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Dyspnoea and cough in a toddler

BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b4436 (Published 12 November 2009) Cite this as: BMJ 2009;339:b4436
  1. Malcolm Brodlie, Medical Research Council/Cystic Fibrosis Trust clinical research fellow12,
  2. Michael C Mckean, consultant respiratory paediatrician1
  1. 1Paediatric Respiratory Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP
  2. 2Institute of Cellular Medicine, Newcastle University, Medical School, Newcastle upon Tyne NE2 4HH
  1. Correspondence to: Dr M Mckean michael.mckean{at}nuth.nhs.uk

    A 15 month old girl presented to the accident and emergency department with a three day history of increasing dyspnoea and cough. On examination, her pulse rate was 120 beats/min, respiratory rate 50 breaths/min, temperature 37.4°C, and oxygen saturation 96% in room air. Chest radiography was performed (fig 1). Pregnancy had been unremarkable and she was born at term by normal vaginal delivery. There were no concerns during the neonatal period, and she had been generally healthy before this episode. Her height and weight were on the 50th centile and her developmental age was appropriate.

    Fig 1 Chest radiograph (anteroposterior view)

    Questions

    • 1 What were the findings on chest radiography?

    • 2 What is the most likely diagnosis and what are the other possibilities?

    • 3 What further imaging should be performed?

    • 4 What further management is appropriate?

    Answers

    Short answers

    • 1 The chest radiograph shows a gas filled structure above the right hemidiaphragm and midline (fig 2). Opacification and atelectasis are also present in the right lower zone. The left lung field is clear and the heart and mediastinum are normal.

    Fig 2 Chest radiograph showing a gas filled structure (G) above the right hemidiaphragm and midline, along with opacification and atelectasis in the right lower zone

    • 2 The most likely diagnosis is a (congenital) diaphragmatic hernia accompanied by right middle lobe collapse or consolidation. A less likely differential diagnosis is a hyperexpanded lobe caused by a congenital lung abnormality, such as a congenital cystic adenomatoid malformation. The gas filled structure on the radiograph is the stomach, which has entered the chest …

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