INDEX OF SUSPICION

Clinicians often form a diagnostic impression at the time of a patient's first presentation. Usually the initial impression is correct because commonly encountered illnesses come to mind and are, of course, most likely to be responsible. Sometimes, however, a less familiar disorder is responsible and will not be detected or will be diagnosed after a prolonged delay unless the physician maintains a suspicion of the unusual. This section reminds clinicians of those conditions that can present in a misleading fashion and require suspicion for early diagnosis. Emphasis has been placed on conditions in which early diagnosis is important and that the general pediatrician might be expected to encounter, at least once in a while. The reader is encouraged to put in writing possible diagnoses for each case before turning to the discussion, which is on the following page. We invite readers to contribute case presentations with discussions. Case 1 Presentation A 4-year-old black boy known to have sickle cell disease is brought to your office by his mother, who is concerned because he has become listless and weak during the past 12 hours. He has been complaining of abdominal pain and is breathing "harder and faster" than usual. On examination, a greatly enlarged, tender spleen is palpated.