Everyone who is involved in the care of children these days is being asked to "do more with less." We are all very busy in our practices, offices, hospital wards, and nurseries and are constantly being challenged to prioritize our daily schedules. You must decide which patients need to be seen immediately, who can be seen later in the day, and who can wait a day or two. We practice with outside constraints of third-party payers and the ever-present threat of malpractice claims. Each of us will face daily challenges and emergencies and will be required to make clinical decisions.
In this issue of Pediatric Annals, the authors were charged with providing topics that are common, challenging, and rewarding for the practicing pediatric clinician. Diseases of the central nervous system are among the most frightening to families and yet it is very common for the general practitioner to be called on to assess, manage, and prognosticate. The case scenarios described below are typical of what a busy practitioner, like you, may be called on to evaluate.
A worried mother calls you as you are getting into your car to go make rounds in the nursery. She tells you that her 4-year-old son woke up with a headache and has been vomiting each morning when he gets up for the past 3 days. She thought he just didn't like that he started attnending daycare recently. She wants to know should she bring him to the office.
One of your long-time patients, a 17-year-old girl, presents with what she describes as the "worst headache of her life." Her parents are at work, and because your office is on her way home from school, she thought she'd stop in and see what you could give her for the pain. Although it's bad, she has an examination at school the next day and thinks it might just be nerves.
You are called from the nearby community hospital emergency department because one of your patients, a 16-month-old, was brought in for fever of 39 degrees C. During the physical examination, the baby is noted to have a staring episode, and then a generalized tonic-clonic seizure ensues. It lasts approximately 7 minutes, and the infant is now sleepy. The resident wants to know if she should order a computed tomography scan of the head or perform a spinal tap.
A grandmother is babysitting for her 5-month-old grandson and notices that he seems to throw his arms up in the air and let out a shrill cry on occasion. She was holding him during one of these episodes, and he seemed to fall forward. She calls the office to ask if this is normal and if her daughter should bring the baby in when she returns from her trip to the mall.
You are out to dinner with your husband at a local restaurant, and an old acquaintance comes over to say hello and to ask you about his friend's nephew since he knows you have read this issue of Pediatric Annals. The child has epilepsy and has failed several medical regimens and seems to be "out of it at" school. Your friend wants to know if you know anything about something called a vagus nerve stimulator, or if you have heard about "brain surgery" for seizures.
One of your first-time moms calls your office and leaves a voice mail that she needs to see you right away. She was at her niece's birthday party with her 4-month-old son, and her mother told her that the baby's head "looks funny." She wants you to see the baby right away.
A 9-year-old boy with known sickle cell disease is having breakfast and notices that his right arm is quite weak. His mom keeps him home from school and calls you later in the day to ask what should she do. He says it feels a bit better now, but he has a tingling sensation around his mouth.
A mom calls the office as she is new in town and is looking for a pediatrician to follow her son who had open heart surgery a few months earlier. He seems to be weak on his left side, and she would like an appointment.
Your office is called by a new parent who has obtained legal custody of her nephew, who has moderate cerebral palsy. She is concerned that he cannot sit in his wheelchair, and she is curious if there is anything she can do to help "loosen him up."
The myriad questions that these nine cases generate are explained wonderfully in the subsequent six articles. Each author has been chosen for expertise in the areas of headache, seizures, craniosynostosis, spasticity, stroke, and the new frontier of pediatric epilepsy surgery. Although many of these conditions will require the expertise of neurologists and neurosurgeons, the general practice pediatrician is the front line for these children and their families. Your role is to serve as the central hub for your patients' care.
I hope these articles help you in your daily practice and that you enjoy reading them as much as I enjoyed editing them.