Recent growth in per-capita admissions for bronchiolitis is not accounted for by physician intolerance for diagnostic uncertainty. Physician risk attitudes should be considered in the context of hospital admissions for other pediatric conditions with unclear prognoses.
Summary
Key wordsHeart; congenital defects.
Case historyThe patient was a 16-year-old male with Down's syndrome. At birth he was noted to have a heart murmur, but was not cyanosed. Apart from frequent hospital admissions for pneumonia during his first 5 years of life, he had led a normal life until 3 years prior to his present admission. Since then he had developed progressively worse dyspnoea and cyanosis on exercise, and for the past 2 years he had been taking digoxin with some symptomatic improval but was unable to play sports or climb more than five steps without resting.Cardiac catheterisation was performed at 10 years of age with the following findings: pulmonary hypertension-100/50mmHg, mean 69 mmHg; evidence of left-to-right and right-toleft ventricular shunting, with pulmonary arterial oxygen saturation (SaO,) 87%; angiographic evidence of a complete endocardial cushion defect.'On this occasion the patient was admitted to hospital with a fracture of the left medial epicondyle, and he was scheduled for open reduction and fixation of the fracture.Other than severely limited exercise tolerance, he was asymptomatic. Examination showed the typical features of Down's syndrome; height 129 cm and weight 43 kg. He had central
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