Index of Suspicion * Case 1: Abdominal Pain, Fever, and Cough in a 3-year-old Boy * Case 2: Emesis, Irritability in 9-year-old Boy Who Has Autism * Case 3: Skin Lesions and Pulmonary Nodules in a 17-year-old Boy

Abstract

* CGD: : chronic granulomatous disease CNS: : central nervous system CT: : computed tomographic ED: : emergency department GI: : gastrointestinal Ig: : immunoglobulin VATS: : visually assisted thoracic surgery A mother brings her 3-year-old son to the emergency department (ED) for 1 day of abdominal pain and subjective fever. The mother states that the boy generally is healthy. He has not had any nausea, vomiting, or diarrhea, but he has been eating less than normal and has been constipated for 3 days. He coughs occasionally but does not have shortness of breath. He was treated 3 days ago for right otitis media with high-dose amoxicillin at another ED. His immunization status does not meet the recommended standards. On physical examination, the boy cries and actively tries to get away from the physician assistant, but he is consoled easily by his mother when the examination is finished. While crying and fighting, his temperature is 98.2°F, his heart rate is 156 beats per minute, his respirations are 24 breaths per minute, and his oxygen saturation is 97% in room air. His ear, nose, and throat examination is notable only for opaque and slightly erythematous tympanic membranes. Respiratory and cardiac findings are normal. His bowel sounds are hypoactive, his abdomen is soft, and he withdraws with right upper quadrant palpation. The findings from the rest of his examination are unremarkable. An acute abdominal radiologic series is ordered. A 9-year-old autistic boy presents to the ED with a 3-day history of bilious emesis and one loose stool with no visible blood. His mother states that he has been increasingly irritable, and his behavior has become more erratic. He has not been wanting to eat or drink over the past few days and has had decreased urine output on the day of presentation. There is no history of fever, upper respiratory tract infections, illness contacts, or travel. He takes no medications and has not had surgery. Physical examination results reveal a well-nourished boy who …