Clinical Case: Julie Mackenzie's Cough



Julie Mackenzie is a 3 year old little girl who's brought to you because of a cough and flu-like symptoms. Her aunt is the one with her today because Julie's parents are on a week's vacation. They have given permission for medical care as needed.

Julie and her aunt are waiting for you in the examining room.



What about this cough ?


More on Julie's cough.
  • It's worse when she first gets up of a morning.
  • Kind of a "hack," and it's non-productive (no sputum).
  • It's a bit like a smoker's hacking cough.
  • Neither parent smokes.
  • Her aunt doesn't smoke.
  • Julie is on no medication.
  • She's been to daycare this week, but no one there is sick.
  • Julie lives in a 4 year old house, and most of it is carpeted.
  • The family owns a cat.
  • Julie's parents are on a short Caribbean cruise, and have been gone three days.
  • This is the first extended time her parents have been away.
  • The aunt has a letter from the parents granting permission to seek medical care if Julie becomes ill.
Physical exam
  • Julie is a well nourished little girl having appropriate physical development for three years of age.
  • She is appropriately curious but doesn't want to be separated from her aunt.
  • Vital signs:
    1. T = 99.2
    2. P = 88 and regular
    3. BP = 122/74 mmHg
    4. R = 18 and regular
  • Mildly reddened pharynx with slight post nasal drainage.
  • Mildly enlarged tonsils.
  • Ear drums clear with no fluid
  • No significant cervical lymph adenopathy.
  • Mild wheezing over both lung fields
  • Heart sounds normal, no murmurs.
  • No abdominal masses
What can we make of Julie's symptoms?
  • It doesn't really sound serious.
  • She seems to have a mild pharyngitis
  • The cough is probably due to her nasal drainage.
  • The wheezes may indicate an allergic problem.
  • If she hasn't had any aspirin or Tylenol recently, then it would seem her fever is pretty minimal.

What will help make a diagnosis?
  • CBC
  • Throat culture and gram stain
  • Chest X-Ray
So what's so worrisome about the X-Ray?

  • Nodular deformity of several ribs.
  • Intensely calcified.
  • These are non-lytic.
  • Lytic lesions, on the other hand, would indicate bone destructive lesions.
These are healed fractures

  • Densely calcified with periosteal bone formation.
  • Take another look.
  • So what does this mean?
    1. She's clumsy?
    2. Coughs too hard?
    3. Has an inherited bone weakness?
    4. Nutritional problem?

The problem is, these healed fractures are also consistent with child abuse.
  • Other than a major fall, auto accident or the like, an otherwise healthy kid doesn't break a bone.
  • Yes, toddlers and young children fall all the time.

  1. They have extremity bruises.
  2. Facial and truncal injuries should raise suspicions.
  3. Rib fractures are are frequently a sign of abuse.
  4. Even healed fractures, such as these, need an explanation.

What is the health care worker's obligation?

  • First, care for the child's injuries.
  • You can always admit the child if need be.
  • As a health care worker you are not the one to determine if there is actually child abuse.
  • Call the local Welfare Office and talk to
  • Office of Child Protective Services.
By doing this you are filling out a state form 310, suspicion of child abuse.
  1. This is a highly confidential process.
  2. The welfare office will investigate.
  3. They will deal with the court if they feel protective services are indicated.

If you are concerned of the child's safety, they can intervene within the hour.