Episodes of lost balance, "wiggling" eyes, a family history of convulsions: does this toddler have epilepsy, or is something else going on?
You walk in to see your first patient of the day. The chief complaint on the chart says: “Concerned about seizures.” The patient is a 21/2-year-old, who has been your patient since his birth. You flip through the chart and see that he was last seen about 6 months ago for his 2-year checkup and at that time everything was fine. His development was appropriate; he was starting to put short phrases together, including “Go bye bye, NOW,” which he said so often that you made note of it in the chart. You wonder what could be going on.
You greet the mother, and say hi to Alex, who looks fine-and for the first time that you can remember, Alex is smiling at you. You ask mom what her concern is. She tells you that for the past few months, Alex seems to suddenly lose his balance periodically. Initially mom thought little of it, figuring he was still working out the kinks in his walking skills, but she got concerned when she noted that Alex seemed to get very upset when this was happening. She also thought he looked a bit pale during each "episode," which lasts about 5 minutes. During one episode, she thought she saw Alex’s eyes “wiggling.” She mentioned these episodes to her mother, who reminded her that her cousin had convulsions. Now she’s worried.
Of course, findings from your examination of Alex are perfectly normal.
• What is your differential diagnosis?
• Are there missing elements of the history that would be helpful?
• What studies, if any, should you get?
• Will this child need medication?
• Can you adequately reassure mom?
I invite you to leave your comments below and then click here to read the discussion.