Professor’s Pearls
Section III: The Inpatient Ward
1 Case: An 8-year-old boy is admitted to the hospital for daily fever for more than 2 weeks. No diagnosis has been made despite several careful physical examinations as an outpatient and multiple negative cultures, including throat, blood, urine, and stool. The patient had had some initial abdominal pain and mild diarrhea, which resolved. Other routine laboratory work results includes an elevated sedimentation rate and C-reactive protein. What would be the most helpful part of your initial evaluation? What other tests should be done (e.g., computed tomography [CT], bone marrow examination)?
2 Case: A 10-year-old girl is sent to the hospital emergency department by her primary care physician because of the sudden onset of decreased movement of the left side of her face. She has been previously well and had a flulike illness with onset about 4 days ago. What conditions are associated with facial paralysis? Specifically, are there conditions that should be treated promptly? What other clues might be present on physical examination?
3 Case: A 15-year-old girl presents to your office for increasing headaches for the past 4 weeks and several episodes of morning vomiting. She has been followed closely in your office for the past year because of moderate weight gain. She has been well otherwise. Examination reveals an obese girl who is alert and cooperative, with normal vital signs. What part of the physical examination is most critical in this case? Is imaging of the brain necessary? What are the possible causes of her headache?
4 Case: A 14-month-old boy is sent for admission by his primary care physician because of swelling of his lower extremities and pallor. He has been a healthy infant with normal growth and development. Immunizations are up to date. Diet includes whole milk and some table food. Initial screening laboratory tests include the following: hemoglobin, 5 g/dL, and hematocrit (Hct), 17%, with normal white blood cell (WBC) and platelet count; comprehensive metabolic profile is normal except that the total protein is 3.5 g/dL and albumin 1.5 g/dL. What is the most likely cause of the swelling? What key laboratory tests should be done promptly? What additional history is critical?
5 Case: A 10-year-old girl is undergoing evaluation by an endocrinologist for short stature. She was normal at birth and grew at the 50th percentile for her first 18 months. She then had a slow decline in growth parameters and now is at the 10th percentile with only a 3 cm increase in the past year. She has been fairly healthy otherwise except for some irritability and poor weight gain in addition to decreased growth velocity. Parents and siblings are all of average height. What further questions might help make a diagnosis in this case? Could there be clues on examination? What screening laboratory test is important?
6 Case: A 9-year-old boy is brought to the office for ankle pain and swelling and some abdominal pain for 24 hours. He was previously well but developed mild crampy abdominal pain without emesis 1 day previously, and then this morning noted some swelling and pain in the left ankle. He has been afebrile but was given some acetaminophen for discomfort. What are key parts of the physical examination in this case? What condition must be considered first? What laboratory testing could be helpful?
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