Index of Suspicion

Case 1 Presentation

A 4-year-old boy has had 6 days of intermittent nausea and vomiting without diarrhea or fever. Two days into the illness, he was given promethazine suppositories for presumed viral gastroenteritis; overnight the vomiting subsided. He now experiences an unsteady gait and needs help to stand still for urination. He says that he sees “two daddies.” There has been no weight loss, headache, mental status changes, upper respiratory tract symptoms, skin lesions, or trauma.

On physical examination, his weight, height, and head circumference are appropriate for age. His vital signs are normal, and he appears comfortable, talkative, and playful, although slightly pale. His abdomen is soft and nontender with normoactive bowel sounds. He has a well-healed scar resulting from pyloromyotomy in the first postnatal month. Despite the acute history of ataxia and diplopia, a thorough neurologic evaluation reveals normal findings, as does the rest of the examination.

An imaging study reveals the cause of his vomiting, ataxia, and diplopia.

Case 2 Presentation

A 15-year-old girl who experienced menarche at age 13 years has had no menstrual periods for 7 months. Her only symptom is an occasional headache occurring at the end of the day. She denies sexual activity, medication use, and substance abuse and has had no recent weight change, heat or cold intolerance, skin or hair problems, difficulties with vision, or fainting. The patient’s family history includes a granduncle who has acromegaly.

On physical examination, she looks well. Her height is in the 50th percentile, weight is in the 75th percentile, blood pressure is 113/62 mm Hg, and pulse is 90 beats/min. Her skin is not flushed or dry, and she has no rashes or abnormalities of hair pattern or hirsutism. Extraocular movements, visual fields by confrontation, and pupils all are normal. Heart, lung, abdominal, and neurologic examinations yield normal findings. Breasts and …