asthma or viral-induced wheeze

Wheeze *** Moderate SOBoe, failure to thrive Isolated, persistent ‘wheeze’ usually arises from the

nose (stertor, e.g. adenoidal hypertrophy) or the largest

airways (stridor, e.g. laryngomalacia). Episodic wheeze

with cough suggests asthma or viral-induced wheeze

Chest pain * High Exercise Non-specific chest pain, musculoskeletal chest pain,

very rarely cardiac ischaemia

a

Respiratory sounds: clarify what noise the parent or child is describing. The history sometimes reveals the source, e.g. nose (stertor), throat (stridor) or chest (rattle or

wheeze). A constant respiratory sound is more likely to be stertor, stridor or rattle (a sound associated with vibration of the chest). A very loud sound, such as one heard in

the next room, is not genuine wheeze. b

Coexistent failure to thrive or weight loss always increases the significance of any symptom.

LRTI/URTI, lower/upper respiratory tract infection.

The history • 309

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not blanch with pressure are of most concern. These may be viral

in origin but importantly can be an early sign of meningococcal

disease (particularly if the child is febrile). A differential diagnosis

of a purpuric rash is idiopathic thrombocytopenic purpura.

Chronic skin excoriation, most commonly in the flexures,

suggests eczema, while plaques on the elbows/knees may

indicate psoriasis.