If there is nasal stuffiness and a postnasal drip, a trial of antihistamines or decongestants is indicated before starting an expensive workup. All patients require a CBC and differential count, a sedimentation rate, and a chemistry panel. A sputum for routine smear and culture should be done, and in chronic cases a sputum for AFB culture and smear must be done. One should keep a high index of suspicion for Mycoplasma pneumoniae and Legionnaire’s disease. Also, sputum for fungi culture should be done on chronic cases.
Asthma can be further elucidated and confirmed by doing a sputum for eosinophils. Carcinoma of the lung can be confirmed with a sputum for Pap smear. If there is fever, blood cultures may be useful and febrile agglutinins should also be done. An x-ray of the chest with anteroposterior, lateral, and apical lordotic views should be done, and when a tumor is suspected, tomography should be done or a CT scan. In cases of chronic cough, skin testing for coccidioidomycosis, cystoplasmosis, tuberculosis, and blastomycosis should be done. A Kveim test to rule out sarcoidosis may be necessary. When these tests fail to make a diagnosis, bronchoscopy and possibly bronchograms to look for a bronchiectasis should be done. Lung biopsy may be necessary also. Pulmonary function tests should be done in suspected cases of emphysema and asthma. Allergy skin testing is extremely valuable in cases of asthma. Look for alpha 1-antitrypsin deficiency in difficult cases. If congestive heart failure is suspected, an arm-to-tongue circulation time would be valuable. A trial of diuretics may also assist in the diagnosis. If reflux esophagitis is suspected, prolonged monitoring of esophageal pH may be diagnostic. A trial of therapy with an H 2 antagonist may also be diagnostic.
EARACHE: DIAGNOSTIC WORKUP
It should go without saying that diagnosis begins with an adequate otoscopic examination. If the drum is obscured by wax, gentle lavage after using Cerumenex? will usually clear the canal. If there is an exudate, a culture and sensitivity should be ordered. Perhaps a throat culture should be done also. X-rays of the mastoids and petrous bones should be done if the exudate is believed to be from a deeper source. Perhaps a CT scan is also needed. If there is hearing loss, an audiogram needs to be done and a tympanogram will be useful in diagnosing serous otitis media. A trial of carbamazepine (Tegretol®) or phenytoin (Dilantin®) may be useful in diagnosing glossopharyngeal neuralgia or tic douloureux. If the discharge is thought to be cerebrospinal fluid, a CT scan and RISA study should be done.
Referral to an ear, nose, and throat specialist or neurologist should be considered before ordering expensive diagnostic tests.
Cough, barking: History and physical examination
Ask the child’s parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?
Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a sudden high fever. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.
