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An 18-Month-Old Boy Is Brought to the Emergency Department for Evaluation

question 716

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An 18-month-old boy is brought to the emergency department for evaluation of a productive cough and fever.  He has had 8 office and emergency department visits over the past year, all of which required antibiotics for diagnoses of sinusitis and pneumonia.  He was delivered vaginally without complications.  His older brother has had similar recurrent infections throughout his life.  Temperature is 38.9 C (102 F) , blood pressure is 90/60 mm Hg, pulse is 120/min, and respirations are 30/min.  The patient's pulse oximetry is 99% on room air.  Examination of the oropharynx reveals mildly enlarged tonsils without erythema or exudate.  Auscultation reveals rales and rhonchi in both lungs, and point of maximal impulse is displaced to the right side of the chest.  What is the most likely diagnosis?

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