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(Pediatrics in Review. 2008;29:201-206.)
© 2008 American Academy of Pediatrics

Index of Suspicion

The first 300 words of the full text of this article appear below.


   Case 1 Presentation
 
A 21-month-old boy presents with 5 weeks of progressive abdominal distention and vomiting. The left side of his abdomen would swell, particularly after meals, and then recede; for the last 10 days, however, his abdomen has been distended constantly. He vomits shortly after any attempt to eat, and the vomitus is not bilious or bloody. When not vomiting, he appears comfortable. He has been afebrile.

Prior to this episode, he has been well, developing normally and growing along the 10th percentile for height and weight. He has had no recent infections or trauma and is receiving no medications.

On physical examination, his temperature is 99.0°F (37.2°C), heart rate is 104 beats/min, respiratory rate is 22 breaths/min, and blood pressure is 93/58 mm Hg. He appears cachectic and weighs 10.4 kg (5th percentile). His abdomen is grossly distended, dull to percussion, and not tender. A solid, firm mass encompasses the left flank, extending 4 cm past midline to the right. The superior and inferior edges cannot be discerned, and the liver and spleen cannot be distinguished as either separate from or part of the mass.

His white blood cell count is 17.0x103/mcL (17.0x109/L) with a normal differential count, Hgb is 11.3 g/dL (113 g/L), Hct is 36.1% (0.361), mean corpuscular volume is 76.1 fL, and platelet count is 653.0x103/mcL (653.0x109/L). Results of serum chemistries and hepatic function tests are normal except for a bicarbonate concentration of 17.0 mEq/L (17.0 mmol/L). C-reactive protein is elevated at 2.2 mg/dL (0.22 mg/dL). Urinalysis yields normal results.

An abdominal radiograph leads to additional imaging, but the final diagnosis is made only after a procedure.


   Case 2 Presentation
 
An 8-year-old boy is evaluated for severe abdominal pain. Two weeks ago, he developed severe, sharp, right-sided lower quadrant . . . [Full Text of this Article]


David M. Barrett, MD, PhD
 The Children's Hospital of Philadelphia, Philadelphia, Pa

Christine S. Cho, MD, MPH
 Children's Hospital and Research Center Oakland, Oakland, Calif., UC San Francisco, San Francisco, Calif

Nicolas Brown, MS-IV
Su-Ting T. Li, MD, MPH
 University of California, Davis, Sacramento, Calif

Selvi Senthilnathan, MD
Todd M. Poret, MD
Jodi K. Wenger, MD
 Dartmouth Hitchcock Medical Center, Lebanon, NH

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