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INDEX OF SUSPICION

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 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 write possible diagnoses 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
 While driving to work, a 17-year-old female high school senior who has been in good health has an abrupt syncopal episode resulting in a headon collision at 40 miles per hour. She is alert and oriented right after the accident, but complains of sternal pain as well as pain in her left chest, left shoulder, and the right side of her jaw. Evaluation in the emergency department reveals slight tachypnea of 26 breaths/min, blood pressure of 90/60 mm Hg, a midsternal abrasion, a left pneumothorax, and nondisplaced fractures of the left clavicle and right mandible. Results of her neurologic examination, including mental status, are normal.
 She denies the use of any medication, street drugs, or alcohol, but she does report a 9-month history of brief spells of lightheadedness, diaphoresis, nausea, and visual blackouts, with one previous episode proceeding to complete syncope.