Quick answer
How should I present a viral croup case on rounds?
Lead with the barking cough and stridor at rest, since stridor at rest, not just with agitation, defines the severity. State explicitly that there is no drooling or tripod positioning, which helps exclude epiglottitis. Give the Westley score and vitals before naming moderate croup. End with dexamethasone and nebulized epinephrine together, plus the required observation period afterward.
Before you speak
Define the moment and the information you actually have
An emergency-department presentation at 2 a.m. immediately after the initial nursing assessment and airway exam.
A supervising physician deciding on steroid and nebulized-epinephrine treatment.
History, vital signs, and a focused airway exam including a Westley score and neck radiograph. Laboratory studies are not part of this simulation.
About 65 seconds
Fictional training case: The presentation is locked to the simulated patient JSON. It names important unknowns instead of inventing an examination, vital signs, allergies, or tests.
Complete spoken example
First, read it once without stopping
The paragraph breaks show the clinical shape. In a real presentation, pause briefly between ideas rather than announcing the headings.
This is a 2-year-old boy with two days of a mild runny nose and low-grade fever who now has a loud, barking cough and stridor at rest.
His barking cough and stridor became dramatically worse tonight after lying down in a warm bedroom, and his mother is frightened by the loud, high-pitched breathing sound, wondering if he has swallowed a toy or has severe asthma. He is not drooling and is not sitting in a tripod position.
He has no prior medical history, and this appears to be a first episode of this kind of breathing difficulty.
His vitals show a heart rate of 132, respiratory rate 36, a mild fever of 37.8 — in the 37-to-38 range, consistent with the viral illness — and oxygen saturation 96% on room air. He sits comfortably on his mother's lap when calm but has audible stridor at rest with mild suprasternal and intercostal retractions, giving a Westley croup score of 4, consistent with moderate croup. His oropharynx is clear without drooling, and neck X-ray shows the classic steeple sign of subglottic narrowing.
My diagnosis is moderate viral croup, based on the barking cough, stridor at rest, Westley score of 4, and the steeple sign on imaging, with epiglottitis made unlikely by the absence of drooling or tripod positioning.
I would give a single weight-based dose of oral dexamethasone and nebulized racemic epinephrine given the stridor at rest, then observe him for three to four hours afterward for any recurrence of stridor before considering discharge, since epinephrine's effect can wear off and rebound.
Build the presentation
Give every sentence one job
A presentation is a compressed clinical argument, not a chart read aloud. These six moves keep the facts connected to your reasoning.
Opening one-liner
Name the cough character and its severity marker
“This is a 2-year-old boy with two days of a mild runny nose and low-grade fever who now has a loud, barking cough and stridor at rest.”
Why it belongs: Naming stridor at rest, not just with crying, in the opening sentence signals moderate-to-severe croup rather than mild disease, which changes the treatment plan.
This is a toddler with a bad cough.
He has a barking cough and stridor at rest, following two days of a mild cold.
Why: Naming that stridor is present at rest, not only with agitation, is the specific severity marker.
History of present illness
Give the progression and exclude the dangerous mimic
“His barking cough and stridor became dramatically worse tonight after lying down in a warm bedroom, and his mother is frightened by the loud, high-pitched breathing sound, wondering if he has swallowed a toy or has severe asthma. He is not drooling and is not sitting in a tripod position.”
Why it belongs: Explicitly stating the absence of drooling and tripod positioning addresses epiglottitis, the dangerous mimic that must be excluded before treating this as routine croup.
He's had a cough that's gotten worse and his mom is worried.
His cough and stridor worsened after lying down, and he is not drooling or sitting in a tripod position, arguing against epiglottitis.
Why: Naming the specific negative findings that exclude epiglottitis is more clinically useful than a general worsening description.
Relevant background
Confirm this is a first episode with no complicating history
“He has no prior medical history, and this appears to be a first episode of this kind of breathing difficulty.”
Why it belongs: An unremarkable background without prior airway problems supports a typical viral croup presentation rather than an underlying structural airway abnormality.
He's healthy otherwise.
He has no prior medical history and no previous episodes of this kind of breathing difficulty.
Why: Confirming this is a first episode is more specific than a general statement of health.
Objective data
State vitals, the airway exam, and the Westley score
“His vitals show a heart rate of 132, respiratory rate 36, a mild fever of 37.8 — in the 37-to-38 range, consistent with the viral illness — and oxygen saturation 96% on room air. He sits comfortably on his mother's lap when calm but has audible stridor at rest with mild suprasternal and intercostal retractions, giving a Westley croup score of 4, consistent with moderate croup. His oropharynx is clear without drooling, and neck X-ray shows the classic steeple sign of subglottic narrowing.”
Why it belongs: The Westley score of 4 objectively classifies this as moderate croup, which determines whether nebulized epinephrine is added to dexamethasone, and the steeple sign supports the diagnosis while a clear oropharynx further argues against epiglottitis.
His vitals were okay and his X-ray looked like croup.
His Westley score is 4, consistent with moderate croup, and neck X-ray shows the classic steeple sign.
Why: Naming the specific score and imaging finding is more useful than a general reassurance.
Assessment
Commit to the diagnosis and its severity grade
“My diagnosis is moderate viral croup, based on the barking cough, stridor at rest, Westley score of 4, and the steeple sign on imaging, with epiglottitis made unlikely by the absence of drooling or tripod positioning.”
Why it belongs: Naming the severity grade, moderate rather than mild, directly determines whether nebulized epinephrine is added to treatment, not just dexamethasone alone.
This is croup.
This is moderate viral croup, based on the Westley score, with epiglottitis made unlikely by the absence of drooling.
Why: Naming the severity grade and the reasoning against epiglottitis together is more complete than the diagnosis alone.
Plan
State steroid and epinephrine treatment with required observation
“I would give a single weight-based dose of oral dexamethasone and nebulized racemic epinephrine given the stridor at rest, then observe him for three to four hours afterward for any recurrence of stridor before considering discharge, since epinephrine's effect can wear off and rebound.”
Why it belongs: Naming the specific required observation period after epinephrine is essential, since discharging too early risks missing a rebound in symptoms as the medication wears off.
I'll give some steroids and a breathing treatment.
I would give dexamethasone and nebulized epinephrine, then observe for three to four hours for any rebound stridor before discharge.
Why: Naming the required observation period is the safety-critical part of this plan.
Do not fill the blanks
Say what has not yet been established
Real presentations often happen before the chart is complete. A brief, explicit limitation is safer and more credible than a polished invention.
Response to nebulized epinephrine over time
Say: “His response to nebulized epinephrine over the observation period is not yet available in this simulation, and I would reassess him repeatedly during that window.”
A single point-in-time exam does not confirm sustained improvement; the observation period does.
Feeding and hydration status
Say: “His ability to take oral fluids is not documented in this simulation and is part of the standard discharge readiness assessment.”
Discharge decisions depend on adequate hydration as well as resolved stridor at rest.
Clinical compression
What leads, what stays, and what can wait?
| Source detail | Decision | Reason |
|---|---|---|
| Barking cough and stridor at rest after two days of a mild cold | Lead | This is the core presentation and its severity marker. |
| No drooling or tripod positioning | Lead | These specific negatives are what exclude epiglottitis, the dangerous mimic. |
| Worse after lying down in a warm room | Include | This is a recognized pattern in croup and helps confirm the typical clinical course. |
| Westley score of 4 and steeple sign on X-ray | Lead | These objectively grade severity and support the diagnosis. |
| No prior medical history or previous episodes | Compress | Brief confirmation that this is a typical first presentation, not requiring extensive discussion. |
After the presentation
Likely attending questions
Answer the question first, then give the evidence. If the source case does not contain the answer, say what you would verify.
How do you know this isn't epiglottitis?
The absence of drooling, tripod positioning, and a toxic appearance, together with a clear oropharynx and the classic barking cough, all argue against epiglottitis, which typically presents with a more abrupt, toxic picture and drooling rather than a barking cough.
Why give nebulized epinephrine in addition to dexamethasone?
Stridor at rest indicates moderate-to-severe croup, and nebulized epinephrine provides rapid, though temporary, relief of airway narrowing while the slower-acting dexamethasone takes effect over several hours.
Why does he need to be observed for three to four hours after epinephrine?
Nebulized epinephrine's effect can wear off before dexamethasone takes full effect, causing rebound stridor, so an observation period confirms the child remains well without stridor at rest before being considered safe for discharge.
Self-check
A 30-second check before you present
- Name stridor at rest, not just with crying, in the opening sentence.
- State the specific negatives that exclude epiglottitis: no drooling, no tripod position.
- Give the Westley score and vitals explicitly.
- Name the severity grade, not just 'croup.'
- State both dexamethasone and nebulized epinephrine when stridor is present at rest.
- State the required observation period after epinephrine.
- Note that oral intake is part of discharge readiness.
- Avoid discharging based on a single improved exam without the observation window.
Common presentation problems
Repair the habits that make a case hard to follow
Saying 'stridor' without specifying whether it's at rest or with agitation
Repair: State explicitly whether stridor is present at rest, since this determines severity and treatment.
Treating with dexamethasone alone despite stridor at rest
Repair: State that nebulized epinephrine is added for stridor at rest.
Discharging immediately after epinephrine improves symptoms
Repair: State the required three-to-four-hour observation period before discharge.
Not addressing epiglottitis explicitly
Repair: State the specific negative findings that make epiglottitis unlikely.
Frequently asked questions
Oral case presentation questions
Do I need to state the full Westley score breakdown?
Stating the total score and the general severity category it represents is usually enough; be ready to describe the individual components if asked.
Should I mention humidified air or mist therapy?
No, current evidence does not support these interventions, so they should not be presented as part of the treatment plan.
How long should this presentation be?
This worked example targets about 65 seconds. A child in severe respiratory distress would need a more urgent, focused presentation on airway status alone.
Practice out loud
Turn the patient encounter into your own presentation
Bedside English lets you interview an AI patient, then practice presenting the collected case to an AI attending and respond to follow-up questions.
Editorial record
Sources, provenance, and review boundary
The patient facts come from simulated case peds_007. Clinical framing and presentation design were checked against the sources below. This page teaches clinical communication and reasoning; it is not medical advice or a local protocol.
- Acute Management of Croup in the Emergency DepartmentCanadian Paediatric Society · accessed 2026-09-03
- Feedback on Oral Presentations during RoundsStanford Medicine · accessed 2026-09-03
- Clinical Teaching Tools: OMP and SNAPPSUCSF Medical Education · accessed 2026-09-03
Published: · Last source, safety, and language review: