Index of Suspicion

Case 1 Presentation

An 8-year-old boy who has asthma presents to the ED with the acute onset of sharp, right-sided abdominal pain. His pain is 10/10 on the pain scale. He denies fever, nausea, vomiting, diarrhea, or trauma to the abdomen. His last bowel movement was yesterday. He admits to some pain with urination. He remains hungry despite the pain. He has no known sick contacts.

Physical examination reveals an uncomfortable child, crying with pain. His temperature is 37.0°C, heart rate is 85 beats/min, blood pressure is 118/71 mm Hg, respiratory rate is 20 breaths/min, and oxygen saturation is 99% on room air. He weighs 40 kg, which is at the 95th percentile for his age. He has hypoactive bowel sounds, a mildly distended abdomen, and right lower quadrant abdominal tenderness. He also has voluntary guarding but no rebound tenderness. The Rovsing and obturator signs are negative.

His laboratory results are as follows: WBC count, 8.1×10³/mcL (8.1×10⁹/L) (63% neutrophils, 21% lymphocytes, 9% monocytes, 6% eosinophils); Hgb, 11.7 g/dL (117 g/L); Hct, 35% (0.35); and platelet count, 268×10³/mcL (268×10⁹/L). His serum electrolyte concentrations are normal, and urinalysis shows clear yellow urine with negative leukocyte esterase and nitrite tests, 1 WBC/high power field (hpf), and 1 red blood cell/hpf. An imaging study reveals the diagnosis.

Case 2 Presentation

A 10-month-old boy presents to a southern California ED with cough and hemoptysis. He was well until 1 month ago, when he developed fever and cough productive of blood-streaked sputum. At his initial presentation, he had hypoxia and tachypnea, and a chest radiograph showed a right upper lobe consolidation. He was hospitalized and treated with cefotaxime for 5 days. A purified protein derivative (PPD) tuberculosis skin test was negative at 48 hours. Once his fever, hypoxia, and hemoptysis resolved, he was discharged …