Childhood Asthma OSCE - New Asthma Diagnosis

Case Overview

• Age/Sex: 7-year-old male
• Occupation: Primary school pupil
• Setting: Emergency department / clinic with parent as historian
• Chief complaint: "He's been wheezing and coughing"

Patient Script

Who I Am

I'm his mum — he's 7, in Year 2 at primary school, normally a lively boy.

What Brings Me In

He has been wheezy and coughing a lot and it seems worse tonight, so I brought him in because I'm worried.

My Story

He's had a cough on and off for a few weeks but it got worse after he had a cold. Over the last 3 days he's had more noisy breathing and now has a more obvious wheeze when he breathes out. He coughs more at night and he wakes up sometimes, and he gets out of breath when he runs about at school or during football — that started a few weeks ago too. This evening he was breathing faster and there was a lot of wheeze, so I brought him in. He did have a sore ear last week and the GP gave him a short course of amoxicillin 5 days ago, but he hasn't had a high fever since the cold settled. He had a bad chest infection as a baby and needed to be seen in hospital once, but never had an inhaler before.

My Medical Background

• Past medical history: bronchiolitis as an infant (required observation in hospital once)
• Medications: none regular, only the recent amoxicillin
• Allergies: none known
• Social: lives with both parents and an older sister, no one smokes in the house; they have a pet rabbit
• Development/vaccinations: normal development, vaccinations up to date
• Family history: father has seasonal hay fever; maternal aunt has asthma

What I Think & Worry About

• I think he might have something serious in his chest; I'm worried he might not be getting enough air.
• I want to know if this is something that will keep happening and what we should do at home.
• I would like to know if he needs antibiotics or an inhaler.

If You Ask Me About Other Symptoms...

• Fever: He had a mild fever with the cold but hasn't had a high temperature for the last 2 days.
• Cough: Mostly dry with some noisy wheeze, worse at night and with exercise.
• Sputum: He doesn't bring anything up.
• Chest pain: He says his chest feels tight when he runs.
• Voice/stridor: Noisy on breathing out, no high-pitched stridor.
• Recent travel/contacts: No travel, no known TB exposure.
• School: He's missed one day of school this week; teachers said he seemed breathless after running.
• Home remedies: We've given paracetamol for fever and warm drinks; no inhalers used at home.
• Red herrings/distractors: He had a sore ear last week treated with antibiotics; they also have a rabbit at home (we have not linked this to his breathing), and he choked once on a small grape about a year ago but recovered quickly.

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Clinical Summary

Examination

• General: alert, sitting upright with mother; not lethargic
• Respiratory rate: 30 breaths/min (age-appropriate baseline ~20)
• Heart rate: 110 bpm
• Temperature: 37.4°C
• Oxygen saturation: 96% on room air
• Work of breathing: mild subcostal/intercostal recession when active, speaking in short sentences
• Chest auscultation: bilateral diffuse expiratory wheeze louder on forced exhalation; no focal crepitations
• No cyanosis, no peripheral edema, no lymphadenopathy

Investigations

• Peak expiratory flow (age/height predicted ~260 L/min): measured 210 L/min (reduced)
• Spirometry (attempted — child cooperative): pre-bronchodilator FEV1 70% predicted; FEV1/FVC 0.72 (reduced)
• Spirometry post-bronchodilator: FEV1 increased to 85% predicted (improvement ~21%) (significant reversibility)
• Chest X-ray: peribronchial cuffing and hyperinflation, no lobar consolidation
• Full blood count & CRP: WCC 9.2 x10^9/L, CRP 4 mg/L (not suggestive of bacterial pneumonia)
• Optional allergy tests (arranged later): specific IgE to dust mite pending

Diagnosis

• Primary diagnosis: Asthma (new diagnosis) — supported by episodic wheeze and cough, worse at night and with exercise, family history of atopy, and reversible airflow obstruction on spirometry (FEV1 improvement >12%).

• Differentials:

  • Viral-induced wheeze/post-viral reactive airways disease: plausible given recent cold and age, but spirometric reversibility and recurrent pattern favour asthma.
  • Pneumonia: less likely — low-grade/no fever, normal WCC/CRP, CXR without focal consolidation.
  • Foreign body aspiration: unlikely — no sudden onset choking event with persistent unilateral signs; exam and CXR not consistent.
  • Upper airway problem (eg. croup/stridor): not consistent — noise is expiratory wheeze rather than inspiratory stridor.

Management

• Immediate/acute:

  • Administer inhaled short-acting beta-2 agonist (salbutamol) via spacer with appropriate mask/mouthpiece; repeat doses as needed and reassess.
  • If moderate exacerbation or poor response: give oral prednisolone (e.g., 1–2 mg/kg single daily dose for 3–5 days; max per local guidance) and continue bronchodilator therapy.
  • Monitor oxygen saturation; give supplemental oxygen if SaO2 <92%.

• Ongoing/long-term:

  • Start a low-dose inhaled corticosteroid (eg. beclometasone 100 mcg two puffs twice daily or equivalent) as controller therapy, with salbutamol via spacer for relief.
  • Provide a spacer and teach inhaler technique to parent and child; observe a return demonstration.
  • Provide a written asthma action plan explaining controller use, rescue therapy, and when to seek emergency care.
  • Arrange follow-up in primary care or asthma clinic within 1–2 weeks for review and formal spirometry if not already completed; consider referral to paediatric respiratory/allergy clinic if needed.
  • Discuss trigger avoidance (identify possible triggers at home/school), influenza vaccination annually, and school management plan.

• Safety netting:

  • Return immediately for increasing breathlessness, difficulty speaking, persistent chest retractions, cyanosis, poor oral intake, or if salbutamol has little effect.
  • Antibiotics are not indicated unless there is clear evidence of bacterial infection.

Key Learning Points

• Asthma in children often presents with episodic wheeze and nocturnal cough, and exercise-induced symptoms; look for pattern/triggers and family atopy.
• Objective demonstration of reversible airflow obstruction (spirometry with bronchodilator reversibility) supports the diagnosis; in an acute setting, response to inhaled bronchodilator and clinical assessment guide immediate management.
• Management includes short-acting bronchodilator via spacer, early use of oral steroids for moderate exacerbations, initiation of inhaled corticosteroid controller therapy when indicated, and provision of an asthma action plan with education on inhaler technique.