1) A 2-month-old female infant presented with a 30-minute seizure associated with fever and bluish discoloration. She had a history of intermittent fever over the past 2 days. 2) On examination, she had respiratory crackles but was otherwise normal. Initial assessments included febrile seizure or pneumonia. 3) Laboratory results revealed the final diagnosis to be bilateral subdural empyema.

1. PEDIATRICS WARD
WORKS
VMUF COLLEGE OF MEDICINE

2. GENERAL DATA
• This is a case of Patient A.P, 2 months old, female, Filipino, roman catholic,
and currently residing Libas san carlos city pangasinan. Admitted for the
second time in PPH.
• Source of information: mother, 90% reliability

3. Chief complaint:
• Siezure for 30 minutes

4. History of present illness
• 2 days prior to admission, the patient experienced high grade intermittent
fever.(mother cannot recall the temperature of the patient). No associated vomiting,
and rashes noted. Acetaminophen oral (tempra) was taken to relieve the symptoms.
Fever was relieved.
• Few hours prior to admission, mother noticed the baby is often irritable and
noticed bluish discoloration on the patients face and lips.
• 30 minutes prior to admission, the patient experienced seizure associated with
fever and bluish discoloration of the face and extremeties hence rushed in PPH

5. • Past medical history:
• Patient had his first hospitalization in PPH due to his delivery. No birth
complications and illnesses prior to hospitalization. Immunization is
complete.
• Birth history:
• Patient was born via NSD. Mother had regular prenatal check up; and no
birth injuries noted.
• Feeding history
• Breasfed from birth up to present. Patient is breasfed 4x in a day.

6. Growth and development:
Normal developmental milestone.
General milestone
age milestone
birth Turns head side to side
Keeps hands tightly fisted(fine motor milestone)
Attunes to human voice
Develops differential recognition of parents voice(basic language milestone)

7. Primitive reflexes (all normal)
Primitive reflexes appears dissappears
Moro reflex, symmetrics abduction and
extension of arms with trunk extension,
followed by adduction of upper extremeties
birth 4 months
Hand grasps, reflex grasps of any object placed
in palm
birth 1-3 months
Rooting reflex, turning of head towards same
side as stimulus when corner of infant’s mouth
is stimulated
birth 6 months

8. • Family history
• Parents had no history of asthma, hypertension, kidney disease, diabetes, cancer or
any heredo familial diseases.
•
• Personal and social history
• The patient is the only child in the family.The patient lives in a medium sized build
house.water supply is mineral water, garbage is being collected every Tuesday of the
week. No relevant travel history of the patient.
• The patient sleep 10 hours. The patient is not irritable.

9. REVIEW OF SYSTEMS
• A. General
• [+] fever [-] chills [-] malaise [-] fatigability [-] weight change
• B. Integumentary
• [-] pruritus [-] dark pigmentation [-] lesions/sores (-) rash (+) bluish discoloration
• C. Head and Neck
• [-] headache [-] dizziness [-] head injuries [-] syncope [-] blurring of vision
• [-] diplopia[-] photophobia [-] eye pain
• [-] ear pain[-] hearing loss [-] ear discharge [-] tinnitus
• [-] vertigo [-] loss of sense of smell [-] nasal obstruction [-] hoarseness
• [-] sore throat [-] disturbance of taste

10. • D. Respiratory
• [-] dyspnea [-] chest pain [-]cough [-] orthopnea
• [-] trepopnea [-] platypnea [-] sputum:
• E. Cardiovascular
• [-] easy fatigability [-] palpitation [-] dyspnea [-] orthopnea
• [-] chest pain [-] shortness of breath [-] PND
• F. Gastro-intestinal
• [-] poor appetite [-] dysphagia [-] nausea [-] odynophagia [-] vomiting
• [-] hematemesis[-] constipation [-] diarrhea [-] abdominal pain[-] flatulence
• [-] abdominal enlargement [-] steatorrhea [-] hematochezia [-] melena

11. • G. Genito-urinary
• [-] dysuria [-] anuria [-] flank or suprapubic pain [-] polyuria
• [-] oliguria [-] hematuria [-] frequency [-] incontinence [-] dribbling
• [-] passage of stone [-] discharge
•
• H. Musculoskeletal
• [-] muscles pain[-] joint pain & stiffness [-] swelling [-] weakness
• [-] bone deformity [-] restriction of motion [-] contractures [-] atrophy

12. • I.Neurologic
• [-] syncope [-] weakness or paralysis [+] seizures [-] headache
• [-] tremors [-] loss of memory [-] depression [-] dizziness
• [-] delirium [-] hallucination
•
• J. Endocrine
• [-] weight gain [-] heat intolerance [-] goiter [-] polyuria [-] cold intolerance [-] abnormal growth
[-] polydipsia [-] polyphagia
•
• K. Hematologic
• [-] easy bruisability [-] easy fatigability [-] pallor

13. PHYSICAL EXAMINATION
• General survey
• The patient is calm and cooperative.
• Vital signs:
• Temperature: 36.3
• Heart rate: 163
• Pulse rate: 25
• Respiratory rate: 72
• Head circumference: 38.5 cm
• Weight: 5.2 kg
• Length: 57 cm

14. • HEENT
• Head: finely distributed hair, no lesions or any lump.
• Eyes: symmetrical eyelids, white sclera, pink conjunctiva, no lesions any sores
• Ears: no discharge, tympanic membranes without erythema with good cone of light
bilaterally
• Nose: no discharge, moist nasal mucosa
• Throat: no ulcer on oral mucosa,no exudates
• Skin: moist; no rash, no erythema, and no bluish discolorations.

15. • Neck: no lymphadenopathy, no nuchal rigidity noted
• CV: no murmurs, no thrills or heaves palpated.
• Resp: positive inspiratory crackles noted; no retractions
• Abd:no tenderness, bruits, and any lesions or scars..
• GU: normal appearing external genitalia;
• Ext: warm, symmetric tone, muscle development and strength
• Neuro: no atrophy; moves all extremities equally

16. Case discussion:
• Subjective: high grade intermittent fever and seizure for 30 minutes,
associated with irritability, bluish discoloration of the face and extremities.
• Assessment: this is most likely to be the manifestation of febrile seizure.
• Treatment plan:
• Give acetaminophen 250 mg q4-6 hours.
• IV fluid if necessary

17. • Subjective: high grade intermittent fever
• Objective: respiratory crackles upon examination.
• Assessment: this is most likely to be the manifestation of
Pneumonia.
• Treatment plan: antimicrobial therapy-Ceftriaxone or cefotaxime can
be administered as a single agent (for >28 d to 5 y).

18. • Differential diagnosis
• Febrile siezure
• Meningitis
• Pneumonia

19. Final diagnosis according to laboratories
result:
• Bilateral subdural empyema