Index of Suspicion

Case 1 Presentation

You are assisting in the care of a 3-day-old term baby girl who has brachial palsy and mild respiratory distress. The baby’s birthweight was 3.25 kg, and the delivery was complicated by posterior asynclitism, an oblique presentation of the infant’s head. Delivery of the infant from her exhausted mother was accomplished with “low” forceps. A cord wound tightly three times around the neck was reduced immediately. Because of a lack of respiratory effort, positive pressure ventilation was given for 2 minutes with bag and mask, producing a good response.

On physical examination, the baby is hypotonic and demonstrates a poor cry and suck. Her right arm is extended, internally rotated, and limp; only a slight grip is present. The Moro reflex is absent on that side. There is no movement at the shoulder or elbow. No swelling or crepitus is noted on examination of the arm and clavicle. Deep forceps marks are present on both sides of the face. Midway down the right side of the infant’s neck is a small bruise underlying a tiny break in the skin. The baby demonstrates mild nasal flaring, intercostal retractions, and very little bulging of the abdomen upon inspiration. Auscultation reveals good air exchange bilaterally.

Ampicillin and cefotaxime have been administered since the baby was 18 hours old; at this point, a blood culture shows no growth. The required concentration of inspired oxygen has decreased from 32% to 28% over the past 24 hours. Chest radiographs performed on the first and second days of life appear normal. You order a procedure that clarifies the diagnosis.

Case 2 Presentation

A 2-year-old boy presents with pain in his right foot that has worsened over the past 2 days to the point that he refuses to walk or bear weight and only will crawl. When asked what is bothering …