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(Pediatrics in Review. 2006;27:73-78.)
© 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 16-year-old boy comes to the ED after awakening with waxing and waning central chest pain, aggravated by deep inspiration and described as a sensation of "pushing." Two days ago, he experienced fever to 102.6°F (39.3°C), sore throat, mild fatigue, and several bouts of vomiting. He denies dyspnea, presyncope, syncope, palpitations, edema, coughing, and orthopnea. There is no family history of congenital heart disease, cardiomyopathies, or sudden cardiovascular death.

Examination reveals a healthy-appearing young man in no distress. His temperature is 98.6°F (37°C), heart rate is 71 beats/min, blood pressure is 105/69 mm Hg, and oxygen saturation is 99%. He has tenderness to palpation over the mid-to-lower sternum and at the mid-left and right sternal borders. His apical impulse is within the mid-clavicular line. There is a grade I–II/VI soft systolic pulmonary flow murmur audible at the upper left sternal border, with a physiologically split second heart sound of normal intensity. No rubs, diastolic murmurs, or gallop rhythms are present. His chest is clear, his liver is not enlarged, and he evidences no peripheral edema. His pulses and perfusion are normal.

The WBC count is 6x10³/mcL (6x10⁹/L) with 75% neutrophils and no bands, and the ESR is 18 mm/h. Values for electrolytes, BUN, creatinine, calcium, total cholesterol, and triglycerides are normal, as are findings on urinalysis. Results of his urinary toxin screen are negative. Chest radiography reveals a normal heart size with normal pulmonary blood flow and no pneumothorax. Additional laboratory tests lead to the diagnosis.

	Case 2 Presentation

 
A 15-year-old girl presents with a 3-day history of fever, sore throat, vomiting, and periumbilical pain. She does not appear toxic and has a temperature of 101.1°F (38.4°C). Her other vital signs are normal. The pharynx is erythematous without exudates, and left anterior cervical lymphadenopathy with swelling and . . . [Full Text of this Article]

Peter S. Chang, DO
J. Peter Harris, MD
University of Rochester School of Medicine & Dentistry, Rochester, NY

Nasreen Bhumbra, MD
Mark Puczynski, MD
Medical University of Ohio, Toledo, Ohio

Nizar Kherallah, MD
Terrance J. Lewis, MD
Mercy Children’s Hospital, Toledo, Ohio

Neena Shilen, MD
Howard Track, Children’s National Medical Center, Washington, DC

Sohail Rana, MD
Howard University Hospital, Washington, DC

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