Index of Suspicion

doi:10.1542/pir.18-2-63

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This section of Pediatrics in Review reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions inn which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encourage to write possible diagnnoses for each case before turning to the discussion, which is on the following page. We invite readers to contribute case presentations and discussions.

Case 1 Presentation

The mother of a 2-month-old infant calls you after hours, concerned that her son might be having a seizure. You know her well because you have seen the child several times recently for feeding difficulties. Last week he was diagnosed at a tertiary care center as having gastroesophageal reflux and was placed on ranitidine and metoclopramide. The mother reports that he has been acting strangely for the past 30 minutes, with stiffening of all extremities, an unusual cry, and a lack of normal responsiveness. A nurse who is a neighbor corroborates the mother’s story and believes that the child is having a seizure. She adds that the child’s breathing is somewhat irregular and that he is pale, although he is not cyanotic. You advise the mother to call an ambulance to take him to the hospital.

On arrival at the emergency department, the infant is unresponsive, stiff, and pale. His heart rate is 210 beats/min, respirations are 32 breaths/min with grunting, and pulse oximetry is 88% in room air. His temperature and blood pressure are normal. He is given oxygen and intravenous diazepam, which causes a slight improvement in the tachycardia and rigidity. After another dose of diazepam, he is more relaxed and more responsive, and his cry sounds normal. A full evaluation for seizures is initiated. …