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SS (registrar) and AC (resident)
A 5-year-old female presents to a tertiary paediatric hospital in Australia with a 2-day history of fever, vomiting and abdominal pain. Her past history consists of three episodes of otitis media in the preceding 12 months, all resulting in tympanic membrane perforation. Her parents report an ‘innocent heart murmur’ diagnosed by a paediatric cardiologist. There is no history of travel or animal exposure. With regard to family history, she is the child of non-consanguineous Caucasian parents, and her father has Crohn's disease. On examination, she is febrile (40.0°C) and tachypnoeic (45 breaths/min) with normal oxygen saturations (99% room air). Bronchial breath sounds are auscultated posteriorly in the left lower zone. She has a 3/6 systolic murmur heard at the apex and lower left sternal edge with no radiation. Her first full blood examination showed a neutrophilia (13.9×109/L, normal <8.5×109/L) and mild lymphopenia (1.9×109/L, normal >2.0×109/L) which resolved. Her C-reactive protein (CRP) is elevated at 157 mg/L (normal <8 mg/L). A chest radiograph (CXR) shows left lower lobe consolidation with an irregular area of radiolucency suggestive of an evolving abscess (see figure 1A). The patient is commenced on intravenous flucloxacillin (50 mg/kg, 6 hourly) and ceftriaxone (50 mg/kg, 12 hourly). Despite this, she continues to spike high-grade fevers (>39.0°C). Blood cultures on two occasions are negative.
AS (general paediatrician and paediatric infectious diseases physician)
The initial presentation with fever and abdominal pain is not uncommon in patients with pneumonia. Tachypnoea is a sensitive and specific sign of pneumonia, and CXR is the most appropriate initial diagnostic investigation.1 The presence of fever, …
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