PRESENTING FELLOW
Dr. Joanna E. MacLean
Respiratory Medicine Fellow
Hospital for Sick Children, Toronto, Ontario
THE CASE
A case
of family matters.
OUTLINE
– Case
history, physical & preliminary investigations
–
Differential
Diagnosis
–
Investigations
–
Return
to the case findings & diagnosis
–
Comments
on the case
–
Review
of relevant background
–
Conclusion
of the case
CASE OF SS
This is a previously well 13 year old male who immigrated from Zimbabwe in Jan 2001. He presented with a 1 month history of runny nose & nasal congestion. Two weeks prior to presenting, he developed a cough, which was productive but no haemoptysis. One week prior to presentation he began to vomit with onset of shortness of breath one day prior to presentation. He had an unspecified weight loss, but no fever nor night sweats.Review of systems revealed no prior history of respiratory disease, no chronic cough, no history of diarrhea or change in stools, no rash or skin changes, and no sick contacts including close contacts with anyone with a chronic cough or TB.
Past medical history showed that he was born by spontaneous vaginal delivery with no concerns as an infant. He underwent laporotomy in 1999 for what was described as a hernia repair. He did not receive blood products during the surgery nor at other times. He had no known allergies, immunizations were up to date for the Canadian guidelines, and he was not on any medications. Family history showed SS to be the younger of 2 children born to his parents. His younger brother was 10 years old and healthy. His father died of an undetermined heart problem at 37 years of age. His mother was alive and well. The family had left Zimbabwe because of civil unrest and was seeking refugee status in Canada.
Physical exam showed him to be afebrile, with a respiratory rate of 34, heart rate of 120, with a blood pressure of 110/70, and O2 saturation of 93% on room air. His weight of 27.3kg plotted less than the 3rd percentile and with his height of 135 cm also plotting less than the 3rd percentile. He was in moderate respiratory distress, was unwell appearing, cachectic but non-toxic. Positive findings on general exam included diffuse shoddy cervical lymphadenopathy, mild intercostal indrawing, decreased breath sounds with dullness to percussion on the right side of the chest, and scattered crackles diffusely with no wheeze. Liver was palpable 4-5 cm below the right costal margin with spleen palpable 2 cm below the left costal margin. Two laparotomy scars were seen; one measuring 10 cm running horizontally above the umbilicus, and the second measuring 2 cm in the left lower quadrant. Marked clubbing of fingers and toes was also noted.
Preliminary investigations included:
– WBC 10.9 (10% LS), Hgb 108 (MCV 82), Plt 272
– Electrolytes and renal function within normal limits
– Capillary blood gas (CBG) -- pH7.39 pCO2 30
– Liver functions within normal limits
– Blood culture: no growth at 48 hours
A
CHEST X-RAY taken at that time can be seen below.
ENLARGE
THIS CHEST X-RAY
WHAT IS YOUR INTERPRETATION?
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