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You an F1 doctor on your paediatric rotation. You’re working on admissions and have been asked to see a 13-year-old boy who has recently had shortness of breath. His name is Ben Zos and he is with his parents.

Please take a focused paediatric history and perform the appropriate examination. Once finished, please discuss the case with your examiner.

You are a 13-year-old boy who has been referred from your GP to paediatric admissions due to your ongoing breathlessness. On occasion, you may mention things your parents have noticed or are worried about.

HPC: Over the past few weeks you have been noticing that you have been more breathless on exertion than normal. You are a keen boxer since you were 9 and have never had any problems before. A few weeks ago, you noticed after training that you could not keep up as before. This got gradually worse, to the point where you was getting breathless going up the stairs. Your parents have noticed this also now, despite you initially trying to hide this. You also have had some wheeze and your chest has been all “rattley” lately. You also have had a persistent cough. You have been bringing up icky green stuff, but this is not just now: it’s been going on for months. When asked about this, you feel it is thick and green and comes up in the morning mainly. There is blood mixed in recently, but this has happened once or twice in the past. You have never woken up breathless and your symptoms are not worse in the cold. You love the cold! You haven’t noticed any rash, eczema, bowel or bladder changes, ear of throat problems or fevers. You don’t think that you have lost weight, but you don’t pay much attention to that kind of stuff.

ICE: You don’t know what this could be. You’re a bit worried that it could be affecting his boxing as you hope to go to the Olympics eventually. You really want it to be sorted today, as you are a bit fed up with it all. You’ve heard your parents talk about it, and they seem to wonder if it could be an infection. However, they are mainly concerned that it could be “that thing where you need to rub their chest.

PMH: No previous past medical history – No asthma, no chest problems when younger. No bowel troubles before.

FH: You have no brothers or sisters. A few of your cousins have asthma. Only family illnesses are heart attacks in grandparents later in life.

BH: (from mum) Born at 38 weeks via elective section (maternal choice) Born at 3180g. No antenatal complications. Developed Neonatal Jaundice, but quickly resolved.

Feeding H: Eats well, never been a fussy eater. Was breast fed initially.

Drug History: No medications, never needed any inhalers. Immunisations all up to date. NKDA.

Development and Growth: Reached all milestones as child (parent mention if anything, he was ahead). No problems at school. No behavioural issues

SH: No smoking (from parents or himself), No alcohol. Had a dog, which has been with them for 10 years. No recent travel. Normally very active, although his boxing gym has very dusty, dirty equipment.

The student should take a thorough history of Ben’s symptoms, gathering information from him and potentially the parents, whilst eliciting the Ideas, Concerns and Expectations. The appropriate examination would be a respiratory examination.

Findings on Examination: • On exam (despite what is heard/found) you see a otherwise healthy boy, but his chest sounds wheezy and audible inspiratory crackles.

Differential Diagnosis: • Bronchiectasis – This could be a differential, but more investigation would be required. The main point of the history would be longstanding thick mucus production • Cystic Fibrosis – Would be a late presentation, but should be ruled out. • Chest Infection – This would need to be ruled out with various investigations • Allergic Alveolitis – Has been using dusty equipment in his gym for several years • Other respiratory pathology

Possible topics for discussion may include causes of bronchiectasis, investigation and management of cystic fibrosis, the MDT management of CF and immunodeficiency.