Index of Suspicion

Case 1 Presentation

A 17-year-old boy is evaluated because of declining school performance. Although he was an honor student while working a part-time job 6 months ago, he now is at risk of failing several of his classes. The boy and his parents cannot pinpoint a precise cause for his recent decline, but the parents express concern that now he is “hanging around with the wrong crowd.” Without his parents present, the boy denies drug or alcohol use or a history of physical abuse.

His past medical history reveals allergic rhinitis. His only medication is a nonsedating antihistamine. Family history includes allergic rhinitis, asthma, and maternal hyperthyroidism. According to the patient, the review of systems is completely negative, but his parents report that he is more fatigued than usual, somewhat irritable, and sleeping poorly. On physical examination, he is a tall, thin adolescent male who has normal vital signs. Besides his obvious “allergic shiners” and slight fullness of the anterior neck, results of his physical examination are unremarkable. Due to his unexplained academic decline and behavior changes, laboratory studies are obtained that reveal the cause of his failing grades.

Case 2 Presentation

A 3-year-old girl has been irritable for 1 week and for 3 days has had nonbloody, nonbilious emesis one to four times a day. She has vague intermittent abdominal pain and a mildly decreased appetite; her last bowel movement was 3 days ago. She is afebrile and has no dysuria.

On physical examination, the child is irritable and cries at times, but she also is observed looking through books and playing. Her vital signs are normal, although an attempt to measure blood pressure is unsuccessful due to poor cooperation. Her physical findings are normal otherwise, with no abdominal masses or tenderness present.

Determinations of CBC with differential count, serum electrolytes, liver enzymes, amylase, and …