Volume 1, Case 6

Diminished Breath Sounds and Air in the Chest
Radiology Cases in Pediatric Emergency Medicine
Volume 1, Case 6
Loren G. Yamamoto, MD, MPH

This is a 23-month old female with a history of vomiting 3-4 times per day for three days. She has a past history of reactive airway disease and congenital heart block (maternal systemic lupus) requiring a permanent implanted pacemaker. She was seen three days prior to this in the emergency department for wheezing and stomach pain. She was noted to have bilateral wheezing. Her respiratory rate was 32. An oxygen saturation was not recorded. Her abdominal exam was benign. The wheezing was treated with beta adrenergic agents resulting in improvement, and the patient was discharged. At discharge, her lungs were noted to be clear. She was instructed to continue albuterol and theophylline.

Since that visit, she began vomiting. She was seen by her pediatrician today, who placed her on amoxicillin for otitis media. Her mother called her pediatrician, noting the child was more fussy, lethargic, and her mouth appeared to be dry. She was referred to the hospital for inpatient rehydration.

Admission exam: VS T36.6 (ax), P110, R32, BP 112/70, weight 10.1kg (10th percentile). Her weight three days ago in the ED was 10.66kg. Oxygen saturation was 98-99% in room air. She was noted to be crying, but somewhat lethargic. HEENT exam significant for somewhat sunken eyes, dry oral mucosa, and absence of tears when crying. Neck supple. Heart regular without murmurs. Lungs clear with decreased breath sounds at the left base. No wheezing was noted. There was a left thoracotomy scar and a left subcostal scar. Abdomen noted to have a palpable pacemaker in the left anterior abdominal wall and a reducible umbilical hernia. The abdomen was flat and soft without masses, organomegaly, or tenderness. Bowel sounds were active. Capillary refill time in the extremities was two seconds and the skin turgor was good.

An admission work-up included the following laboratory results: CBC WBC 8.9, 56 segs, 32 lymphs, 12 monos, Hgb. 12, Hct 38, platelets adequate. Na 132, K 4.2, Cl 100, Bicarb 21, BUN 14, Cr 0.7, glucose 94. A chest radiograph was obtained.

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 Loren Yamamoto, 
      MD, MPH Associate Professor of Pediatrics University of Hawaii John A. Burns 
      School of Medicine loreny@hawaii.edu