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You are an F1 working in A&E and have been asked to review Di, a 2-year-old girl. Please take a full history and undertake the relevant examination. You will then be asked to discuss the case with the examiner.

Your name is Alex and you have brought you daughter Di into A&E as she had had a cough and fever for a couple of days which has suddenly got worse this evening. You’re really quite scared about this: Di may be 2, but you still feel like you’re learning with this whole parenting thing. Every time she gets even remotely sickly, you feel like it triggers your anxiety and that the most awful thing in the world must be happening to Di. You know that this isn’t always the case, but this time you are seriously worried. HPC- You first noticed Di wasn’t herself a couple of days ago when she started having a runny nose and a slight cough. She has also felt quite hot to touch: your thermometer is broken but she felt scorching! Obviously this set off alarm bells for you. Then there is the cough. There’s no phlegm or anything, but it just sounds odd. It’s really harsh and hacking: it sounded just like Jake, your corgi, when he barks! This cough seems to be worse at night and as such Di has got much sleep latterly and is more agitated then usual. She’s not the only one! Over the last couple of hours, she has started becoming short of breath and you have noticed a noise when she breathes in. This has terrified you, so you have brought her straight into A&E. You’re not on the best terms with your GP and didn’t want to mess about: you don’t want to take any chances. PMH- Fit and healthy ICE- You think that she might have asthma as you had asthma when you were little. You definitely grew out of it, though. You are worried about her struggling and noisy breathing. You would like her to be checked out to make sure everything is okay. DH- You have given her some calpol but nothing else. No regular medications. Di is not allergic to anything that you know of. FH- You had asthma as a child, and a touch of eczema too. Your partner has no health conditions. Nothing runs in the family. SH- The birth was natural delivery, term and her weight was 7lb 10oz. You did have to get a blood transfusion after the birth, as you lost a lot of blood. To be honest, you were more concerned about Di than yourself at the time: you think this is where the anxiety started. Di is up to date on her vaccinations, but you did have to think twice about vaccinating: some of your friends run a website that investigates mercury in these things. In the end your old GP convinced you before she retired. You just haven’t told your friends that Di is vaccinated! Di is a very fussy eater and won’t eat anything green or yellow. However, she does eat a good amount, and was always on the 75th centile for height and weight. The last couple of days she hasn’t been drinking besides sips of juice you have given her. You and the health visitor had no concerns with her development. There are no smokers in the house. You have Jake the corgi and live on a working farm. You have good social support from friends and family and there is no involvement from social services.

Observe the student taking the history. Making sure they cover all areas of the history and ICE. They should interact with the child and try to put the child at ease. You should perform a general paediatric exam with a focus on the respiratory system. You should not examine the throat. Ask the student to summarise the history, exam and give a list of differential diagnosis with relevant justification. Points for discussion: - What are the most common causes of croup? - What investigations would you like to perform? - Why would you not examine the throat of this child? - Do you know of any scoring systems for croup? - Do you know of any risk factors for croup? - What would be an appropriate management plan for this child?