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Index of Suspicion

Thomas C. Bisett, MD^*
Sol Rockenmacher, MD^*
Isabelle G. De Plaen, MD
Maryann Buetti-Sgouros, MD

^* Lahey Hitchcock Clinic, Manchester, NH

The Children's Memorial Hospital, Chicago, IL
Columbia-Presbyterian Medical Center, New York, NY

	Case 1 Presentation

Although a participant in the Special Olympics, this girl is not an active person; her mother is concerned that she has gained too much weight in the last year. Findings on physical examination include a weight of 128 lb (75th percentile on Down syndrome growth chart; was 50th at last examination 3 years ago) and a height of 56 in (40th percentile; was 75th). Her blood pressure is 90/60 mm Hg, her pulse 52 beats/ min, she is Tanner stage 5 in breast maturity, and her face is mildly puffy. Her lungs are clear. Cardiac findings include a normal apical impulse, heart sounds of normal intensity with a split second sound that closes on expiration, and peripheral pulses of normal amplitude. A grade I/VI systolic ejection murmur is audible along the left sternal border, radiating across the precordium. No neck masses, neck vein distension, or hepatomegaly are noted.

Results of an EKG show sinus bradycardia, borderline low voltage, and nonspecific T-wave flattening. A chest radiograph shows normal heart size and pulmonary vascular markings. A limited echocardiogram reveals a significant abnormality. Blood chemistries are ordered that explain her clinical findings.

	Case 2 Presentation

 
A 4-day-old boy is brought to the emergency department because of anuria and vomiting. Born vaginally after an uneventful pregnancy, the baby was discharged from the nursery at 24 hours of age but developed increasingly severe nonbilious vomiting. He had passed meconium on the first day of life and a dark stool yesterday. He wet several diapers earlier, but his urine output has decreased. His family . . . [Full Text of this Article]

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