Index of Suspicion * Case 1: Persistent Fever and Cough Following Episodes of Emesis in a 7-year-old Girl * Case 2: Blurry Vision and Unilateral Dilated Pupil in a 14-year-old Girl * Case 3: Swelling, Pain, and Erythema of the Thumb in a 10-year-old Girl With Habits of Nail Biting and Thumb Sucking

Abstract

* CT: : computed tomography ESR: : erythrocyte sedimentation rate IV: : intravenous WBC: : white blood cell A 7-year-old girl presents to the emergency department with persistent fever and cough for 9 days. She was in her usual state of good health until she vomited twice 11 days earlier. She subsequently developed cough and fever, prompting three visits to an urgent care center in the preceding 9 days. She denies shortness of breath, chest pain, diarrhea, rash, urinary symptoms, or sore throat. A chest radiograph on the fourth day of fever was normal. Physical examination reveals a temperature of 102.9°F, heart rate of 115 beats per minute, respiratory rate of 28 breaths per minute, blood pressure of 110/65 mm Hg, and pulse oximetry reading of 98% in room air. Generally, she appears well, with occasional coughing during the visit. On respiratory examination, there is good air movement bilaterally, and no rales or wheezes are heard. The rest of the physical findings are normal. Her white blood cell count (WBC) is 25×103/μL with 88% neutrophils, 8% lymphocytes, and 4% monocytes; her C-reactive protein level is 16 mg/dL (normal <0.5); and an erythrocyte sedimentation rate (ESR) is 70 mm/hour. Results of her complete metabolic panel and urinalysis are normal. A blood culture and urine culture come back negative. An additional imaging study reveals the cause of her prolonged illness. A previously healthy 14-year-old girl presents with blurred vision in the right eye of a few hours’ duration. The blurring is worse while looking at close rather than at far objects. There is no history of trauma, ingestion of toxic substances, or recent illness, including headache, nausea, vomiting, weakness or tingling of the extremities, eye pain, ptosis, diplopia, or other symptoms referable to the cranial nerves. The past, social, and family histories are noncontributory, other than the presence of asthma and dry eyes in the mother. On physical …