An Unvaccinated Girl With Wheezing After Foreign Body Removal

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 4-year-old girl with a history of developmental delay is brought to the emergency department (ED) by her parents for wheezing. According to her parents, the patient started wheezing about an hour before her arrival in the ED. They state that she felt warm to touch at home; however, her maximum temperature was 99°F (37.2°C).

The parents did not notice any abnormal breathing pattern or increased work of breathing. They state that the child was never cyanotic and that she has had no rash, pallor, or jaundice. They report that the child is tolerating oral intake and has otherwise been normal in affect and behavior. She has not had a runny nose, vomiting, diarrhea, or any other specific complaints. The parents state they are not aware of any sick contacts.

A review of the patient's electronic medical record shows that she has had three recent visits to the same ED: one a month prior for fever, which was thought to be due to a viral illness; one 2.5 weeks prior for "just not acting right"; and one a week prior for swallowing a foreign body, which turned out to be a button battery that was removed endoscopically. She has had no prior visits for wheezing or respiratory symptoms.

The patient was born full-term, without complications. Other than developmental delay (not otherwise specified), she is not known to have any chronic medical problems. She is not on any medications and has no known allergies. The child's parents have refused the recommended vaccination schedule and state spontaneously that they would not like to discuss childhood vaccinations further at this time.

Physical Examination and Workup

Upon physical examination, the patient is a well-appearing, well-developed girl with weight and height in the 80th and 60th percentiles, respectively. Her oral temperature is 99.1°F (37.3°C), her heart rate is 118 beats/min and regular, and her respiratory rate is 30 breaths/min. Blood pressure has not yet been documented at the time the patient presents to you.

The patient is alert and interactive. She responds well to instructions from the examiner and has a normal-sounding voice when coaxed to speak by the parents. Her breathing shows good excursions. She has no nasal flaring or stridor and no retractions. Upon lung examination, expiratory wheezing and occasional scant crackles are noted bilaterally and are heard best in the upper lung fields. Her skin is normal in color; she is not pale, cyanotic, or mottled.

Upon further examination, the neck is supple, with no adenopathy, stiffness, or meningismus. The posterior pharynx is nonerythematous. No swelling, lesion, exudate, or pooling of secretions is noted. Auscultation of the heart shows regular rate and rhythm S1 and S2. No jugular vein distention is observed. No murmurs are heard. Her abdomen is soft, flat, and nontender. Capillary refill is < 2 sec. Neurologically, the patient is alert. Her parents describe the patient as being at her neurologic and behavioral baseline.

The patient is given nebulized albuterol, and a chest x-ray is obtained. Findings are similar to those shown in the example image below.

(Enlarge Image)

Figure 1.

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