Case by Jessica Williams MD, Children’s National PEM Fellow

18 yo female presents with cough for the past 2 weeks now complaining of shortness of breath for the past 2 days. She also endorses tactile fever for the past 2 days. No vomiting but feeling nauseous. Normal urine and stool output. Up to date on immunizations. Cannot lie down flat because she has trouble breathing. Endorses dizziness and denies history of wheezing. Patient up to date on immunizations, no significant personal/surgical/family history. On depo provera. No sick contact. No recent travel.

Vitals: 95% on RA, T 36.8C, HR 137, RR 38, BP 135/87

Physical Exam
General: Alert, appropriate for age, cooperative
Skin: warm, dry, intact
Head: normocephalic, atraumatic
Neck: supple, trachea midline, no tenderness, no lymphadenopathy
Eyes: PERRLA, EOMI, normal conjunctiva, no discharge, no jaundice
ENMT: normal TMs, oral mucosa moist, no pharyngeal erythema or exudate. Dentition intact
Cardiovascular: regular rate and rhythm, normal peripheral perfusion, extremity pulses equal
Respiratory: inspiratory and expiratory wheezing heard in the left lung fields, diminished air entry into the right lungs. Nasal flaring, and substernal retractions are present. The patient is able to speak in short sentences. However, she gets short of breath at the end.
MSK: normal ROM, moves all extremities.
GI: soft, nontender, nondistended, normal bowel sounds
Neurologic: developmentally normal

CXR: Near complete opacification of the right lung with tracheal deviation. Large right effusion. Underlying mass or infiltrate cannot be excluded. Obliterated right mainstem bronchus with narrowed left mainstem bronchus. Left lung is clear. Differentials include right lung mass, infiltrate.

POCUS: Large R effusion with hepaticized lung, L side without effusion and normal lung sliding, small pericardial effusion but normal function.

VBG: 7.427/31.6/53.6/88.7/20.8/-2.4

CMP, Mg, Phos normal.

WBC 12.70, Hgb 14,4, Hct 43.4, Plt 341, ANC 8.45, Diff unremarkable. 

CRP 4.77 and ESR 21

Flu/RSV/Covid neg

Got CTX and bolus. Accepted to the PICU for chest tube placement and given a dose of Vancomycin. Started on HFNC and now able to lie flat, breathing comfortably. ECG – sinus tach, RAD, nonspecific T wave abnormality