For my Pediatrics rotation, I had the opportunity to present my patient cases to Professor Maida. Of the 2 cases I presented, I found the 4 year old female with pneumonia the most interesting. The patient had a history of febrile seizures, was up to date on all immunizations, and presented to the emergency department with fever and cough for 3 days. Her mother stated the patient began with an oral temperature of 101.2 degrees F, with the last temperature of 102 F the previous night. Tylenol was given the night before around 8pm for the fever with mild improvement. Her mother also endorsed the patient had been less active and had decreased appetite and rhinorrhea. She also admitted to decreased urine output. Mom also denied nausea, vomiting, diarrhea, dysuria, hematuria, ear pain, sore throat, no recent sick contacts, no recent travel, no recent antibiotic use.

My initial differential diagnoses based on this history were pneumonia, influenza, COVID-19, and rhinovirus. 

On exam, the patient was tachycardic and tachypneic, but afebrile. The patient also was showing signs of accessory muscle use, bilateral wheezing and right lower lobe rales, prolonged expiration, and decreased air entry bilaterally. Patient was reassessed on multiple occasions after receiving DubNeb treatments and Decadron, and upon reassessment patient was noted to have intercostal and supraclavicular retractions.

Initially, the only labs ordered were a respiratory viral panel, COVID-19 test, and CXR; all of which were negative. After the patient was reassessed post-treatment with DuoNebs and Decadron, a CBC with differentials, BMP, hepatic panel and UA were ordered. The only labs that were significant were the UA which showed trace ketones and the BMP which showed low CO2 of 17, elevated glucose of 276, and anion gap of 21. A VBG was also ordered with an elevated PO2 of 70, a low PCO2 of 33, a low HCO3 of 18, a glucose of 232, and a lactate of 4.6.

Based on the physical exam findings and labs, my leading differential was pneumonia; however, the patient could have also been going into early DKA. Unfortunately, the patient was transferred to a different hospital and was unable to follow up on the final diagnosis. With that being said, I feel as though the clinical picture presented most like pneumonia, although labs and imaging didn’t show evidence of infection.

After receiving feedback from my site evaluator, it was discussed to include more information in the social history, such as what grade the patient was in. He also mentioned that kids 4 years old should be in a booster seat, so they shouldn’t just be in a seatbelt when in a car. Professor Maida also commented on obtaining more information on the history of febrile seizures, such as how many times it has happened and when the last incidence was. The physical exam also needed some changes, particularly the chest exam.