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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.

 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
 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.

According to the mother, pt had delayed
crying at birth and required resuscitation, OGT
was placed for feeding and was on incubator for 1
 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
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
 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:

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

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.

 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
 Cardiovascular: easy fatigability
 Respiratory: no difficulty of breathing
 Gastrointestinal: no vomiting, normal bowel
 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

 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
 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
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
 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


 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

*Pt presented w/ signs of Complex Febrile Seizure

such as episodes of multiple seizures in 24 hr
period (3x) associated w/ an elevation of
*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
 4. CBC – WBC count for infection
 Management:
 -Paracetamol- 250mg/5ml, 5ml syrup q 6’ for fever
 -Phenobarbital – 30 mg 1 tab as maintenance for
 -Ceftriaxone- 100mg/kg/day x 7days
 Thank you!!