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A 2-week-old baby boy, J, presented to the local accident and emergency (A&E) department of with a two-day history of diarrhoea and vomiting and a one-day history of abdominal distension and difficulty breathing.
Baby J was the first child of healthy parents. The pregnancy had been normal until 31 weeks gestation when an antenatal ultrasound scan revealed a large left renal cyst. He was born by spontaneous vaginal delivery at full-term with a birth weight of 3500 g. The Apgar scores were 9 at 1 minute and 9 at 5 minutes of age. He was initially breastfed on demand. At postnatal examination he had bilateral positional talipes and a deviated nasal septum. Meconium was passed by 24 h of age. An ultrasound scan at 48 h of age revealed a probable dysplastic left kidney and dilatation of the right ureter with calyceal blunting. Urea and electrolytes at 2 days of age were normal. He was noted to have a normal urinary stream. There was no relevant family history. He was discharged home on prophylactic trimethoprim pending further investigations (DMSA and micturating cystourethrogram).
He had been reviewed by a consultant neonatologist at 10 days of age because of the renal abnormalities. The deviated nasal septum was confirmed and the rest of the examination was normal. He was feeding well on formula milk and had regained his birth weight. Arrangements were made to review him after the renal investigations.
On examination in the A&E department he was dehydrated and his temperature was 37.5°C, respiratory rate of 40/min and oxygen saturation 100% in air. He had poor air entry in his chest. His abdomen was soft and non-tender. The examination was otherwise normal.
The senior house officer in A&E thought that the most likely diagnosis was a chest infection. He organised a chest …
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