Index Of Suspicion In The NurseryCase 1: Projectile Vomiting in an 11-day-old GirlCase 2: Abnormal Facies in a Newborn

Case 1 Presentation

An 11-day-old female infant presents to the hospital because of “projectile vomiting.” According to her mother, the infant vomits after every feeding and subsequently appears hungry. She has three wet diapers and one bowel movement per day. Her emesis is reported to be bright yellow but does not appear to be the color of her formula. The patient was born at term via normal spontaneous vaginal delivery. She weighed 3.7 kg and there were no complications or infection. She was sent home on cow milk formula, feeding 2 oz every 3 hours. Today, she is acting appropriately and has no fever, cough, congestion, or sick contacts.

On physical examination, her temperature is 36.4°C, heart rate is 160 beats/min, respiratory rate is 44 breaths/min, blood pressure is 87/40 mm Hg, weight is 3.065 kg (10th percentile), length is 50 cm (50th percentile), and head circumference is 33.5 cm (5th percentile). The infant is awake, alert, active, and in no acute distress. She has a normocephalic head with an open and soft anterior fontanelle and no evidence of trauma. The eye examination reveals bilaterally symmetric red reflexes and anicteric sclera. Findings on the oropharyngeal examination are normal, with no exudates, an intact palate, and moist mucous membranes. Cardiovascular examination demonstrates no murmurs, a regular rate and rhythm, good femoral pulses, and a capillary refill of less than 2 seconds. Lungs are clear to auscultation bilaterally. Abdominal examination documents active bowel sounds over a soft, nontender, and nondistended abdomen, with no masses or notable hepatosplenomegaly. Genitourinary examination notes normal female genitalia with a patent anus. Extremity examination shows no clubbing, cyanosis, or edema.

The laboratory results on admission are:

• White blood cell count of 10.0×10³/mcL (10.0×10⁹/L) with a normal differential count

• Hemoglobin of 13 g/dL (130 g/L)

• Hematocrit of …