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(Pediatrics in Review. 2008;29:97-102.)
© 2008 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-month-old girl is evaluated in the ED for increased work of breathing. She had been seen 4 days ago for rhinorrhea, cough, vomiting, diarrhea, and fever, all of which appeared to have resolved. At that time, she had a normal CBC and serum electrolyte measurement and was treated with intravenous fluids and discharged. Two days later, she again developed cough with posttussive vomiting and rhinorrhea, but no fever or diarrhea.

On physical examination, the girl is awake and alert but in mild-to-moderate respiratory distress. Her respiratory rate is 50 breaths/min, pulse oximetry saturation is 94%, and heart rate is 161 beats/min. She is afebrile. She has moderate pharyngeal erythema, clear rhinorrhea, and a hyperemic right tympanic membrane. Intercostal retractions, mild wheezing, and occasional scattered crackles are present. The rest of her physical findings are normal. She is given three treatments of albuterol and prednisolone and responds with a lower respiratory rate of 40 breaths/min but a pulse oximetry saturation of 92% in room air.

Initial laboratory studies include negative results for respiratory syncytial virus (RSV) and influenza A and B antigens. A chest radiograph shows no acute disease and mild hyperinflation. She is admitted to the hospital.

Over the next 3 days, she develops a temperature to 101°F (38.4°C) and has no improvement, despite frequent albuterol treatments. On day 4, her WBC is 9x103/mcL (9x109/L), with 41% neutrophils, 2% bands, 43% lymphocytes, and 7% monocytes, and her platelet count is 775x103/mcL (775x109/L). A urine culture is negative, but a blood culture is reported positive for gram-negative diplococci.


   Case 2 Presentation
 
A 10-year-old boy is admitted to the hospital after 4 days of progressive vision loss in his right eye. His symptoms began 4 days ago with eye pain on lateral . . . [Full Text of this Article]


Courtney Peshkovsky, MD
Robert J. Leggiadro, MD
 Lincoln Medical and Mental Health Center, Bronx, NY, and Weill Medical College of Cornell University, New York, NY

Lauren Kupersmith, MD
 University of California at Davis Medical Center, Sacramento, Calif

Seth Septer, DO
Cristina Fernandez, MD
Fernando Zapata, MD
 University of Nebraska/Creighton University School of Medicine, Omaha, Neb

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