Send for a Chest Radiograph today

You contact the local hospital and arrange the radiograph, explaining to Rory’s mother where to go. She thanks you for you time and care.

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A few hours later you get a telephone message from the local hospitals X-Ray department.

“I just wanted to let you know that a patient of yours has just had a fit in the department just after his X-Ray. We called the crash team and he was taken to the Emergency Dept. The radiograph is going to be reported, but is also available electronically.”

You access the chest radiograph.

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You are now the attending paediatric trainee in the Emergency Department (ED). You have been urgently called to the xray department where an outpatient having a chest xray has just had a seizure. The resus team decide to take him to the ED for further management, but first put him in the ‘recovery’ position, put on an oxygen mask and attach monitoring.

His mother is very frightened, saying that he had been a little unwell with a cold, that the doctor said he had a chest infection, that he has had all his immunisations, that the doctor had said he had a chest infection and he needed a chest xray, so she came to the hospital, that as soon as he had had it he started staring, then his eyes rolled up and he started shaking all over.

He is taken into the resus area and monitoring attached. His capiliary blood glucose is 5.6 mmol/L. A cannula is sited and he is given intravenous lorazepam and then examined:

HR 170/min, RR30/min, SaO₂ 95% in mask oxygen, BP 95/45 mmHg

Airway clear

Chest moving well, large airway inspiratory crackles

Heart sounds normal, capiliary refill 3-4 seconds

Abdomen soft

Moving all limbs rhythmically 3 beats/sec.

Anterior fontanelle full

Unresponsive.

He is given a second dose of intravenous lorazepam and shortly after the seizure terminates. He remains stable from a cardiorespiratory point of view. The resuscitation team smile and leave you to continue the management.

Some blood tests that were sent on admission now have results available.

Hb       103 g/L

Wcc    16.3 x 10⁹/L

Plats    341 x 10⁹/L

Urea    3.8 mmol/L

Na       141 mmol/L

K          4.6 mmol/L

Creat   42  micromol/L

Urine is sent for microscopy and culture.

The chest radiograph is now available.

It is twenty minutes now since his seizure terminated. You review him and take a history from his mother, who is now less distressed.

He was born at term normally. He is her first baby – it was a surprise for her and her boyfriend but she was very pleased that she was having a baby. He has been well up to this episode, and has had all the required immunisations. He is beginning to use his hands now, smiles, and follows moving objects with his eyes.

He was well up until the last 3 days, when he developed a runny nose and then a cough. She does not think her son has had a temperature. Since then he has been increasingly irritable and she cant seem to settle him. Feeding is not consistent and regular like it was before.

She has also noted a new mark on his skin and wonders if it is ringworm. She looked it up on the internet. He has two other birthmarks.

He is still very sleepy and barely responsive to pain. His respiratory rate is 30/min, temperature 37.4C and HR 120/min, but otherwise his examination is unchanged.

The new marks:

The birth marks:

 What would you like to do now?