HISTORY TAKING PATIENT DETAILS Name
: Nur Hayati Bin Mohamad Ridwan
Date of birth : 13 June 2014 Age
: 7months
Gender
: Female
Religion
: Muslim
Race
: Malay
Address
: TBG 333, Jalan Sg. Betik, Teluk Gadong, 41000 klang, Selangor.
Informant
: Mother (reliable)
ADMISSION DETAILS Bed no.
: 20
Ward no.
: 6B
Registration no.
: HTAR 1525546
Date of admission
: 13 January 2015
Date of clerking
: 14 January 2015
CHIEF COMPLAINTS A 7 months old girl presented with fever for 3 days and 1 episode of fits on the day of admission at Hospital Tengku Ampuan Rahimah (HTAR).
HISTORY OF PRESENTING ILLNESS According to mother, the child was apparently well 3 days prior to admission until she developed fever. Patient has fever for 3 days of duration, characterized as high grade fever of sudden onset and intermittent in nature which associated with chills, cough, and diarrhoea. It was not associated with vomiting or rashes. The temperature documented at home was 38°C. Mother brought the child to Klinik Kesihatan Teluk Gadong on the next morning after the onset of fever. The child was given antipyretic (ibuprofen) and antibiotic. Fever subsided with sweating. However, fever does not subside completely and the child developed fever and one episode of fits yesterday (13/01/2015) for the first time and her parents immediately brought her to Klinik Kesihatan Teluk Gadong. Patient developed 1 episode of fit in the evening (4.00 p.m.) which lasted for 5 minutes. During pre-ictal phase, the child was lying on the bed. During the ictal phase, both the upper and lower limbs had jerky movement, up rolling of eyes, presences of drooling of saliva, had bluish discolouration over the face and no urinary and bowel incontinence. Post-ictal phase, the child appears lethargic and eyes were closed. After 5 minutes the child cried and responds to mother`s call. At Klinik Kesihatan Teluk Gadong, her temperature was 40.3°C and rectal diazepam was given. Then fever subsides to 38°C when brought to Emergency Department of HTAR. Cough and running nose was associated by fever for 3days. Cough is more frequent when the child cries and during sleep. Cough is characterizes as productive cough with whitish sputum which worsen in the morning. The cough is not associated with post tussive vomiting and noisy breathing. It is not a prolonged cough and no forced expression present. Regarding running nose, it was whitish mucus with no blood stain present and no nose block or difficulty in breathing present. Patient has diarrhoea for 2 days of duration. The frequency of diarrhoea was 3 times in a day. Diarrhoea was characterized as small quantity, watery and mucous stools. No blood stain present. Colour of diarrhoea was yellowish and no foul smelling. Diarrhoea not associated with vomiting.
The child tolerates less orally where she does not even complete 3 ounce of milk and usually she drinks 8-10 ounce of milk a day. However, there was no significant weight loss. She was less active as well. There was no sick contact at home. Recently travelled to Banting to relative’s house, there was a sick child with fever and cough.
SYSTEMIC REVIEW General Respiratory system
No rashes or weight loss. Less active. No shortness of breath and no noisy breathing or rapid
Cardiovascular
breathing. No bluish discolouration on feeding and no history of murmur.
system Ear, nose & throat Gastrointestinal
No ear discharge or earache and no sore throat. No vomiting, constipation or abdominal pain.
system Genitourinary
Not crying on micturition. Less urine output (only changes
system Muscular
pampers twice a day). Urine colour was yellowish. skeletal No limb swelling and no functional abnormalities.
system
HISTORY OF PAST ILLNESS This was her first hospitalization. Past medical history: No any significant past medical history. Past surgical history: No history of surgery. Trauma: No history of trauma. Medication: Currently, patient is on syrup paracetamol and antibiotic to reduce fever and suppository rectal diazepam to prevent recurrent episodes of seizure. She is not on any long-term medications.
BIRTH HISTORY a)
Antenatal:
This was 4th gravida and 3rd parity. Health of mother during pregnancy was good as she had supervised antenatal check-ups and antenatal follow-ups. Antitetanus toxoid injection was given once at 2 nd trimester. There was no fever with rash during pregnancy. The result of serological test for Hepatitis B, VDRL and HIV was not reactive. Mother is a known case of asthma and she was hospitalised once for 1day, in 2 nd trimester due to acute exacerbation of Bronchial asthma. She was given nebulization twice and discharged on the same day. She does no consume any other medication apart from vitamin and iron supplementation that doctor provided. During pregnancy there was no exposure to radiation, alcohol or smoking. There was no history of trauma during pregnancy and the growth of baby was normal. There was no antepartum haemorrhages, no gestational diabetes mellitus and no pregnancy induced hypertension. b)
Natal:
This was a term baby of 40 weeks of gestation. The mode of delivery was Normal Spontaneous Vertex Delivery (NSVD). The duration of labour was 1 hour. Place of delivery was at HTAR. No premature rupture of membrane (PROM), no meconium stained liquor and no chorioamnionitis. c)
Post natal:
The infant cried vigorously and breathe immediately after birth. The birth weight was 3.2kg. There were no breathing problems and normal heart beat was noticed at birth. The child was given to mother for breast feeding within 1 hour. The baby passed out urine and meconium on the same day. d)
Neonatal:
The infant had jaundice on day 2 of life which lasted for 2 days and was not on phototherapy. There were no other complications such as pneumonia or meningitis. FEEDING/DIETARY HISTORY There was no pre-lacteal feeding given to the child. The baby was exclusively breast-fed for 2 months, and then started to give Dumex formulated milk because
mother started to work. Usually 4 scoops with 6 ounce of water for every 2-3 hours. Currently, 2 ounce of milk of 2 scoops for 8 times a day. Complementary feeding started on 6 months of age, porridge with mashed chicken, carrot and potato.
IMMUNIZATION Immunization is up-to-date as per scheduled in National Immunization schedule for Malaysia. Below stated as in immunization record book: i)
BCG: 1st dose given at birth
ii)
Hepatitis B: 1st dose at birth and 2nd dose at first month of age
iii)
DTap, IPV and Hib: 1st dose was given at 2 months old, 2nd dose was given
at 3 months old and 3rd dose was given on 5 months old. iv)
Hepatitis B: 3rd dose given at 6 months of age.
There are no optional or additional vaccines were given.
DEVELOPMENTAL HISTORY Gross motor:
Sits with support. Bears weight on legs.
Prone - Supports weight on hand of chest, upper abdomen off couch. Rolls prone to supine and rolls from supine to prone.
Vision and Fine motor:
Palmar grasp of cube, ulnar approach. Moves head, eyes in all directions. No
squint. Feeds self with biscuits. Transfer objects from one hand to the other. Rakes at pea.
Hearing, Speech and Language:
She able to babble in single syllables.
Social, emotional and behavioural:
She has stranger anxiety.
DRUGS AND FOOD ALLERGY No known drugs and food allergy.
FAMILY HISTORY
Both the parents are 27 years old. She is the last child out of 2 children. Her brother is 2 years old. It is a non-consanguineous marriage. Her eldest brother has history of febrile seizure at the age of less than 1 year old and hospitalised for 1 day. Mother is a known case of asthma and maternal uncle passed away due to Tuberculosis.
There is no history of hypertension, diabetes mellitus, malignancy and other genetic illness in the family.
SOCIAL HISTORY The primary caretaker is the babysitter together with her brother. Both parent’s education until secondary school level. Father working as despatch and mother is a general worker in Gardenia Company. Income is RM2500. House has adequate basic amenities. No pets or carpet at home. No smoker in the family.
PHYSICAL EXAMINATION GENERAL INSPECTION
The child was pink in the room air, alert and conscious. The child was sleeping in the supine position with one pillow supported and not on respiratory distress. The R/N tag was on her left dorsum of hand and cannula on the right hand.
VITAL SIGNS Temperature = 37°C (afebrile) Pulse rate
= 159 beats/minute (Mild tachycardia)
Blood pressure
= 102/74mmHg (Normotensive)
Respiratory rate
= 35 breaths/minute (Normal)
Oxygen saturation = 98%
ANTHROPOMETRIC MEASUREMENT Weight
= 8 Kg (
percentile)
Height
= 72 cm (
percentile)
Head circumference = 44 cm (
percentile)
GENERAL EXAMINTION a) EXTREMITIES The peripheries are warm and moist. Capillary filling time (CFT) is less than 2 seconds. No deformity, oedema, cyanosis or clubbing b) SKIN No rashes. c) HEAD Shape of the head is normal. Anterior frontanel is opened.
d) EYES No icterus on sclera. The conjunctiva not pallor. e) EARS No discharge and inflammation of ear canal. f) NOSE Has watery coryza discharge. No bleeding. Nasal septum is symmetrical. g) MOUTH Tongue: Red smooth tongue, symmetrical. No teeth. No enlargement of tonsils. No oral ulcer. Lips are pink. Throat mildly injected. h) NECK No neck swelling. i) LYMPH NODES No lymphadenopathy.
SYSTEMIC EXAMINATION a) NERVOUS SYSTEM Inspection - Alert. - Position at rest is frog position in hypotonia. - No dysmorphic signs. - Normal movements. No fasciculations. - Base of spine: No sacral dimple or tuff of hair. Palpation: - No bulging frontanelle. Motor examination - No muscle bulk. - Tone: Easy to move joints freely. At supine position, baby lies in frog’s leg position (hypotonia). At prone position, head and shoulders raised. On pull to sit, head lag (hypotonic).
On axillary suspension, baby bears weight. - Power: Sub-maximal movement against resistance. - Coordination: Not done. Reflexes - Upper Limbs:
-
Lower Limbs:
Meningeal Irritation Test - Kernig’s sign: Negative - Brudzinki sign: Negative Sensation: Not performed.
Impression: Physiologically normal.
b) CARDIOVASCULAR SYSTEM Inspection: The chest wall is symmetrical and normal in shape. There
was no scar, no precordial bulging and no abnormal pulsation. Palpation: The apex beat was located in the 4 th intercostal space, at the mid-clavicular line. There was no thrill and heave. The peripheral
pulses were present with normal rhythm and volume. Auscultation: The first and second heart sounds were normal. There were no murmurs heard. Increased heart rate was noted.
Impression: Physiologically normal.
c) RESPIRATION SYSTEM a) Inspection: The chest moved symmetrically with respiration with no deformity seen. There was no sign of respiratory distress. There were no scar, prominent dilated. b) Palpitation: Trachea centrally located. The chest expansion was equal anteriorly and posteriorly at all three zones of the lungs. No area of tenderness. c) Percussion: The lung was resonant bilaterally, anteriorly and posteriorly. There were normal liver and cardiac dullness. d) Auscultation: Bilateral air entry was noted. There were vesicular breath sound anteriorly and posteriorly at all three zones. No added sounds heard. Impression: Lungs clear.
d) ABDOMEN Inspection: No surgical scar. No abdominal distension. No jaundice. Palpation: Soft and non-tender. No splenomegaly or hepatomegaly. No
groin hernias. Percussion: Not done. Auscultation: Not done.
Impression: Physiologically normal. e) GENITALIA Not examined.
SUMMARY A 7 months old, Malay girl is hospitalized for first time. Patient presented with fever for 3 days which developed 1 episode of fits which lasted for 5 minutes. Also, presented with cough and running nose for 3 days and diarrhoea for 2 days. Patient has poor bottle feeding and decreased activity.
Upon physical examination, patient has no stiffness of the body and no muscle bulk on extremities. Easy to move joints freely. The power was sub-maximal movements against resistance. Babinski reflex was negative. The vital signs were normal.
PROVISIONAL DIAGNOSIS Simple febrile seizure Fever associated with fits, temperature above 38°C, intermittent fever and tachycardia (RR=159 beats/min). The seizure of one episode characterized as generalized tonic-clonic and lasted for 5 minutes. No recurrent episodes of seizure.
DIFFERENTIAL DIAGNOSIS a) Meningitis Points supporting: Acute generalised tonic-clonic seizure, up-rolling of eyeball, drooling of saliva, cyanosis (mouth area) and associated by fever. Points against: No neck stiffness. Kernig’s sign, Brudzinki sign and Babiniski reflex are negative. b) Complex febrile seizure Points supporting: Fever and seizure. Age of the child between 3 months to 6 years. Points against: No recurrent seizure in one febrile event. No nausea or vomiting.
INVESTIGATION a) Full Blood Count WBC
5.7
6.0-15.0 (x100)
Low
RBC distribution width
32.3
30.0100.0
Normal
Hemoglobin
12.0
10.5-14.0
Normal
Hematocrit
36.4
33.0-42.0
Normal
Mean cell Hb
25.7
25.0-31.0
Normal
Mean cell volume
72.0
70.0-74.0
Normal
Mean cell Hb concentratio n
34.8
28.0-34.0
Normal
Platelets
435
110-450
Normal
Calcium
2.54
2.20-2.67
Normal
Magnesium
0.86
0.7-1.1
Normal
Phosphate
1.43
0.14-1.52
Normal
Interpretation: Normal b) Electrolytes
Interpretation: Normal level of ca2+,Na2+ mg2+, PO42, random glucose indicate that there is no metabolic derangement in this patient. c) Renal Profile Urea
4.8
1.7-6.4
Normal
Sodium
137
135-150
Normal
Potassium
3.7
3.5-5.0
Normal
Creatinine
45.0
27.0-62.0
Normal
Chloride
105.0
98.0-107.0
Normal
Interpretation: Normal renal profile and this result exclude any dehydration as she had reduced in oral intake (fluids and solid food). d) Lumbar Puncture
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.
PLAN OF MANAGEMENT i) ii) iii) iv) v) vi) vii) viii)
Fits chart Suppository paracetamol (PMC) stat Syrup paracetamol Strict urinary input/output chart Stools for inspection Monitor vital signs for temperature spikes Start IV fluid (37cc/hour) with full maintenance. Parental education on First aid measures during seizure.
DISCUSSION Definitions: Febrile fits (F.C.) are defined as fits 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 metabolic derangement that could be the cause of the fit. Febrile fits, febrile convulsions and febrile convulsions are synonymous terms. Children with previous afebrile fits are excluded from this definition. Magnitude of Problem: There is no comprehensive local epidemiological data. Studies in Western Europe quote a figure of 3-4 % of children 5 years experiencing febrile fits with higher figures of up to 8% in Japan. This makes febrile fits the single most common problem in paediatric neurology. Types of Febrile Fits: Febrile fits are classified as either simple or complex. Simple febrile fits are short, less than 15 minutes, generalised fits that do not occur more than once in a febrile
episode. Febrile fits that are either prolonged ( 15 minutes) unilateral or recur within a single febrile episode are classified as complex.
Issues in management of Febrile Fits: The major issues are:a Risk of recurrent febrile fits. b Risk of subsequent afebrile, unprovoked fits or epilepsy. c Prognosis for neurological, motor, intellectual and behavioural outcomes. d Need for admission. e Investigations for the individual child. f
Need for electroencephalogram (EEG).
g Need for prophylactic treatment. h Type of prophylactic treatment to be used.
Current Recommendation: Based on the above discussion, the following approached is recommended: a Parents of children with febrile fits should be counselled on the benign nature of this condition. b They should be taught effective measures of temperature control such as tepid sponging with tap water and antipyretic administration. Paracetamol is still the safest antipyretic and can be given at a dose of 15 mg/kg 6 hourly. Alternately NSAIDs can also be used. The mechanism of action of tepid sponging namely heat loss from the body surface should be explained to the parents. c
The parents should also be advised on first aid measures during a fit, if this was to recur namely:
i
i) Do not panic, remains calm. Note time of onset of fit. ii) Loosen the child’s clothing especially around the neck
ii
iii) Place the child in the left lateral position with the head lower than the body.
iii iv) Wipe any vomitus or secretion from the mouth iv v) Do not insert any object into the mouth even if the teeth are clenched
v
vi) Do not give any fluids or drugs orally
vi vii) Stay near the child until the fit is over and comfort the child as he/she is recovering. vii viii) The caregiver of children with a high risk of recurrence, ie more than 3 risk factors, should be supplied with a preparation of diazepam rectal solution at 0.5 mg/kg of the child’s weight. They should be advised on how to administer this in case the fit last more than 5 minutes. viii ix) Rectal Diazepam solution is a list C item in the Ministry of Health’s drug list and hence should be available in all government health facilities. ix x) In the event that the fit is not aborted by rectal diazepan they should seek urgent medical help to stop the fit before status epileptics develops. x
xi) If the fit is aborted, they should also seek medical advice to determine the cause of the fever.
These recommendations apply both to children who have had a simple or a complex febrile fit.
REFERENCE 1. Clinical examination by Nicholas J Tally and Simon O’Connor, 6 th edition, 2010, published by Elesvier. 2. Paediatrics and Child health, 2 nd edition by Mary Rudolf and Malcolm Levene published by Blackwell on 2006 of pages 17 to 41. 3. http:// emedicine.medscape.com/article/978654-overview 4. http://www.adhb.govt.nz/starshipclinicalguidelines/_Documents/Convulsions %20-%20Febrile%20.pdf 5. The New England journal of Medicine, Seizure Recurrence after a First
Unprovoked Seizure W. Allen Hauser, M.D., V. Elving Anderson, Ph.D., Ruth B. Loewenson, Ph.D., and Stella M. McRoberts, B.R.N.N Engl J Med 1982; 307:522-528August 26, 1982DOI: 10.1056/NEJM198208263070903
