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Norombaba, Maria Mediatrix O.

SWU-MHAM gr 19
Informant: pt’s Mother

Reliability: 80%

Date & Time of Interview: July 17, 2017 @ 10:30am

General data:
A case of JRC, 5 y.o., male, filipino, Roman catholic,
born Feb 9, 2012, currently residing at Pahina San Nicolas,
Cebu City, admitted for the first time at VSMMC on July 14,
2017 at 6pm.
 Chief Complaint:
o Seizure
o (“mag seizure sya basta
hilantan”) -mother
 History of Present Illness:

3 days PTA, pt had onset of runny nose with watery


discharge, no associated symptoms, no meds taken.

1 day PTA, pt developed undocumented fever, associated w/


runny nose. Pt was given Paracetamol (Tempra) 5 ml syrup,
unrecalled dose, given twice at 6 hours interval which provided
temporary relief.

5 hrs PTA, fever persisted associated with an episode of


convulsions lasting for 5 mins, characterized by stiffening of the
whole body and rolling of the eyeballs. No medication was taken.

4 hrs PTA, still febrile, pt had 2 successive convulsions w/ the


same characteristic lasting for 30-45 secs per episode. Pt was
then rushed to CCMC and was subsequently admitted, then
referred to VSMMC for further management.
 PERSONAL HISTORY:

 Gestational History:
 Prenatal:
 Mother was 20 y.o. at pregnancy,
 OB score was G1P0(0000)
 1st prenatal visit at 8 wks AOG at the Health
Center on regular visits per schedule.
 Given caltrate & ferrous sulfate as prenatal
supplements, received tetanus toxoid, 2 doses.
 During pregnancy, mother was not diabetic,
hypertensive, non smoker & doesn’t drink
alcohol.
 On 28 weeks, she had UTI, given w/ an
unrecalled antibiotic taken for 1 week at the
health center.
 Natal:
 Pt was premature on delivery at 32 weeks AOG
via NSD attended by a physician at Miller
Hospital. Birth weight was 1800 grams.

Neonatal:
According to the mother, pt had delayed
crying at birth and required resuscitation, OGT
was placed for feeding and was on incubator for 1
week.
 Feeding history:
Pt was exclusively fed w/ breast milk via
OGT for 1 month then breastfed for another
month, then given w/ formula milk.
 Complimentary feeding starts at 6 months
w/ cerelac, mashed vegetables, fish and am
until 2 yrs old when solid foods were
introduced.
Pt has good appetite. Usual diet consists of
rice, vegetables, meat, fish & dairy.
Multivitamins: Ferlin and Tiki-tiki syrup once
daily, unrecalled dose.
 Developmental / Behavioral History:

 Mother was unable to recall developmental


milestones, verbalized delayed motor, speech,
cognitive & psychosocial developments.
 Pt cant talk properly, not yet toilet trained and just
started to walk at 4 yrs, 9months.
 Pt is currently attending Special education at San
Nicolas Elementary School, where he also had his
occupational therapy sessions once a wk.
 Past Illnesses:
 Pt didn’t had measles, varicella, mumps, pertussis

 Previous Hospitalizations:
 2013 – Velez Hospital due to Gastroenteritis, 1 week
confinement.
 2014– Velez Hospital due to Pneumonia

Seizure history:
2014 – 1st seizure episode associated w/ fever and
cough, seek consult in a private clinic, prescribed w/
phenobarbital 30 mg 1 tab/day for 60 days but with
poor compliance. Only given w/ 30 tabs.

-Pt has no known allergies to food and drugs


 Immunization History:

 Mother claimed pt received complete vaccines in


the immunization card by DOH which are:
 BCG1 ( visible scar @ R upper deltoid)@birth
 @6, 10, 14 wks
 DPT3
 OPV3
 HEP B3
 AMV @ 9 months
 given at the Health center.
Family History:

Parents:
Mother is 25 y.o., housewife, and the primary
caretaker. Father is 26 y.o., unemployed. Both
parents are healthy.

Siblings:
pt is the only child

Familial Illnesses:
HFD includes DM & HPN on paternal side. No
family history of epilepsy.
 Socioeconomic History:
 Family lives on a 2 story house made of mixed
wood & concrete w/ 3 rooms, 1 restroom. There
are 8 persons living in the house. Extended
family setting.
 The financial support of the family came fr the
pt’s paternal grandparents. In varying amounts.

Environmental History:
Pt is not exposed to cigarette smoke. Observe
Proper garbage segregation. They have their own
septic tank. Water for drinking is purified water,
while water for bathing/washing is fr MCWD.
 REVIEW of SYSTEMS:

 GENERAL: the mother claims Pt did not loss


weight, still w/ good appetite but had less activity
level since the onset of illness.

 Cutaneous: no pruritus
 Head:
 Eyes: no abnormal lacrimation observed
 Ears: no discomfort observed
 Nose: runny nose w/ watery discharge, no
epistaxis
 Cardiovascular: easy fatigability
 Respiratory: no difficulty of breathing
 Gastrointestinal: no vomiting, normal bowel
movement
 Genitourinary: clear light yellow urine, no itching
 Endocrine: no cold/heat intolerance
 Nervous/ behavioral : hx of convulsions (3x), gets
upset when hungry and no food was offered
 Physical Exam

 General Survey:
 Examined a conscious, afebrile, weak looking
child, not in respiratory distress w/ the ff V/S
of:

 T- 36.9’C
 CR-98 bpm
 RR- 24 cpm
 BP- 90/60
 O2 sat- 96%
Anthropometric Data:

Wt: 23 kg
Ht: 98cm
Hc: 47cm
Cc: 75cm
Ac: 83cm

BMI: 23.9
WHO: wt for ht: overweight
BMI for age: overweight
Ht for age: Normal
 Skin: fair complexion, -rashes, -edema, -jaundice,
good turgor except lower extremities dry, cracked
 Head: Normocephalic, no lesion, hair- normal
texture, no lice/ nits
 Face: symmetrical, no unusual facies, no deformities
 Eyes: no redness, PERRLA, -discharges, visual acuity
not assessed.
 Ears: No lesion, no discharges, responds when called
 Nose: no alar flaring, septum at midline, watery
discharge fr runny nose
 Mouth and throat: dry pinkish lips, milk teeth- plenty
of dental carries
 Neck: no venous engorgement, no rigidity, no visible
swelling.
 Chest & Lungs: no lesion, equal chest expansion, n
adventitious breath sounds
 Heart & Vascular System: adynamic precordium, PMI not
visible, regular rhythm, distinct S1&S2
 Abdomen: no lesions, distended w/ visible veins (AC 83cm)
 Genitalia: not assessed
 Extremities: no clubbing of fingers, no cyanosis, CRT
<2secs, small hands and feet
 Spine: no deformities
 Neurologic:
 Behavior: pt had limited focus, mostly didn’t follow
commands
Mental Status: awake, oriented to person, not cooperative
most of the time
Motor: no involuntary movts
Reflexes: not assessed.
 Cranial Nerves:

 CN 1: able to smell alcohol


 CN 2, 3 : +pupillary light reflex, visual acuity not
assessed
 CN 3,4,6: not assessed
 CN 5: able to chew food
 CN 7: able to smile, no facial asymmetry
 CN 8: respond when called
 CN 9, 10 : able to chew and drink water
 CN 11: able to turn head fr side to side
 CN 12: tongue at midline on protrusion.
Salient features

History:

 5 yo, male
 Fever(unrecalled), runny nose, weakness
 -recent hx multiple episodes of febrile convulsions
lasting (1) 5 mins, (2) 30-45 secs.
 Prior hx of febrile convulsions

 PE:

 No nuchal rigidity or meningeal signs


 Primary Impression:
 Complex Febrile Seizure (secondary to Viral
Influenza)

*Pt presented w/ signs of Complex Febrile Seizure


such as episodes of multiple seizures in 24 hr
period (3x) associated w/ an elevation of
temperature.
*Inluenza - pt presented w/ fever, runny nose,
weakness, less activity.
 Differential Diagnosis:

1. Bacterial Meningitis:
Rulled in : +fever, +seizures
Rulled out: -nuchal rigidity, -brudzinski
sign, - kernig’s sign

2. Colds
r/i : +fever, +runny nose, + weakness
r/o : -seizures
3. Epilepsy
r/in : +seizures
r/o: seizure present only on febrile
state, -family history of epilepsy
 Diagnostic Procedures:

 1. EEG – detects electrical activity of the brain and


would identifies origin of seizure activity.
 2. CT scan – show physical cause of seizures
(tumors) or rules out
 3. Lumbar puncture- check CSF for possible
infection
 4. CBC – WBC count for infection
 Management:
 -Paracetamol- 250mg/5ml, 5ml syrup q 6’ for fever
 -Phenobarbital – 30 mg 1 tab as maintenance for
seizure
 -Ceftriaxone- 100mg/kg/day x 7days
 Thank you!!