Qhasmira Bt Abu Hazir 2008409674
NurAmira Bt MohdAsri 2008409708
Nurjuliana Bt Noordin 2008402524
PATIENT NAME: FATIN AQILAH
R/N: SB 00300220
PATIENT’S INITIAL: FA
AGE: 2YEARS AND 3 MONTHS
ETHNIC GROUP: MALAY
DATE OF ADMISSION: 24TH NOVEMBER 2010
DATE OF CLERKING: 29TH NOVEMBER 2010
DATE OF DISCHARGE: 1ST DECEMBER 2010
FA, 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.
FEVER ( 1st day)
Warm to touch
Intermittent in nature (on and off)
Temporarily relieved by syrup Paracetamol
Not ass. with rigors
4 episodes per day
Occur after taking food or fluid
Vomitus contained stomach content and no blood stained
Loss of appetite but not lethargic
FEVER (2ND day)
Same presentation as before
Went to private clinic
Due to poor oral intake, she was given per rectal paracetamol
Temperature documented 38.5˚C
- Temporarily relieved
- Same presentation as before
3 EPISODES OF FITS
1st episode of fit
Occurred at home while she was playing (10am)
Witnessed by her grandfather. Her mother was away.
Was described as generalized stiffness
Lasted for 5 minutes
Her grandfather failed to explain more regarding on her granddaughter’s condition.
Mother was informed via phone and rushed to home
Post-ictal (1st episode)
Able to communicate with her parents
2nd episode of fit
Occurred at private clinic while she was on her mother’s lap (15 minutes after 1st episode)
Was described as generalized stiffness of both 4 limbs followed by jerky movement.
Ass with up rolling of eyes, clenching of teeth and drooling of saliva
No bluish discoloration of lips, skin and nail bed
Lasted for 5 minutes spontaneously
Mother noticed that her daughter was feverish and warm to touch
No temperature was documented
No medication given
Post-ictal (2nd episode)
Regain consciousness and crying after the attack. Able to communicate with parents
Not tolerate feeding and feel nauseated
No vomiting episodes
Was referred from private clinic to HSB for further management
3rd episode of fit
Occurred at ED of HSB (30 minutes after 2nd episode)
Witnessed by her father
fit was presented like before
Lasted less than 1 minute
Aborted by per rectal medication which her father did not know
Post-ictal (3rd episode)
Not able to communicate with her parents
Was admitted to ward 8C (3pm)
She 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.
She 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.
Her 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.
All of the developmental parameters were appropriate to her age.
She 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.
SOCIAL HX AND ENVIRONMENTAL HX
Her 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.
HX OF CONTACT
There was no significant history contact
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.
She was sitting comfortably unsupported on her bed, holding marker pen and scribbling
Conscious, cooperative, alert to person and place.
No respiratory distress, no dysmorphic feature, no abnormal movement and no muscle wasting.
well hydrated and well nourished
Pulse rate: 126 bpm, normal rhythms&vol.
Respiratory rate: 36 bpm
Temperature : 37 dc
Blood pressure: 86/75 mmHg
Height: 86 cm (at 50thcentile)
Weight: 13 kg (at 50thcentile )
Central nervous system
Mental 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 hypertonia
Muscle power: all of her muscle power were 5/5
Reflexes- all reflexes were normal
Cerebellar signs - she was able to walk steadily without support.
Involuntary movement : no presence of any involuntary movement
Signs of meningeal irritation : no neck stiffness, negative brudzinski’s and kernig’s
Sensory function: cannot be tested
Impression: no abnormality detected.
CVS, Resp., abdominal, CNS :all NAD
FA, 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.
Complex febrile fits
-points to support:
Recurrent seizures in one febrile event
Age, febrile fits usually occur in 3 months to 6 years of age.
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
normal renal profile and this result exclude any dehydration as she had reduced in oral intake(fluids and solid food)
there is no presence of bacteremia, or bacteuria
Lumbar puncture is performed to obtain cerebrospinal fluid (CSF) to rule out any CNS infection. However, parents of this patient refused lumbar puncture to be done to her daughter. Therefore, CNS infection was failed to be ruled out.
BRAIN IMAGING (CT SCAN)
To detect any brain pathology
No intracranial bleeding
No focal brain parenchymal lesion
CHEST X-RAY (not done)
Chest x-ray was not indicated as there was no abnormality in the physical examination suggesting infection of lower respiratory tract. Altogether the history, physical examination and investigation had excluded a lower respiratory tract infection.
to find out abnormal brain function
EEG is recommended to be performed on children who are neurologically abnormal or experience a complex seizure.
Complex febrile fits with presumed meningitis
On the day of admission, she had multiple seizures attack:
1st episode occurred at home, lasted for 5 minutes and aborted spontaneously
2nd episode occurred at private clinic, lasted for 5 minutes and aborted spontaneously
3rd episode occurred at Emergency Department of HSB, lasted for 1 minute aborted by suppository Valium (diazepam) 5 mg
4th episode occurred in ward 8c around 3.30pm lasted for 1 minute and aborted by suppository Valium 5mg
5th episode occurred at 6pm in ward 8c, lasted for less than 1 minute and loaded with IV Phenytoin and started maintenance
There was total of 5 episodes of fits and patient was febrile at that time
No more episode since then.
She had good response towards antibiotic given to her.
Take off clothing & tepid sponging
Anti pyretic eg; syrup/rectal Paracetamol 15mg/kg 6hrly
Antipyretic is indicated for patients comfort, but there is no evidence that by using it, it can reduce recurrence rate /risk of febrile convulsion.
As for this patient, she was given syrup Paracetamol (200 mg) 6 hourly
Control fits/recurrent fits
Rectal Diazepam (valium) 5 mg
Parents should be advisedon first aid measures during a convulsion;
Not to panic, remain calm. Note time of onset of fit
Loosen child’s clothing especially around neck
Place child in left lateral position with head lower than the body
Do not insert any object into mouth even if the teeth are clenched
Wipe any vomitus of secretion from the mouth.
Do not give any fluids/ drug orally
Stay near the child until convulsion is over and comfort the child as she is recovering
This is a very important point, as febrile fits can recur. Therefore his parents should be counsel about this upon discharged
Patient was treated as presumed meningitis.
IV Ceftriaxone for 1/52(complete 7 days) she had good response toward antibiotic given
Convulsion occurring in association with fever in children between 3 months and 6 years of age, in whom there is no evidence of intracranial pathology or any metabolic derangement.
Causes of febrile fit
Otitismedia (middle ear infection)
Respiratory tract infection
Urinary tract infection (infection of bladder,urethra/kidneys)
Viral infection- such as chicken pox or influenza
It is generally believed that a febrile seizure is an age-dependent response of an immature brain to fever.
This was postulated due to (80-85%) febrile seizure occurs between 3 months to 6 years of age ,with a peak at 18 months.
It is well known that febrile seizure tend to occur in families because of it is an autosomal dominant inheritance.
Prognosis in Febrile Seizure
it is a benign events with excellent prognosis
30% recurrence after 1st attack
48% after 2nd attack
2-7% develop subsequent afebrile seizure or epilepsy
No evidence of permanent neurological deficits following febrile convulsions or even febrile status epilepticus
No deaths were reported from simple febrile convulsion
Risk factors for subsequent epilepsy
Complex febrile fits
Family history of epilepsy
Brief duration between onset of fever and initial convulsions
It is also called a spinal tap
is a common medical test that involves taking a small sample of CSF for examination.
In a lumbar puncture, a needle is carefully inserted into the lower spine to collect the CSF sample.
Suspected meningitis, encephalitis
Intrathecal chemotherapy for oncology patient
In selected patient being investigated for neurometabolic disorder
Increased intracranial pressure due to space occupying lesions (from signs, symptoms, raised blood pressure, fundoscopic sign)
Bleeding tendency (platelet <50, 000/mm3) or prolonged PT/APTT
skin infection over site of lumbar puncture