- FA, a 2-year-old Malay girl, was admitted to the hospital due to 3 episodes of seizures associated with 2 days of fever and vomiting. - On examination, she was conscious and alert with no abnormalities detected. Tests ruled out metabolic causes and infection. - She received antipyretics, anti-seizure medication, and antibiotics. No further seizures occurred and she improved with treatment. Her diagnosis was complex febrile seizures presumed to be caused by meningitis.

1. CASE PRESENTATIONQhasmira Bt Abu Hazir 2008409674NurAmira Bt MohdAsri 2008409708Nurjuliana Bt Noordin 2008402524

2. PATIENT DEMOGRAPHICPATIENT NAME: FATIN AQILAH R/N: SB 00300220PATIENT’S INITIAL: FASEX: FEMALEAGE: 2YEARS AND 3 MONTHS ETHNIC GROUP: MALAYINFORMANT: MOTHER/FATHERRELIABILITY: FAIRWARD: 8CDATE OF ADMISSION: 24TH NOVEMBER 2010DATE OF CLERKING: 29TH NOVEMBER 2010DATE OF DISCHARGE: 1ST DECEMBER 2010

3. CHIEF COMPLAINTFA, a 2 years old Malay girl was admitted to the Sungai Buloh Hospital on 24th November 2010 due to fever and vomiting for 2 days prior to admission and 3 episodes of fits on the day of admission.

4. HOPI24TH NOVEMBER22ND NOVEMBER23RD NOVEMBERFEVER ( 1st day)Warm to touch

5. Intermittent in nature (on and off)

6. Temporarily relieved by syrup Paracetamol

7. Not ass. with rigorsVOMITINGnon-projectile

8. 4 episodes per day

9. Occur after taking food or fluid

10. Vomitus contained stomach content and no blood stained

11. Loss of appetite but not lethargic

12. Less activeFEVER (2ND day)Same presentation as before

13. Went to private clinic

14. Due to poor oral intake, she was given per rectal paracetamol

15. Temperature documented 38.5˚C- Temporarily relievedVOMITING- Same presentation as before3 EPISODES OF FITS

16. 1st episode of fitOccurred at home while she was playing (10am)

17. Witnessed by her grandfather. Her mother was away.

18. Was described as generalized stiffness

19. Lasted for 5 minutes

20. Her grandfather failed to explain more regarding on her granddaughter’s condition.

21. Mother was informed via phone and rushed to homePost-ictal (1st episode)Able to communicate with her parents

22. Appeared weak2nd episode of fitOccurred at private clinic while she was on her mother’s lap (15 minutes after 1st episode)

23. Was described as generalized stiffness of both 4 limbs followed by jerky movement.

24. Ass with up rolling of eyes, clenching of teeth and drooling of saliva

25. No bluish discoloration of lips, skin and nail bedLasted for 5 minutes spontaneouslyMother noticed that her daughter was feverish and warm to touchNo temperature was documentedNo medication given

26. Post-ictal (2nd episode)Regain consciousness and crying after the attack. Able to communicate with parents

27. Appeared weak

28. Not tolerate feeding and feel nauseated

29. No vomiting episodes

30. Was referred from private clinic to HSB for further management3rd episode of fit Occurred at ED of HSB (30 minutes after 2nd episode)

31. Witnessed by her father

32. fit was presented like before

33. Lasted less than 1 minute

34. Aborted by per rectal medication which her father did not knowPost-ictal (3rd episode)Appeared drowsy

35. Not able to communicate with her parents

36. Was admitted to ward 8C (3pm)SYSTEMIC REVIEW

38. PAST MEDICAL HXShe had no history of fit before. She also had never been hospitalized or undergone any surgery before. She had no long term illnesses.

39. DRUG HXShe had no known drug history

40. ALLERGY HISTORYNo allergy noted

41. BIRTH HXShe was born full term by spontaneous vertex delivery at SgBuloh Hospital. The birth weight was 3.15 kg. The delivery was uncomplicated and there was no resuscitation required. Antenatal, intrapartum and postnatal period were uneventful.

42. NEONATAL HXNeonatal period was uneventful

43. FEEDING HXShe was not breastfed since birth and she was given formula milk instead. She was first introduced to solid foods when she was 6 months old. At that time, she was given Nestum. She started to eat rice at the age of 1 year old. Currently, she is given porridge together with vegetables, fish and sometimes chicken. She is still given the formula milk (DUMEX 123). DUMEX 4 scoops in 4 oz (120ml), 2-3 hourly, prepared by the mother herself.

44. IMMUNIZATION HXHer immunization was completed up to her age. There was no complication developed after each injection. Her latest immunization was MMR which she took when she was one year old.

45. DEVELOPMENTAL HXAll of the developmental parameters were appropriate to her age.

46. FAMILY HXShe is the only child. There was no history of febrile fits running in both of her parents during their childhood lives. None of them was having fever before the patient even got one. Besides, both of her parents were completely healthy. No history of asthma, hypertension and diabetes mellitus running in her parents. There was also no epilepsy history in the family; including uncles and aunties from both maternal and paternal side. No consanguity noted.

47. SOCIAL HX AND ENVIRONMENTAL HXHer father and mother are working together in nasilemak’s stall owned by family. Both of them are working during the day. Thus, the patient is taken care by her mother’s father (grandfather). The total income of her family is about RM1000 per month. They live in an apartment at Sg Way with complete basic amenities. Her father is not a smoker as well as her mother.

48. HX OF CONTACTThere was no significant history contact

49. EFFECT OF THE ILLNESS She became less active ever since she got the fever. Both the parents were worried about her condition and whether these episodes of fits will recur. Her mother had to take leave from work while her father working to earn for the family.

50. Physical examination

51. Physical examinationGeneral examinationShe was sitting comfortably unsupported on her bed, holding marker pen and scribblingConscious, cooperative, alert to person and place.No respiratory distress, no dysmorphic feature, no abnormal movement and no muscle wasting.well hydrated and well nourished

52. Vital signPulse rate: 126 bpm, normal rhythms&vol.Respiratory rate: 36 bpmTemperature : 37 dcBlood pressure: 86/75 mmHgInterpretation:NADAnthropometryHeight: 86 cm (at 50thcentile)Weight: 13 kg (at 50thcentile )

53. CNS EXAMINATIONCentral nervous systemMental status: She was alert and conscious.Speech: Can speak clearly with no difficulty.Cranial nerves: There was no nystagmus. All her cranial nerves were intact.Muscle tone: There was no hypotoniaand hypertoniaMuscle power: all of her muscle power were 5/5

54. REFLEXES EXAMINATIONReflexes- all reflexes were normal

55. Cerebellar signs - she was able to walk steadily without support. Involuntary movement : no presence of any involuntary movementSigns of meningeal irritation : no neck stiffness, negative brudzinski’s and kernig’ssignSensory function: cannot be testedImpression: no abnormality detected.

56. CVS EXAMINATIONNO ABNORMALITY DETECTED

57. RESPIRATORY EXAMINATIONNO ABNORMALITY DETECTED

58. ABDOMINAL EXAMINATIONNO ABNORMALITY DETECTED

59. Systemic examinationCVS, Resp., abdominal, CNS :all NADSummaryFA, a 2 years old Malay girl was admitted to SgBuloh Hospital on 24th November 2010 due to 3 episodes of generalized tonic-clonic fits on the day of admission associated with fever for 2 days and vomiting for 2 days prior to admission with no LP done.

60. Provisional diagnosisComplex febrile fits-points to support:Fever Recurrent seizures in one febrile eventAge, febrile fits usually occur in 3 months to 6 years of age.

61. Differential diagnosis

62. Investigation FBCInterpretation: NAD

63. Electrolyte-: normal level of ca2+,Na2+ mg2+, PO42, random glucose indicate that there is no metabolic derangement in this patient hence - rules out fitting due to metabolic derangement

64. RENAL PROFILEnormal renal profile and this result exclude any dehydration as she had reduced in oral intake(fluids and solid food)

65. MICROBIOLOGICAL CULTUREthere is no presence of bacteremia, or bacteuria