Case File #4

A 5-year-old girl comes to your clinic for the first time with complaints of fever, malaise, and a cough for 2 days. She has a history of asthma for which she uses a steroid inhaler daily and an albuterol inhaler as needed. She has been tried on various over-the-counter cold and allergy remedies, but her respiratory symptoms have been worsening over the past several months. Her past medical history is notable for an episode of rectal prolapse and "sinusitis" during each of the past two winter seasons. Her mother also reports that her daughter has "always been small for her age." Your examination reveals a moderately ill-appearing child whose height and weight are at the fifth percentile for age. Her temperature is 101 degrees F and respiratory rate 32 breath/min. She has scant purulent rhinorrhea bilaterally, wheezy breath sounds in all lung fields, and diminished breath sounds on the right side. Heart sounds and capillary refill are normal, yet she has digital clubbing.

What is the most likely diagnosis?

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