Case 1: A toddler with recurrent chest problems

Abstract

A 19-month-old boy presented to the emergency room with a five-day history of progressive cough and nasal congestion. On the day of admission, he had an increased respiratory rate with distress and audible wheezing, a two day history of fever and a poor appetite with decreased urine output. His parents also noted pale, loose stools and no vomiting.He was born at term after an uncomplicated pregnancy. His birth weight was 3.52 kg (50th percentile). He was diagnosed with 'asthma' at five months of age and has had five 'asthma exacerbations', none of which required hospitalization. He was treated with salbutamol and inhaled steroids. He also had four previous episodes of otitis media.On examination, he looked pale and tired. His weight was 10 kg (third to 10th percentile) and height was 83 cm (just below 50th percentile). He was tachypneic with a rate of 50 breaths/min to 60 breaths/min with moderate respiratory distress. He was having severe paroxysms of cough lasting 2 min to 3 min, and he had bilateral wheezing with no crackles. His heart rate was 140 beats per minute and the cardiovascular exam was otherwise normal. His abdomen was mildly distended but soft and nontender. There was no hepatosplenomegaly. The rest of the physical examination was within normal limits.Chest x-ray revealed hyperinflation with bibasilar coarse bronchovascular markings.The patient was admitted with a diagnosis of 'asthma exacerbation'; and therapy was initiated with inhaled salbutamol and systemic steroids. With this treatment, he gradually improved from a respiratory point of view. While in hospital, further investigations were initiated that revealed his underlying problem. Case 2: Edematous toddler with acute abdominal painA previously healthy three-year-old boy with a three-week history of intermittent abdominal pain presented with a sudden exacerbation of pain. The pain was diffuse but was most severe in the right lower quadrant. In addition, his parents noted some abdominal distension and fever starting on the day of presentation to the physician. There was no associated anorexia, vomiting, change in bowel habit or blood in the stools.On examination he had a temperature of 38.5°C, a pulse of 120 beats/min, a blood pressure of 94/56 mmHg and a respiratory rate of 35 breaths/min, and he appeared distressed. Examination of his abdomen confirmed a distended and diffusely tender abdomen that was most tender in the right lower quadrant with guarding and rebound tenderness. No organomegaly or masses were felt. The rest of the examination was unremarkable except for some mild periorbital edema and bilateral ankle edema.Laboratory investigations revealed a white blood cell count of 18.1×10 9 /L (polymorphs 10×10 9 /L, band cells 3×10 9 /L and lymphocytes 3×10 9 /L) with normal hemoglobin and platelet counts. The sodium level was slightly low at 132 mmol/L, and the other electrolyte levels were in the normal range. Blood urea nitrogen, creatinine, transaminases and alkaline phosphatase levels were all in the normal range.Blood cultures w...