Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is the same 8 month old boy, Carl. The fever started 1 day after the rhinorrhea. It started as a “low-grade” fever of 99.6 and has climbed over the last day to what it was this morning at 101.5 degrees Fahrenheit. This morning, Carl has struggled to breathe through his nose and has developed a hacking cough. After a bout of coughing, Carl’s lips will become a little blue which is why he was brought in. He has also been very lethargic lately and has not made many wet diapers since yesterday, probably 3-4 and he normally soaks 8-10 diapers a day. He has also struggled with feeding for the past two days. Carl’s older brother had similar (but milder) symptoms late last week.
PMH: Carl has had a URI in the past, but it was never this severe. Same PMH and FMH as long case.
Physical Exam: Vital signs are the same as long case except respiratory rate is 60 per minute and O2 saturation at baseline is 97% with desaturations to 92% after coughing. TMs are normal. Respiratory exam shows tachypnea with audible wheezing, loud wheezing throughout the lung fields which is worse with exhaling, and accessory muscle use is present. Nares are patent but edematous and erythematous, oropharynx is also erythematous, no tonsillar hypertrophy or exudates.
Labs: RSV antigen positive. CXR negative. B-agonists are ineffective.