Browse categories and answer follow-up questions to refine your symptom profile.
History
Presentation profile
Lethargy and altered mental status pattern
Decreased arousal
Confusion
Somnolence
Unresponsiveness
Time course and context
Sudden onset
Gradual onset
Fluctuating course
Baseline neurodevelopment and behavior
Baseline interaction
Baseline speech and motor function
Prior episodes
Similar events
Prior evaluations and diagnoses
Recent events and triggers
Intercurrent illness timeline
Fever onset
URI symptoms onset
GI symptoms onset
Trauma possibility
Witnessed head injury
Unwitnessed fall
Exposure history
Household medications access
Substances
Carbon monoxide exposure risk
Ingestion risk window
Last seen well time
Potential access time
Associated symptoms
Neurologic
Seizure activity
Postictal period
Headache
Focal weakness
Ataxia
Vision change
Infectious
Fever
Neck pain
Photophobia
Rash
Cardiopulmonary
Dyspnea
Cyanosis
Palpitations
GI and hydration
Vomiting
Diarrhea
Poor intake
Decreased urine output
Endocrine and metabolic
Polyuria
Polydipsia
Weight loss
Feeding and elimination
Intake and hydration
Last oral intake
Ability to keep fluids down
Urine output
Wet diapers count
Dysuria
Stool pattern
Diarrhea
Constipation
High yield pediatric specifics
Age specific risks
Neonate and young infant serious bacterial infection risk
Toddler ingestion risk
Immunization status
Up to date
Not up to date
Sick contacts
Household illness
Daycare exposure
Alarm Features
First 5 minutes stabilization triggers
Immediate resuscitation triggers
Airway not protected
Apnea
Persistent hypoxia
Shock
Active seizure
Danger vital signs
Hypotension for age
Severe tachycardia for age
Bradypnea
Severe hyperthermia
Hypothermia
High risk neurologic red flags
Intracranial process concern
GCS less than 13
New focal neurologic deficit
Persistent vomiting with headache
CNS infection concern
Meningismus
Petechiae or purpura
Bulging fontanelle
Non accidental trauma concern
Inconsistent history
Bruising patterns concerning for abuse
Retinal hemorrhage concern signs
Toxicologic red flags
High risk ingestion signals
Miosis and respiratory depression
Hyperthermia and agitation alternating with somnolence
Wide QRS
Prolonged QTc
Metabolic and endocrine red flags
Hypoglycemia risk
Diabetes medications exposure
Poor intake with vomiting
DKA and HHS concern
Kussmaul respirations
Dehydration with altered sensorium
Inborn errors of metabolism concern
Lethargy after fasting
Recurrent vomiting episodes
Failure to thrive
Medications
Current and recent medications
Home medications
Prescription list
Recent dose changes
Over the counter exposures
Cold and cough products
Antihistamines
Acetaminophen products
Ibuprofen products
Supplements and herbals
Melatonin
Herbal products
High risk medication classes
Sedatives and opioids
Benzodiazepines
Opioids
Psychotropics
Tricyclic antidepressants
Antipsychotics
Cardiovascular agents
Beta blockers
Calcium channel blockers
Metabolic agents
Insulin
Sulfonylureas
Medication allergy considerations
Antibiotic allergies
Beta lactams
Sulfonamides
Contraindications to likely therapies
QT prolonging agents history
G6PD deficiency history
Diet
Intake and hydration status
Recent intake
Poor oral intake
Normal intake
Hydration indicators
Reduced tears
Dry mucous membranes
Decreased urine output
Exposure related diet history
Caffeine and stimulants
Energy drinks
Caffeinated sodas
Possible toxin ingestion via diet
Homemade alcohol exposure in household
Herbal teas or remedies
Special diets
Ketogenic diet
Restrictive intake patterns
Review of Systems
General
Systemic symptoms
Fever
Chills
Weight loss
Toxic appearance
Poor perfusion
Reduced interaction
Neurologic
Neuro symptoms
Seizure
Syncope
Headache
Weakness
Gait instability
HEENT
Head and neck
Neck stiffness
Ear pain
Sore throat
Vision and hearing
Vision change
Photophobia
Respiratory
Respiratory symptoms
Cough
Shortness of breath
Wheeze
Cardiovascular
CV symptoms
Chest pain
Palpitations
Cyanosis
Gastrointestinal
GI symptoms
Vomiting
Diarrhea
Abdominal pain
Genitourinary
GU symptoms
Dysuria
Hematuria
Reduced urine output
Skin
Rash patterns
Petechiae
Urticaria
Signs of trauma
Bruising
Burns
Collateral History and Family History
Collateral source and reliability
Source
Parent or guardian
EMS
School or daycare
Reliability considerations
Witnessed timeline
Multiple caregivers with differing accounts
Family history
Neurologic
Epilepsy
Migraine
Cardiac
Sudden unexplained death
Long QT syndrome
Metabolic and endocrine
Type 1 diabetes mellitus (E10.9)
Inborn errors of metabolism
Hematologic
Sickle cell disease (D57.1)
Bleeding disorders
Social context and supervision
Home environment
Access to medications
Carbon monoxide detector presence
Safeguarding concerns
Prior child protective involvement
Domestic violence exposure
Risk Factors
Infection and immunologic risk
Under immunized status
Missing Hib
Missing pneumococcal series
Immunocompromise
Chemotherapy
Chronic steroids
Indwelling devices
VP shunt
Central venous catheter
Toxic exposure risk
Environmental
Carbon monoxide exposure
Pesticides
Household medication access
Opioids
Cannabis edibles
Clonidine
Adolescents
Alcohol exposure
Polysubstance exposure
Trauma risk
Accidental mechanisms
Fall from height
MVC
Non accidental trauma
Age under 2 years
Prior sentinel injuries
Metabolic risk
Diabetes risk
Known diabetes
New onset symptoms of hyperglycemia
Dehydration risk
Prolonged vomiting
Prolonged diarrhea
Cardiac risk
Arrhythmia risk
Family history sudden death
Exertional syncope history
Differential Diagnosis
Life threatening
CNS infection
Bacterial meningitis (G00.9)
Encephalitis (G04.90)
Intracranial hemorrhage
Traumatic ICH (S06.5)
Non traumatic ICH (I61.9)
Sepsis and shock
Sepsis (A41.9)
Septic shock (R65.21)
Hypoglycemia (E16.2)
Insulin exposure
Reduced intake in infant
DKA (E10.10)
Kussmaul respirations
Dehydration
Toxic ingestion
Opioid toxicity (T40.2)
Sedative hypnotic toxicity (T42.4)
Tricyclic antidepressant toxicity (T43.0)
Carbon monoxide poisoning (T58)
Multiple household members symptomatic
Headache with lethargy
Status epilepticus
Ongoing convulsions
Nonconvulsive status concern
Common
Dehydration from gastroenteritis
Reduced intake
Tachycardia
Febrile illness with sleep deprivation
Viral syndrome
Poor sleep
Postictal state after seizure
Witnessed seizure
Gradual return to baseline
Medication side effect
Antihistamines
Cough and cold products
Concussion (S06.0)
Recent head injury
Headache
Less common
Brain tumor (D49.6)
Progressive headaches
Morning vomiting
Stroke
Pediatric ischemic stroke (I63.9)
Cerebral venous sinus thrombosis (I67.6)
Metabolic disorders
Hyperammonemia (E72.20)
Hypothyroidism (E03.9)
Intussusception (K56.1)
Episodic lethargy with abdominal pain
Intermittent crying spells
Key mimics and pitfalls
Apparent lethargy from hypoxia
Silent hypoxemia
Bronchiolitis
Apparent lethargy from hypothermia
Environmental exposure
Sepsis in neonate
Overreliance on normal initial exam
Early meningitis with minimal signs
Early intracranial bleed with subtle findings
Past Medical History
Medical conditions and prior events
Neurologic history
Epilepsy (G40.909)
Prior CNS infection
Endocrine and metabolic
Diabetes mellitus (E10.9)
Adrenal insufficiency (E27.40)
Cardiac history
Congenital heart disease (Q24.9)
Known arrhythmia
Renal and electrolyte history
Chronic kidney disease (N18.9)
Prior hyponatremia (E87.1)
Procedures and devices
CNS devices
VP shunt
Recent shunt revision
Other devices
G tube
Central line
Baseline function
Functional baseline
Usual feeding
Usual mobility
Care needs
Home nursing
Seizure rescue plan
Physical Exam
Initial global assessment
ABC and stability
Airway protection
Work of breathing
Perfusion
Vital signs interpretation
Fever pattern
Hypotension for age
Oxygen saturation trend
Mental status
Pediatric GCS components
AVPU
General and hydration
Appearance
Toxic appearance
Consolability
Hydration
Capillary refill
Mucous membranes
Skin turgor
Head and neck
Head exam
Scalp hematoma
Bulging fontanelle
Meningeal signs
Neck stiffness
Photophobia
ENT
Otitis media signs
Pharyngitis signs
Neurologic exam
Pupils
Size symmetry
Reactivity
Motor
Tone
Strength asymmetry
Coordination and gait
Ataxia
Truncal instability
Reflexes
Hyperreflexia
Hyporeflexia
Cardiopulmonary
Respiratory
Breath sounds asymmetry
Wheeze
Stridor
Cardiovascular
Murmur
Gallop
Peripheral pulses
Abdomen
Abdominal exam
Tenderness
Distension
Mass
Bowel sounds
High pitched
Absent
Skin and trauma survey
Rash
Petechiae
Purpura
Injury patterns
Bruising in nonmobile child
Patterned bruising
Burns
Lab Studies
Point of care immediate tests
POC glucose
If less than 3.0 mmol/L treat immediately
Repeat glucose 10 to 15 minutes after treatment
Venous blood gas
pH and CO2 assessment
Lactate if shock concern
Urinalysis and ketones
Ketones positive supports DKA context
UTI clues
Core labs by syndrome
CBC with differential
Leukocytosis support for infection
Neutropenia immunocompromise risk
Electrolytes
Sodium
Potassium
Bicarbonate
Renal function
Urea
Creatinine
Liver panel
AST
ALT
Inflammatory markers
CRP
Procalcitonin local protocol dependent
Sepsis and CNS infection workup
Blood culture
Before antibiotics when feasible
Do not delay antibiotics in shock
Serum lactate
Elevated supports hypoperfusion
Trend for response
CSF studies when LP performed
Cell count and differential
Glucose
Protein
Toxicology and targeted labs
Acetaminophen level
Time since ingestion dependent interpretation
Repeat level per nomogram guidance
Salicylate level
Serial levels if concern
Mixed respiratory alkalosis and metabolic acidosis pattern
Ethanol level
Correlate with clinical state
Co ingestants common
Urine drug screen
Limited sensitivity and specificity
Does not reliably detect all synthetics
Carboxyhemoglobin
Measure in suspected carbon monoxide exposure
Pulse oximetry can be falsely normal
Metabolic and endocrine evaluation
Beta hydroxybutyrate
Supports DKA if elevated
Starvation ketosis context
Serum osmolality
Toxic alcohol evaluation context
Hypernatremia context
Ammonia
Consider if unexplained encephalopathy
Handle specimen quickly to reduce false elevation
TSH and free T4
Consider if prolonged altered sensorium
Hypothermia bradycardia context
Imaging
Scoring Systems
Pediatric head trauma decision support
PECARN head trauma criteria
Applicable for GCS 14 to 15 and blunt head trauma
Altered mental status sepsis screening
Pediatric qSOFA is not validated for disposition decisions
Use institutional sepsis pathway local protocol dependent
MRI
Brain MRI indications
Concern for encephalitis with nondiagnostic CT
Posterior fossa process suspicion
MRI contraindications and logistics
Implanted ferromagnetic device
Need for sedation risk
Interpretation pearls
Diffusion restriction in acute ischemia
Temporal lobe involvement in HSV encephalitis pattern
CT
Non contrast CT head indications
GCS less than 13
Focal neurologic deficit
Signs of increased intracranial pressure
CT radiation considerations
Pediatric dose reduction protocols
Alternative imaging if stable and low risk
CT contrast considerations
Contrast allergy history
Renal dysfunction risk
Ultrasound
Abdominal ultrasound indications
Intussusception concern
Appendicitis concern with atypical presentation
POCUS role
IVC assessment in shock context
Lung ultrasound for pneumonia and effusion context
Limitations and pitfalls
Operator dependence
False negatives early in disease course
Special Tests
Lumbar puncture decision logic
LP prerequisites
Hemodynamic stability
No signs of impending herniation
LP deferral triggers
Focal neurologic deficit with concern for mass effect
Severely depressed consciousness with airway risk
CSF interpretation pearls
WBC count age dependent normal ranges
Traumatic tap confounding
EEG considerations
Nonconvulsive status epilepticus concern
Persistent altered mental status without explanation
Subtle automatisms
Timing considerations
Early EEG if persistent AMS after convulsive seizure
Continuous EEG in ICU local protocol dependent
Toxicology consult triggers
Poison control involvement
Unknown ingestion
Sustained release exposure
Decontamination constraints
Activated charcoal only if protected airway
Caustic ingestion excludes charcoal
ECG
Indications in pediatric AMS
ECG indications
Suspected ingestion
Syncope preceding lethargy
Electrolyte derangement concern
High risk ECG findings
QRS greater than 100 ms
QTc prolongation
Patterns suggesting specific toxidromes
Terminal R in aVR with TCA toxicity concern
Bradycardia with AV block in beta blocker exposure concern
Serial ECG logic
Repeat every 2 hours if evolving tox picture
Continuous monitoring if QRS or QTc abnormal
Assessment
Problem representation
Pediatric lethargy and altered mental status
Duration category
Presence of fever
Presence of trauma or ingestion possibility
Severity stratification
GCS category
Respiratory support need
Hemodynamic stability
Leading diagnoses with supporting data
CNS infection concern
Fever with meningismus
Rash with petechiae or purpura
Toxic ingestion concern
Access to medications
Abnormal pupils
ECG abnormalities
Metabolic derangement concern
Hypoglycemia on POC
Acidosis on blood gas
Intracranial pathology concern
Focal deficits
Signs of increased intracranial pressure
Diagnostic uncertainty framing
Complications to rule out
Airway compromise
Seizure recurrence
Alternative diagnoses
Intussusception with episodic lethargy
Sepsis without fever in young infant
Plan
Immediate stabilization
Airway and breathing
Supplemental oxygen for hypoxia
Bag mask ventilation if apnea
Circulation
IV or IO access if unstable
Isotonic fluid bolus 20 mL/kg for shock
Reassess after each bolus
Glucose management
If glucose less than 3.0 mmol/L dextrose
D10W 5 mL/kg IV
D25W 2 mL/kg IV
Seizure management
If active seizure benzodiazepine
Lorazepam IV 0.1 mg/kg
Midazolam IN 0.2 mg/kg
Time critical empiric therapy
Suspected sepsis or meningitis
Antibiotics within 60 minutes for sepsis pathway local protocol dependent
Ceftriaxone IV 50 mg/kg
Add vancomycin IV 15 mg/kg if resistant pneumococcus risk
Suspected encephalitis
Acyclovir IV 10 mg/kg every 8 hours
Renal dosing adjustment if kidney dysfunction
Suspected opioid toxicity
Naloxone IV 0.1 mg/kg
Repeat every 2 to 3 minutes to effect
Diagnostic sequencing
First line tests
POC glucose
VBG
Electrolytes
CBC
Second line tests by suspicion
Blood cultures if infection concern
Toxicology labs if exposure concern
Carboxyhemoglobin if CO concern
Monitoring and reassessment loop
Monitoring
Cardiorespiratory monitoring
Frequent vitals every 15 minutes if unstable
Reassessment timing
Neuro checks every 30 to 60 minutes initially
Repeat glucose after dextrose within 10 to 15 minutes
Disposition
ICU criteria
ICU level care triggers
Need for airway support
Persistent GCS less than 13
Refractory seizures
Shock needing vasoactives
Inpatient admission criteria
Admission indications
Suspected CNS infection
Ingestion requiring monitoring
Persistent abnormal labs
Observation pathway
Improving mental status
Normalizing vitals
Clear diagnosis with low risk course
Transfer criteria
Higher level pediatric center triggers
Need for pediatric ICU
Neurosurgical concern
Continuous EEG need
Discharge criteria
Discharge requirements
Return to baseline mental status
Normal vitals for age
Tolerating oral intake
Reliable caregiver supervision
Follow up timing
Primary care within 24 to 48 hours
Specialty follow up if indicated
Discharge Instructions
Copy discharge instructions
Summary
Today you were seen for sleepiness and behavior change
Testing did not show an emergency cause at this time
Hydration and intake
Encourage frequent small sips of fluids
Monitor urine output
Medications
Use only medicines prescribed or recommended today
Avoid cough and cold medicines unless specifically instructed
Activity
Quiet rest for 24 hours
No risky activities if head injury concern
Follow up
Follow up with your primary care clinician in 1 to 2 days
Return sooner if symptoms worsen
Return to ED now for
Trouble breathing
Blue lips or face
Seizure
Not waking up normally
New weakness
Stiff neck
Purple or spreading rash
Persistent vomiting
Signs of dehydration
References
Guidelines and key sources
Pediatric Advanced Life Support guidelines, American Heart Association, 2020
Pediatric resuscitation algorithms
Pediatric shock management
Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children, 2020
Time sensitive antibiotics and fluids
Vasoactive escalation framework
PECARN Pediatric Head Trauma Prediction Rules, original validation studies, 2009
Imaging reduction strategy
Risk stratification for clinically important TBI
American Academy of Pediatrics guidance on evaluation of febrile infants, 2021
Age based SBI evaluation
Disposition frameworks
Infectious Diseases Society of America encephalitis guidelines, 2018
Empiric acyclovir indications
Diagnostic testing recommendations
Poison control and toxicology management resources, local protocol dependent
Regional toxidrome management pathways
Decontamination criteria
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.