Differential Diagnosis for a 5-year-old child with increased sleepiness

• Single most likely diagnosis
  • Opioid exposure: The child's symptoms of increased sleepiness, difficulty to arouse, and mild difficulty to follow commands are consistent with opioid intoxication. The recent exposure to a friend's brother who is recovering from surgery and may be taking opioid pain medications increases the likelihood of this diagnosis.
• Other Likely diagnoses
  • Infectious etiology (e.g., meningitis, encephalitis): Although the child had no past medical history and was acting normally before the episode, an infectious cause cannot be ruled out. The child's symptoms of sleepiness and difficulty to follow commands could be indicative of a central nervous system infection.
  • Postictal state: If the child had a seizure, she could be in a postictal state, which is characterized by sleepiness and confusion.
  • Hypoglycemia: Low blood sugar can cause symptoms such as sleepiness, confusion, and difficulty to arouse.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Traumatic brain injury: Although the child was playing at a friend's house and there is no reported trauma, a head injury could have occurred, and the child's symptoms could be indicative of a traumatic brain injury.
  • Carbon monoxide poisoning: If the friend's house had a carbon monoxide leak, the child could have been exposed, leading to symptoms such as sleepiness and confusion.
  • Meningitis or sepsis: These conditions can present with non-specific symptoms, including sleepiness, and can be life-threatening if not promptly diagnosed and treated.
• Rare diagnoses
  • Inborn errors of metabolism: Certain metabolic disorders, such as fatty acid oxidation disorders, can present with symptoms such as sleepiness and confusion.
  • Brain tumor: A brain tumor could cause increased intracranial pressure, leading to symptoms such as sleepiness and difficulty to follow commands.
  • Toxic ingestion (e.g., benzodiazepines, sedatives): Although less likely, the child could have ingested a toxic substance, leading to her symptoms.