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Case#1

Amotherbringsher12montholdchild,anewpatientintheclinic,forawellchildvisit.The
infantappearstobesmallforherage.Herweightisbelowthe5thpercentileonstandardized
growthcurves(50thpercentileforan8monthold),herlengthisatthe25thpercentile,andher
headcircumferenceisatthe50thpercentile.Hervitalsignsandherexaminationotherwiseare
normal.Wediagnosedpatientwithfailuretothrive,mostlikelynonorganicinetiologygiven
normalphysicalexam.Patientwasmanagedwithimproveddietaryintake,closefollowup,and
attentiontopsychosocialissues.
Case#2
J.Tisahealthy16yearoldadolescentmalearrivesattheofficewithhisparents,whoare
concernedabouthisseveralmonthshistoryoferraticbehavior.Attimeshehasagreatdeal
moreenergy,decreasedappetite,andlesssleeprequirementthanusual;atothertimeshesleeps
incessantlyandislethargic.Heisdoingpoorlyinschool.Lasteveningheappearedflushedand
agitated,hehaddilatedpupils,andhecomplainedpeoplewereouttogethim.Thefamily
notesthathehasbeenskippingschooloccasionally,andtheyreluctantlyreportthathewas
arrestedforburglary2weekspreviously.Youknowheisingoodhealthandhepreviouslyhas
beenanexcellentstudent.Todayheappearsnormalandonphysicalexam,patientiswellalert
andnormalvitals.Uponfurtherquestioning,patientadmittedtotrycocaineandwereferralhim
toEmoryforfurtherevaluationandbetterequipstohelphim.
Case#3
B.G.isa2yearoldboyhadbeenslightlylessthanthe50thpercentileforweight,height,and
headcircumference,butinthelast6monthshehasfallentoslightlylessthanthe25thpercentile
forweight.Thepregnancywasnormal,hisdevelopmentisasexpected,andthefamilyreportsno
psychosocialproblems.Themothersaysthatheisnowafinickyeater(wantsonlymacaroniand
cheeseatallmeals),butsheinsiststhatheeatavarietyoffoods.Themealsaremarkedbymuch
frustrationforeveryone.Hisexaminationisnormal.Weencounterthisproblemalotintheclinic
becausemost2yearsoldareverypickyeatersowejustreassurethemom.
Case#4:
D.L.isa4yearoldmalepatientisbroughttotheclinicbyhismotherafter5daysoffever(101
F),becauseofcrackingandfissuringlipsandbilateralpainlessconjunctivitis.Onexaminationhe
manifestsastrawberrytongue,unilateralcervicaladenopathy,andrednessandswellingofthe
palmsofthehands.Arapidstrepflocculationtestand,2dayslater,athroatculturewas
negative(lattermeaningnobetahemolyticstreptococcusgrowth).Thefeverremainsoverthe
next2days.PatientwassuspectedofKawasakiandsendtotheEmoryERfortreatment.

Case#5

A.J.isa10yearoldboyisbroughttotheclinicbyhisparentsbecauseoftheonsetof
involuntaryandrandomjerkingmovementsoftheextremities,incoordinationofpurposeful
movementsandslurredspeech,Sydenhamchorea.Furtherhistoryrevealstheboytobeatopic
withasthmathatheoutgrew,pneumoniaononeoccasiontreatedoutsidethehospital,andan
episodecharacterizedbyupperrespiratorysymptomsduringafamilyvacation4yearsagothat
wasnevertreatedbutwasfollowedbyseveralweeksofmildtomoderatechangingjointpains
andtransientbumpsunderskin.Theboyhasbeenasymptomaticsinceandhasparticipated
heartilyinoutdoorplayandathletics.Theboyisatriskofrheumaticfever,averyrarecasein
theU.S.becauseofpenicillinavailability.WethenreferralthepatienttoEmoryhospitalforan
echocardiogram.
Case#6
B.E.isa4yearoldboyisbroughttotheclinicforinspiratorystridorthatbeganlastevening,3
daysaftertheonsetofcoryzaandevolvingtracheobronchialcough.Histemperaturewas99.8
Forally(37.7C).Hedemonstratesinspiratorystridoratrestafteratemporaryresponseto
nebulizedracemicepinephrine(2.25%).Lateralneckxrayswerereadasnormal.Patientshow
classicsymptomsofcroupbutsinceepinephrinedoesntwork,weaddedDexamethasone0.6
mg/kgIMinasingledosetotreatpersistentcroup.Patientwasscheduledtocomebackin2days
forafollowup.
Case#7
E.A.isa16yearoldboyisbroughttotheclinicforthefirsttimebyhisparents,complainingof
increasingfatigability.AuscultationoftheheartrevealsagradeIII/VIsystolicejectionmurmur
andthrillsattherightsecondintercostalspaceandinthesuprasternalnotch.S2isnotsplit,
eitherininspirationorinexpiration.Themurmurisheardneitheroverthecarotidarteriesnorin
theleftaxilla.Thisisthesecondheartcasethisweek,wereferralhimtoacardiologistforfurther
evaluation.
Case#8
C.A.isa4yearoldboyisbroughttoclinicforroutinewellchildexaminationafterhisfamily
movedintothearea,seekinganewphysicianfortheircare.Patienthasmanifestednormal
growthanddevelopment.Hehasnormalenergyoutput,playingoutdoorswithhisagepeers
withoutdifficulty.Hemanifestsnocyanosis.OnexaminationInoticeagradeIV/VIsmooth
sounding(i.e.,notharsh)systolicmurmur,whichisloudestatthepulmonicauscultatoryarea.
Thesecondsoundhasafixedsplit,notvaryingwithinspiration.Wethinkthechildhaveasmall
ASD,althoughasymptomatic,wehavetodofurtherevaluation.Wereferralhimtoanearby
cardiologistforfurtherevaluation.

Case#9
D.R.isa7yearoldboybeganlimpingafterexerciseseveralmonthsago.Theparents
questionedhimatfirstandhedeniedpain.Latertheboybegancomplainingofpainintheright
hipandattimestherightthighandknee.Overthepastweek,thepainhasbeendisabling.Vital
signsarenormal;onexamination,theboyisunabletoactivelyabductandinternallyrotateasa
resultofmusclespasm.ACBCcountisnormal.WethensendthepatienttotheERtogetan
Xrayandfurtherevaluationbecausethechildishurtingandwedontwanttowaitifthesituation
isserious.
Case#10
A.F.isa4yearoldotherwisehealthyboyisbroughttotheofficewithan8dayhistoryof
nonspecificmalaiseandlowgradefeverashebeginstofeelbetternowmanifestsared
maculopapularrashonthecheeksthatonthedayheisbroughtinappearstobecoalescingto
produceadiffuseredcolornowinvolvingthechinandareabehindtheearsaswellasthetrunk
andbuttocks,sparingthecircumoralzone.Thereisnopalpablelymphadenopathyandtheoral
examinationisnotremarkablefordescriptiveabnormality.ThechildshowedclassicB19slap
faceappearancesoallwedoisreassurethepatientparentandtellthechildtoavoidpregnant
familymember.

Case#11
F.U.isa10yeargirl,assumedtohaveviralcroup,failedtorespondtoracemicepinephrineand
otherstandardtreatments;shedevelopedfeverto104F(40C)themorningofthevisitwith
theclinic.Alateralxrayoftheneckshowsnoenlargedepiglottisbutastenoticsubglottic
lumen.Wediagnosedpatientwithtracheitisandamoxillinwasprescribed.Patientwasschedule
tofollowupin2daystoseeiftheantibioticiseffectiveandwhetherthefevergonedown.
Case#12
J.Kisa3weekoldmaleinfantcomeintheclinicforhisfirstwellchildvisit.Onphysical
examination,hehasaharsh,pansystolicloudmurmuratthelowerleftsternaborder.Thereis
alsoaheaveovertheleftprecordium.Thechildhasbeeneatingnormallyandthefamilyhasnot
observedanyepisodesofcyanosisordyspnea.Thereisnocyanosis.Thischildisnormalatand
therearenomurmursduringnewbornexaminations.S2isnormallysplit(increaseswith
inspiration).Again,wereferralthecaseouttoacardiologistforfurtherevaluation.

Case#13
Amotherbringstoyouher4yearoldchildcomplainingofrightsidedearachefor12hours
followingthreedaysofcoryza,givingwaytocoughoverthepast2days.Theexternalearisnot
tendernoristhetemperomandibularjoint.Theeardrumisretracted,fieryred,slightlybulging,

andrevealsapus/fluidlevel.Wediagnosethepatientwithotitismediaandamoxicillinwas
prescribed.
Case#14
J.R.isa16yearoldmalestudentcomplainsofseveresorethroatfor3daysandsaysthathehas
beenunabletoingestsolidfoodsforthepast2days.Heappearsmoderatelyillandinpain,with
hisheadheldinasniffingtypeposition,lipsslightlyparted,grimacingwhileswallowing
saliva.Hisspeechismuffledandsoundsasthoughthepatientistryingtotalkwithahotpotato
inhismouth.Thereisnostridor.Histemperatureis101F.Hiscervicallymphnodesarevisibly
andpalpablyenlargedbutnottendertopalpation;tonsilsarepresentandshowanexudates
whosecolorisamixtureofwhiteandyellowishagainstanerythematousandedematous
background.Therearepalatalpetechiae.Therimoftheepiglottisisvisibleabovethebaseofthe
tongueandappearsnormalincolorandsize.Surveyforotheradenopathyyieldsnothingofnote,
andabdominalexaminationisnegativeformassesandorganomegaly.Arapidstreptococcal
screenisnegative.Therefore,Iorderedastatspottestforinfectiousmononucleosis,whichis
positive.Weinstructthepatienttoavoidcontactsport.
Case#15
A17yearoldgirlisbroughttoyouforthecomplaintofasorethroat.Younotethepresenceof
petechiaeofthemucosaoverlyingthehardpalate.Cervicallymphnodesarenotablyenlarged
andpalpablebutnottender.Infectiousmononucleosisandstreptococcalpharyngitiseachmay
causepetechiaeoverthehardpalate,thoughthequestionregardsanonbacterialcauseonly.
Furthermore,adenopathyduetoBetsstrepisvirtuallyalwaystenderwhereasthatdueto
infectiousmonoisvirtuallynevertender.Inchildren,herpangina(notmentionedamongthe
choices)causespalatalpetechiaeandoccursmostlyinpreschoolagechildren,generallyupto4
yearsofage.Itmayoccur,however,aslateinchildhoodas16years.Inthepresentcase,the
existenceofimpressivelymphadenopathywithouttendernessistypicalofmononucleosis.
Case#16
A16yearoldisundergoingaroutinehealthmaintenanceexamination.Hehashadfive
immunizationsofdiphtheria,tetanus,andpertussis(DTaP;threeinthefirstyear,oneat2years,
andoneat5years);fourshotsofHemophilusinfluenzaetypeB(Hib);fourshotsofinactivated
poliovaccine(IPV);twoshotsofmeasles,mumps,andrubella(MMR)vaccine;avaricella
vaccine;threeshotsofpneumococcalvaccine(PCV);threedosesofhepatitisBvaccine(HBV);
andyearlyinfluenzavaccines.

Case#17
Ayoungmothercomestoyouwithher8montholdformulafedbaby.Sheisconcernedabouta
rashinvolvingthefacialcheeksandthetopsoffoldsofskinovervariouspartsofthebody.On
occasion,thepatchesweepandformcrusts.Thebabydoesnotseemtobebotheredgreatlyby

therash.Boththeparentsarehealthyandwithoutespeciallyapparentinheriteddiseases,except
thatthemotherhasallergicrhinitisintheautumnmonthsandthefatherhadasthmaasachild.

Case#18
A17yearoldatopicmalesalesmanagermakesanappointmentforcomplaintofaprolonged
courseofcold.Untilthelastyear,hisallergicrhinitishasseldomrequiredantihistaminetherapy
duringhispeakseasonofmidAugustuntilthefirstcoolweather.Henotedtheonsetofcoryza2
1/2weeksagoduringthe4thmonthofAugustandthathisrhinorrheahaspersisted,producinga
tenaciousdischarge,sometimesbloodstreaked,fromtherightnaris.Whenheleansforward,he
feelsapaininhisrightfacialregionandsometimesasenseofshiftingfluidintherightcheek
anteriorly.Onexamination,hemanifeststendernessoftherightnasalrimoftheorbit.