The patient is a 7-year-old boy who presents to urgent care at midnight with a four-day history of fever and cough.

Two days prior, a throat culture administered elsewhere showed nothing suspicious. The parents brought him to urgent care tonight because of increasing chest pain, which began after the visit to the primary care physician.

On exam, you find the child is not in respiratory distress, but has decreased air entry on the left side of his chest. His temperature is 101.3°F, with SAT of 94.

View the x-ray taken (Figure 1) and consider what your diagnosis and next steps would be. Resolution of the case is described below.

The x-ray shows an infiltrate and, likely, a pleural effusion. In addition, note the deviation of the trachea.

This child was sent to the hospital, where he had a pleural tap which returned pus. He was put on IV antibiotics.

It is very likely that this was an aggressive pneumococcal pneumonia that literally developed within the short time after the visit to the primary care doctor.

Had the urgent care physician not identified the infection, there is a good chance that the child would have seriously and quickly deteriorated.