Patient Profile

• Name: Master Aarav Singh

• Age/Sex: 8-year-old male

• Residence: Urban, Delhi

• Schooling : Class 3, attends school regularly

• Date of admission :

• Date of examination :

• Informant :

Presenting Complaints

• Whistling sound from chest (wheeze) for 4 days

• Cough for 4 days

• Shortness of breath for 2 days

History of Present Illness

• Child was apparently well 4 days ago when he developed a dry cough, which became productive with scanty white sputum after 2 days.

• Parents noticed a whistling sound from the chest, more pronounced during expiration, especially at night and early morning.

• Shortness of breath developed 2 days ago, initially on exertion, now also at rest.

• Symptoms worsened after playing outside and exposure to dust.

• No history of fever, chest pain, hemoptysis, or vomiting.

• No history of similar complaints in the past.

• No history of foreign body aspiration, choking, or recent travel.

• No nocturnal awakening due to cough or breathlessness.

• No history of contact with tuberculosis

• Review of Systems

  • No weight loss, appetite loss, or night sweats.

  • No skin rashes, joint pain, or other systemic symptoms.

Past Medical and Surgical History

• History of previous wheezing episodes.

• Previous hospitalizations 2 times in last 1 year for similar complaints.

• No known chronic illnesses (asthma, congenital heart disease).

• No prior surgeries.

Family History

• Father has a history of bronchial asthma since childhood.

• No family history of tuberculosis or other chronic lung diseases.

Personal History

• Non-smoker household; no passive smoke exposure.

• Lives in a house near a busy road (exposure to vehicle smoke).

• No pets at home.

• No exposure to biomass fuel.

• Attends school regularly; no recent absenteeism.

Drug History

• Patient is on regular inhalers for past 1 year, now default for 2 days

Socioeconomic History

• Pucca house

• 4 membered family

• Drinks boiled water

• No overcrowding

Summary of Key Findings

• 8-year-old boy with acute onset wheeze, cough, and breathlessness, precipitated by dust exposure, with a positive family history of asthma and environmental risk factors (vehicle smoke exposure).

• No evidence of infection, foreign body, or systemic illness.

Provisional Diagnosis

• Acute exacerbation of bronchial asthma (first episode likely, considering family history and triggers).

Differential Diagnosis

• Bronchiolitis (less likely at this age)

• Allergic bronchitis

• Lower respiratory tract infection (atypical, as no fever)

• Foreign body aspiration (unlikely as no choking episode)

Case of wheeze for a 65 year old male

Patient Profile

• Name: Mr. Rajendra Prasad

• Age/Sex: 65-year-old male

• Occupation: Retired school teacher

• Residence: Urban, Patna, Bihar

• Date of admission :

• Date of Examination :

• Informant : Patients's wife

Presenting Complaints

• Whistling sound from chest (wheeze) for 3 weeks

• Cough for 3 weeks

• Shortness of breath for 2 weeks

History of Present Illness

• Patient was apparently well 3 weeks ago when he developed a cough, initially dry, now productive with scanty whitish sputum.

• Noticed a whistling sound from the chest, more pronounced during expiration and especially at night and early morning.

• Shortness of breath developed 2 weeks ago, initially on exertion, now also at rest.

• No history of fever, chest pain, hemoptysis, or orthopnea.

• Symptoms worsened with exposure to dust and cold air.

• Reports similar but milder episodes over the past 5 years, usually during winters or after respiratory infections, but never required hospitalization.

• No history of childhood asthma, but has a history of progressive worsening of breathlessness and wheeze over the last few years.

• No history of tuberculosis, recent travel, or foreign body aspiration.

• No significant weight loss or loss of appetite.

Review of Systems

• No paroxysmal nocturnal dyspnea, orthopnea, or pedal edema.

• No symptoms suggestive of cardiac failure.

• No gastrointestinal or neurological complaints.

Past Medical and Surgical History

• Known case of hypertension for 10 years, on regular medication.

• Diagnosed with COPD 6 years ago.

• No previous hospitalizations for respiratory failure.

• No prior surgeries.

Family History

• No family history of asthma, COPD, or tuberculosis.

Personal History

• Non-smoker, but significant exposure to biomass fuel (firewood) during childhood and early adult life.

• No alcohol use.

• No pets at home.

• Retired, spends most time at home.

Drug and Allergy History

• On inhaled bronchodilators (irregular use), oral antihypertensives.

• No known drug allergies.

• No history of atopy, eczema, or allergic rhinitis.

Socioeconomic History

• Lives in a well-ventilated house near a busy road (vehicular pollution).

• 2 membered house

• No overcrowing

• Use smokeless stove for cooking

Summary of Key Findings

• 65-year-old male with chronic cough, progressive wheeze, and breathlessness, with a background of COPD, history of biomass fuel exposure, and environmental risk factors (vehicular pollution).

• No evidence of acute infection, cardiac failure, or malignancy based on history.

Provisional Diagnosis

• Acute exacerbation of chronic obstructive pulmonary disease (COPD) with wheeze.

Differential Diagnosis

• Asthma-COPD overlap syndrome (ACO)

• Bronchial asthma (late onset, less likely without atopy or childhood history)

• Endobronchial obstruction (e.g., malignancy, especially if new onset or unilateral wheeze)

• Lower respiratory tract infection (if new symptoms or fever develops)

Viva Questions and Answers: Wheeze

1. What is a wheeze?

Answer:
A wheeze is a continuous, musical, high-pitched sound produced during breathing, typically heard more during expiration than inspiration, caused by airflow through narrowed or obstructed airways.

2. What are the common causes of wheeze in adults?

Answer:

• Bronchial asthma

• Chronic obstructive pulmonary disease (COPD)

• Acute bronchitis

• Cardiac asthma (left heart failure)

• Bronchiectasis

• Foreign body aspiration (rare in adults)

• Endobronchial tumors or obstruction.

3. How do you differentiate between wheeze due to asthma and COPD?

Answer:

• Asthma: Usually has a history of atopy/allergy, episodic symptoms, significant diurnal variation, and is often reversible with bronchodilators.

• COPD: Associated with chronic productive cough, progressive and persistent symptoms, history of smoking or biomass exposure, and less reversibility with bronchodilators.

4. What is the pathophysiology of wheeze?

Answer:
Wheeze is produced due to turbulent airflow through narrowed airways, which may be caused by bronchospasm, mucosal edema, increased secretions, or airway obstruction.

5. What are the important points to elicit in the history of a patient with wheeze?

Answer:

• Onset, duration, and frequency of wheeze

• Precipitating/relieving factors (allergens, exercise, infections)

• Associated symptoms (cough, breathlessness, chest tightness, fever)

• Past history of similar episodes, atopy, or allergies

• Family history of asthma or allergies

• Smoking and occupational exposure

• Response to bronchodilators.

6. How do you clinically assess the severity of an acute wheeze episode?

Answer:

• Degree of breathlessness and ability to speak

• Use of accessory muscles of respiration

• Presence of cyanosis

• Respiratory rate and heart rate

• Oxygen saturation (SpO₂).

7. What are the complications of untreated severe wheeze?

Answer:

• Respiratory failure

• Hypoxemia and hypercapnia

• Pneumothorax (rare, due to barotrauma)

• Cardiac arrhythmias

• Death in extreme cases.

8. What investigations would you order in a patient presenting with wheeze?

Answer:

• Peak expiratory flow rate (PEFR)

• Spirometry (to assess reversibility)

• Chest X-ray

• Complete blood count

• Sputum examination (if productive cough)

• Arterial blood gas (in severe cases).

9. How do you manage an acute episode of wheeze?

Answer:

• Inhaled short-acting bronchodilators (e.g., salbutamol)

• Oxygen supplementation if hypoxic

• Systemic corticosteroids (oral or IV)

• Anticholinergics (e.g., ipratropium)

• Treat underlying cause (e.g., infection, allergen avoidance).

10. What are the indications for hospital admission in a patient with wheeze?

Answer:

• Severe breathlessness or inability to speak

• SpO₂ < 92% on room air

• Poor response to initial therapy

• Presence of comorbidities (e.g., cardiac disease, COPD)

• History of previous severe attacks or ICU admission