a teaching point

A 3 year-old came in to clinic today, referred from a family practice clinic in the area, because he was dehydrated from a presumed gastroenteritis. Here in our tranquil, sleepy town, we see kids who would normally have to go to the emergency room up in our outpatient clinic as long as things aren't too too bad. This little guy needed IV fluids, but maybe not more than that, so was triaged up to clinic.

We gave him 2, 200 cc boluses of normal saline and started maintenance fluids while we monitored his progress in clinic all evening. Even after the 2 boluses, he still looked pretty punky, not fussing too much when I would come in periodically to examine him. After he'd gotten the full 400 cc, I listened to his lungs. Lo and behold, he had crackles! He had been so dry that we hadn't heard his pneumonia. One shot of intramuscular ceftriaxone coming right up. Thirty minutes later, he looked a little better and was asking to go home, which we took to be a step in the right direction. He fussed and fought with our nurse as she tried to take the tape off his arm. Another sign that he was feeling a little better. He wanted chocolate milk, too. I mean, who wouldn't after the day he's had?

So, the moral of this story is that sometimes severe dehydration can mask a bad lung infection. The physical exam is a nebulous target that you'll miss completely if you don't pay attention. If we hadn't heard those crackles, we would have just sent him home and called it a gastroenteritis.

He'll be seen in clinic again tomorrow morning. There's no rest for the weary. Somehow, I don't mind, though, because we caught this one and know how to fix him. Even after a long day of not-so-clear-cut-cases, that feels pretty good.