I forgot to mention this kid had no history of polyuria/ polydipsia. If "torr"
is the same as partial pressure measured in mmHg the conversion factor to
kilopascals is 7.5 giving him an arterial O2 of 75 torr in O2 and CO2 in the low
30s. I cant smell ketones and nobody else mentioned it. I don't think we have
a facility to measure blood ketones as an emergency investigation. It was not
Endocrinology consult recommended insulin infusion so he received this as well
as his regular nebulised salbutamol overnight. We had already started iv
fluids. Despite getting good air entry he remained O2 dependant according to
oximetry and the single initial ABG. Blood sugars dropped to normal overnight.
Na was normal when rechecked (with normal blood sugar). Acidosis resolved over
about 18 hours (checked on venous blood). HbA1 result was normal when obtained.
Following morning he developed a fever and repeat FBC showed elevated WCC with
nuetrophilia. He was treated with antibiotics vs pneumonia. No organism was
identified. Wheeze was gone by 48 hours but he was O2 dependent for almost a
week. Radiologists agreed the CXR typical for asthma rather than pneumonia.
Blood sugar stayed normal off insulin.
Presumed diagnosis- 1st presentation of asthma triggered by pneumonia in a child
with impaired glucose tolerance. No convincing explanation for the acidosis. I
favour the dry, hypoxic child struggled all day with his carers underestimating
the severity of his condition because he remained relatively cheerful theory.
Respiratory paediatrician doing follow up.
Andrew McIntyre- Paediatric Registrar
Emergency Department, Monash Medical Centre, Melbourne.
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