1. Case II – Neurology
Dr. K. Krishnamurthy
Vasha Ramgobin.
Neil Roopchan.
Valmiki Seecheran.
Year V MBBS.

2. Case summary.
• The emergency department (ED) notifies you that one of your
patients is being evaluated for new-onset seizures. The 2 year old
boy was in his normal state of good health until this morning. When
he complained of a headache and then fell to the floor. While
waiting for the ED physician to come to the phone, you review the
patient’s chart and find that he has had normal development. His
family history is significant for a seizure of unknown etiology that
his father had at age 4 years. According to ED physician, the boy’s
mother saw jerking of both arms and legs. When the ambulance
arrived 5 minutes later, the child had stopped jerking but was not
arousable; his heart rate was 108 bpm, respiratory rate 16
breaths/min, blood pressure 90/60 mmHg, and temperature 104oF
(40o). His blood sugar level was 135 mg/dL. By the time the child
arrived to the ED, he was awake and he recognized his parents. His
physical examination in the ED is normal, as are his complete blood
count and urinalysis.

3. Objectives.
• What is the most likely diagnosis?
• What is the best management for this
condition?
• What is the expected course of this condition?
• List factors that include the risk of further
seizure activity.

4. Patient history.
• Demographics.
– Name – John Doe.
– Age – 2 year old.
– Gender – Male.
• Presenting complaint.
– New onset seizures.
– Disinterested in reaching for toys.
• History of presenting complaint.
– Previously good health until this morning.
– Complained of headaches and then fell to the floor.
– His mother reported jerkings of both arms and legs. 5 minutes later, the child had stopped
jerking but was not arousal.
– At arrival of A&E, child was awake and recognized his parents.
• Past medical history.
– Normal developmental chart.
• Family history.
– +ve family history of seizures of unknown aetiology.
– His father had seizures at age four (4).

5. Patient history.
• Vitals.
– HR – 108bpm.
– RR – 16bpm.
– BP – 90/60 mmHg.
– Temperature – 40.0 Celsius.
– Blood sugar – 135mg/dl.
• All physical examinations were normal.
• FBC & Urinalysis was normal.

6. Diagnosis.
• Febrile seizures
– A seizure occurring in the absence of a CNS infection with an
elevated temperature in a child between 6 months and 6 years.
• Simple febrile seizure
– Seizure lasts < 15 minutes without focal or lateralizing signs/
sequalae.
– If more than one seizure occurs in a brief period, the total
episode lasts less than 30 minutes.
• Complex febrile seizure
– Seizure lasts > 15 minutes and may have lateralizing signs .
– If several seizure occur in a brief period, the entire episode may
last for more than 30 minutes.

7. Diagnosis.
• If neurological examination are abnormal, or
seizure occur several days in the illness, a lumbar
puncture may be necessary.
• Bedside investigations. (NB – unreliable in
children < 1 year)
– Brudzinski sign – patient supine, passive neck flexion
results in involuntary knee and hip flexion.
– Kernig’s sign – patient supine, leg flexed at hip, knee
at 90 degrees, pain is induced with leg extension.
• Lumbar puncture generally indicated for patients
< 1 year.

8. Management.
• A diagnosis of FS can only be made after considering CNS infection as a
cause.
• Self-limited.
– If longer than 5 minutes, can be interrupted with lorazepam/ diazepam.
– No need for anti-convulsants.
– Airway management is a priority.
• Parental education.
– 6 months to 6 years.
– 5% of children.
– Non-fatal.
– Genetic basis. (10-20% increase with a first degree relative).
• Injury prevention.
• Fever control.
– Acetaminophen.

9. Expected course.
• Prognosis is generally good, children will not
develop neurologic/developmental
consequences.
• Children < 12 months at time of their first
seizure have a 50% to 65% chance of another
febrile seizure. Older children have a 20% to
30% of reoccurrence.
• Outgrow the condition by 5-6 years of age.

10. Thank you.