Index of Suspicion

Case 1 Presentation

A 17-year-old girl known to have asthma presents to the ED with cough and wheezing of 2 days' duration. She was seen yesterday with the same symptoms, was diagnosed as having an acute exacerbation of asthma, and was discharged with a bronchodilator and oral corticosteroids. Despite using these medications appropriately, she continues to have cough and wheezing. She is the mother of a 2-month-old infant, and 3 weeks ago she completed a 10-day course of amoxicillin for group A streptococcal pharyngitis.

On physical examination, her respiratory rate is 30 breaths/min, heart rate is 129 beats /min, blood pressure is 152/76 mm Hg, and oxygen saturation is 92% in room air. Her body mass index is 34.5 kg/m² (>95th percentile). On auscultation, she has expiratory wheezes in all lung fields. Her abdomen is soft and nontender, but it is difficult to assess organomegaly because of her obesity. Her Hgb is 9.2 g/dL (92 g/L), Hct is 28.1% (0.28), WBC count is 17.1×10³/mcL (17.1×10⁹/L), and platelet count is 261×10³/mcL (261×10⁹/L). Serum concentrations of electrolytes are normal, and her BUN and serum creatinine are 26 mg/dL (9.3 mmol/L) and 0.9 mg/dL (79.6 mcmol/L), respectively. She is diagnosed as having status asthmaticus and treated with a bronchodilator, magnesium sulfate, and corticosteroids and started on bilevel positive airway pressure. Subsequently, she develops pinkish sputum. Additional imaging and laboratory evaluation lead to the correct diagnosis.

Case 2 Presentation

A newborn boy is transferred for additional care because of a heart murmur and deviated hands noted at the time of birth. He was born to a G1P1 woman via normal vaginal delivery and had Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. The mother's cervical culture was positive for group B streptococci, and the infant was treated …