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(Pediatrics in Review. 2006;27:425-431.)
© 2006 American Academy of Pediatrics

Index of Suspicion

The first 300 words of the full text of this article appear below.

	Case 1 Presentation

 
A 10-month-old boy is brought to a community ED because he started vomiting last night and "has not been the same since." This morning, his mother noted that he was breathing fast. He had a low-grade fever this morning, but none prior. He has had no weight loss or diarrhea and has not been exposed to illness. Intravenous access is obtained, and the child is intubated because of respiratory distress and is flown to a children’s hospital.

On examination, the boy’s temperature is 37.6°F (99.7°C), heart rate is 158 beats/min, and blood pressure is 90/44 mm Hg. His respiratory rate had been 60 breaths/min prior to being intubated. He is a plump, robust infant who is sedated on the ventilator. Faint crackles are audible in his lungs. His skin is warm and well perfused. The rest of his findings are normal.

Laboratory findings include glucose, 176 mg/dL (9.8 mmol/L); sodium, 140 mEq/L (140 mmol/L); potassium, 3.1 mEq/L (3.1 mmol/); chloride, 115 mEq/L (115 mmol/L); bicarbonate, 10 mEq/L (10 mmol/L); calculated anion gap, 15 mEq/L (15 mmol/L); BUN, 5 mg/dL (1.8 mmol/L); and creatinine, 0.3 mg/dL (26.5 mcmol/L). A blood gas reveals a pH of 7.29 with a bicarbonate level of 14 mEq/L (14 mmol/L), a carbon dioxide concentration of 14 torr, and a base deficit of –18.6 mEq/L. His WBC count is 14.9x10³/mcL (14.9x10⁹/L) with 71% neutrophils and 2% bands. He is started on vasoactive medication for hypotension and treated for sepsis, but the clinicians are concerned that he has had minimal fever and no rash, and the laboratory findings are puzzling. An additional blood test reveals the diagnosis.

	Case 2 Presentation

 
A 4-year-old boy is brought to the clinic because of a chest deformity. Born at term, his birthweight was 3.8 kg, and his perinatal course . . . [Full Text of this Article]

Katie E. McPeak, MD
Abel Guerra, MD
Christine Nefcy, MD
Mark LaShell, MD
Michael Wolf, MD
Sibel Algon, MD
Children's Hospital of Pittsburgh, Pittsburgh, Pa
374^th Medical Group, Yokota Air Base, Japan
Bristol Myers Squibb Children's Hospital/UMDNJ - Robert Wood Johnson University Hospital, New Brunswick, NJ

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