2. Particulars of the patient
• Name : Laam
• Age : 09 Months
• Sex : Male
• Address : Chanpara,
Jhinaidah
• Date of admission : 11.03.2017
• Date of examination : 11.03.2017
• Informant : Mother
4. History of present illness
According to the statement of the informant mother,
her child was reasonably well 1 month back. Then he
developed recurrent episodes of seizure which was
manifested by sudden symmetrical contraction of all
four limbs towards the trunk followed by slow
relaxation of limbs. The seizure occurred more after
awakening from sleep and was followed by crying.
The seizure occurred in clusters 2-3 episodes per day
and 3-6 spasms per episodes.
5. History of present illness(cont.)
Spasms were not associated with any bowel bladder
incontinence or loss of consciousness. These spasms
aggravated for last 7 days. Mother also complained
that her child can not sit yet independently.
He had no H/O fever, trauma, vomiting, abnormal
urine or body odor.
With the above complaints he was admitted here for
evaluation and management.
6. Birth history
Antenatal: Mother was on regular antenatal check
up. She had no H/O Fever, rash, HTN, DM, but had
H/O UTI in 1st trimester.
Natal: LUCS at 37th weeks of gestation due to PROM
for 2 days. No h/o delayed crying after birth. Birth
weight was 3kg.
Postnatal: There was no h/o neonatal sepsis, seizure.
7. Feeding history
He was on formula feeding from his 1st day of life
along with breast feeding for 6 months, now he is on
complementary feeding.
8. Developmental history
Gross motor: Neck control at 6 month
Fine motor & vision: reaches out for toys at 6
months
Hearing & speech: turns head towards sound in
delayed fashion since 7 month of age
Cognition: Social smile at 3 month
9. Past illness
He has h/o seizure at 1½ month of age, 2-3 times per
day, which was tonic in nature, characterized by
turning of head towards one side and tightening of all
4 limbs. which was not followed by unconsciousness.
Neither was not associated with fever. And it was
stopped after 1 month when he was treated with AED.
10. Treatment history
He was treated with sodium valproate till 6 months of
age along with Piracetam and Phenobarbitone up to 8
months of his age. He also took Syp. Prednisolone for
last 7 days.
12. Family history
He is the only issue of his non-consanguineous
parents. No h/o still birth, affected family members.
Socio economic history
He belongs to below middle socioeconomic
background. Father is a service holder, mother is
home maker.
15. General examination (cont)
BCG mark: Present
Skin survey: Normal
Lymph nodes: Not palpable
Fontanelle : Ant. fontanelle is open, not bulged.
Signs of meningeal irritation: Absent
Back & spine: Normal
Ear, nose, throat: normal
16. General examination (cont)
Vital Signs:
Temperature : 98 ° F
Pulse : 120 b/min
Respiratory Rate : 32 breaths / min
Blood Pressure : 80/30 mm Hg
21. Nervous system
• Higher psychic function: Conscious, playful and
active
• Cranial nerves: Cranial nerves are intact as far could
be examined.
22. Motor function
Upper Limb Right Left
Bulk Normal Normal
Tone Normal Normal
Power 5/5 5/5
Deep
Reflexes(biceps,
triceps, supinator)
Normal Normal
Involuntary
movements
Absent Absent
23. Motor function
Lower Limb Right Left
Bulk Normal Normal
Tone Normal Normal
Power 5/5 5/5
Deep Reflexes(knee
jerk, ankle jerk)
Normal Normal
Plantar Extensor Extensor
Involuntary
movements
Absent Absent
24. Nervous system (cont.)
• Sensory Functions : Intact as far could be
examined.
• Cerebellar Functions Test : Intact as far could be
examined.
• Gait: Not applicable.
25. Respiratory system
Inspection:
Respiratory Rate: 32 breaths/min
Shape of the chest: Normal
Chest Movement: Symmetrical
Palpation:
Trachea: Centrally Placed
Chest Expansibility: Symmetrical
Percussion:
Percussion Note: Resonant all over the chest.
Auscultation:
Breath Sound: Vesicular with no added sound
26. Cardiovascular System
Inspection:
No visible pulsation
Palpation:
Apex Beat: Located in the Left 4th ICS, lateral to the
midclavicular Line.
Thrill: Absent
Left Parasternal Heave: Absent
Palpable P2: Absent
Auscultation:
Heart Sound: 1st and 2nd heart sounds are audible in all
the four areas with no added sound.
27. Gastrointestinal System
Oral cavity: Healthy
Abdomen proper:
Inspection:
• Abdomen was distended
• Umbilicus centrally placed with transverse slit
• No visible peristalsis or pulsation
Palpation:
• Abdomen was diffusely tender
• No organomegaly
• Fluid thrill present
Percussion: Shifting dullness not done
Auscultation: Bowel sound was sluggish
28. Locomotor system
Look:
No joint swelling
No redness
No deformity or periarticular muscle wasting.
Feel:
Local temperature: normal
Joint tenderness: absent
Move:
Joint movement was not restricted
29. Salient feature
Laam, a 9 month old boy, only issue of non
consanguineous parents, partially immunized
presented with the complaints of epileptic spasm for 1
month. The spasm occurred in clusters of 2-3
episodes per day and 5-6 spasms per episode,
aggravated for last 7 days. He had h/o generalized
seizure at his 1½ month of age, which stopped after 1
month with AED. He has delayed developmental
milestone in all domain and there was no further
achievement during last 1 month.
30. Salient feature (cont)
There is no H/O fever, trauma, drowsiness, vomiting,
abnormal urine or body odor. Baby was born at term
by LUCS with birth weight 3 kg and no h/o delayed
cry.
On examination, Laam found conscious, active,
playful, vitals within normal limit, anthropometrically
well thriving except microcephaly, neurological
examination revealed no abnormality except he was
less interest to surrounding, other systemic
examination were normal.
39. Treatment:
• Counseling.
• Inj. ACTH 40 IU IM once daily.
• Syp. Ranitidine.
• Developmental therapy.
• Monitor vital signs regularly.
40. Follow up on day 5 (15.03.17)
Subjective Objective Assesment Plan
Vomiting for 1
time
H/o inconsolable
cry
Pt was conscious
Vital signs
Temp-98.4 F
RR38-b/min
Pulse-120/min
BP-120/85 mmHg
(SBP >99
DBP >99th )
Ant. Fontanelle-open
Lungs: clear
Heart: S1+S2+O
Abd:soft, non tender
Motor examination-
Tone: normal Jerks:
normal
Planter: extensor
HTN Start
antihypertensive
41. Follow up on day 10 (20.03.17)
Subjective Objective Assesment Plan
No new conplaints
Seizure 1 episode
in last 24 hr
Pt was conscious
Vital signs
Temp-98 F
RR32b/min
Pulse-116/min
BP-125/80 mmHg
(SBP >99th
DBP 95th -99th )
Ant. Fontanelle-open
Lungs: clear
Heart: S1+S2+O
Abd:soft, non tender
Motor examination-
Tone: normal Jerks:
normal
Planter: extensor
HTN Reduce dose of
ACTH
Increase dose of
antihypertensive
42. Eye evaluation
Optic disc - pale (left>right)
Fundus – chorioretinal patchy change on both eye
Advice: TORCH screening
43. Subsequent follow up
Clinical
General condition
Response to drug
Side effects of drugs
Investigations
o CBC
o S. Electrolytes
o RBS
