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Index of Suspicion

	Case 1 Presentation

The infant weighed 4,630 g (10 lb 3 oz) at birth. Her mother received complete prenatal care, and there were no complications, including gestational diabetes. There is no family history of congenital heart disease.

The baby’s temperature is 37.4°C (99.3°F), pulse is 180 beats/min, respiratory rate is 85 breaths/min, and blood pressure is 72/45 mm Hg. She is pink without mottling but in moderate respiratory distress. Her lungs sound clear. She has a hyperdynamic precordium, her carotid and extremity pulses are 3/4 in intensity, and a grade 2/6 crescendo-decrescendo murmur is heard at the left midsternal border. Heart sounds S1 and S2 are loud. The liver edge can be palpated 2 cm below the midcostal margin. No skin lesions or birthmarks are present.

Evaluation for sepsis yields results that make infection unlikely. Laboratory findings include normal electrolyte levels; hemoglobin, 10.48 mmol/L (16.9 g/dL); thyroxine, 20.1 nmol/L (6.7 mcg/dL) (normal, 78 to 206.7 nmol/L [6 to 15.9 mcg/dL]); and thyroid-stimulating hormone, 3.8 mcIU/dL (normal, 3 to 18 mcIU/mL). A radiograph of the chest shows an enlarged cardiac silhouette. Echocardiography demonstrates dilatation of the right atrium and ventricle and tricuspid regurgitation.

A detailed examination of the infant’s head and neck suggests a diagnosis that is confirmed by imaging.

	Case 2 Presentation

 
A 6-year-old boy comes to your office because of migratory pain and swelling of his joints. Three days ago he experienced pain and swelling of his right hand and knee. The following day, the pain and swelling had spread to his right ankle. He complains . . . [Full Text of this Article]

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