Index of Suspicion

Case 1 Presentation

A 13-year-old boy comes to clinic having a 3-day history of swelling and redness of his eyes with discharge as well as pain with eye movement for 1 day. Acute bacterial conjunctivitis had been diagnosed elsewhere and topical antibiotic eye drops prescribed.

Now he complains of inability to see with his right eye. In addition, he has had nonprojectile vomiting for 1 week and loose stools for 2 days, but no headache. He has had no fever, trauma, sick contacts, illicit drug use, polyuria, nocturia, or recent travel. He has gained 60 lb over the last 6 months despite normal activity. His grandparents have type 2 diabetes.

Physical examination reveals a cooperative, obese teen who has a temperature of 98.7°F (37.1°C), heart rate of 110 beats/min, respiratory rate of 20 breaths/min, and blood pressure of 161/85 mm Hg. There is slight ptosis of the right upper lid, with lower lid chemosis and bilateral subconjunctival hemorrhage, more prominent on the right. The corneae and lenses are clear, and pupils are equally reactive bilaterally. Horizontal extraocular muscle movement is limited due to pain, with vertical movements intact. The optic discs appear normal. Visual acuity is 20/200 in the right eye and 20/20 in the left.

His WBC count is 10×10³/mcL (10×10⁹/L), Hgb is 13 g/dL (130 g/L), Hct is 39% (0.39), and platelet count is 424×10³/mcL (424×10⁹/L). Electrolytes are within normal range. CT scan of the orbit is ordered, and an ophthalmologist is consulted.

Case 2 Presentation

A 2-month-old infant girl is admitted to the hospital following 8 days of vomiting, diarrhea, and dehydration and is rehydrated intravenously. On day 2, a nurse notes a protrusion in the infant's neck when she cries.

Physical examination reveals an alert, vigorous infant in no distress. Her temperature is 98.6°F …