suspected (lobar consolidation)
• Escalate to IV cloxacillin/flucloxacillin + cefotaxime if S. aureus pneumonia suspected (rapid progression, effusion, pneumatoceles)
• Duration typically 7-10 days depending on organism and clinical response

• Ribavirin - only for immunocompromised or CHD with severe RSV; not routine

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Summary Table - All 4 Patients

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• Always document weight for drug dosing
• Plot weight, length, head circumference on growth chart
• Ask about palivizumab prophylaxis status in the two infants (Beds 13 and 16)
• For Beds 13 and 16 (infants): explicitly ask about apnoea - it is a life-threatening complication of RSV in young infants and can occur without warning
• Bed 15: ask about the patient's personal best PEFR and written asthma action plan
• All 4 patients: assess parental anxiety and understanding - crucial for discharge planning