Case Presentation

Patient IdentificationName : Adam Alha bin RoslinDOB : 9th September 2011

Age : 8 Months OldSex : Male

Religion : IslamAddress : Batu 2¾, Jln. Sg. Bt. Pahat, 01000

Kangar, Perlis

Source of history : MotherSource of referral : Casualty HTFDate of admission : 2nd May 2012Time of admission : 10.35 pm

Chief Complain:

History of Presenting Illness

First episode of fitting

- Patient was apparently well until 1 week ago, this patient started to cough. The cough was intermittent for about 1 week in duration and chesty in nature. There was no post-tussive vomiting, no fever, no runny nose. There was no cyanosis during the cough, no rapid breathing and no noisy breathing. Mother brought the child to GP and was given cough mixture and the cough started to decrease.- Other than that, mother also claimed that the child was having loose stool last 3-4 days, yellowish in colour and mixed in nature. There was no mucous, no bile, no blood, no pale stool, no black stool. Otherwise, there was no vomiting, the child was active with good appetite and tolerating well orally. Bowel habit normal with 1-2 times/day.-

Cont. History of Presenting Illness -Next morning, mother noticed child developed fever with rashes over anterior trunk. Temperature documented at home was 380C. Mother brought child to GP and was given syrup antipyretic and rashes cream. Mother notice the fever unresolved and the child was lethargic. Mother started to worry and brought this child straight to casualty and temperature documented at casualty was 38.60C .-At the casualty, while waiting for the turn to see the doctor, the child develop fitting, stiffness with jerky movement of bilateral upper and lower limb ( tonic clonic seizure) with uprolling of eyeball. There was no drooling of saliva and no bowel or urinary incontinence. The fitting duration was around 5 minutes and associated with post-ictal drowsiness. The child was given supp PCM 125mg stat with tepid sponging. This is the first episode of fitting. Otherwise, there was no history of trauma.

Past Medical history

• 1st hospital admission - day 43+ of life due to cough

• 3rd hospital admission – current illness

• 2nd hospital admission – 4 months old due to cough and received nebulisation

Past surgical history

No history of surgical

Birth HistoryFull term by spontaneous vaginal delivery with birth weight of 3.2 kg.

Immunizationstatus

Up to date:-At birth : BCG, Hep. B-1 mo : Hep. B (2nd dose)-2, 3 and 5 mo : DTaP, IPV, Hib (1st, 2nd and 3rd dose)-6 mo : Hep. B (3rd dose)

Feeding History

Growth & Development

Exclusively breast feeding until 6 months and started formula milk (3-4 oz, 2-3 x/day) + soft diet (Nestum) afterwards

Pull self to stand, crawl , transfer object hand to hand, fees self with biscuits, babbling in single syllables, mouthing, looks for fallen toys.

Family history

- No family history of seizure / epilepsy- No family history of Bronchial Asthma or

Allergy Rhinnitis- No family history of chronic disease

35yo 34yo

7 yo

• Social History - Patient currently lives in the village

house at Jln. Sg. Batu Pahat with hisparents and 1 sister and taking care by mother.

- His father is working at golf club and mother is a housewife.

• History of TravelingNo history of recent traveling.

Physical ExaminationGeneral Survey:

• Alert, conscious, comfortable in supine position in flat bed supported with one pillow , well nourish, good hydration, CRT < 2s, good perfusion, good pulse volume, good built, no clubbing finger, no pallor, no jaundice, no central or peripheral cyanosis, no swelling/edema. No gross deformity, no sign of distress, not tachypnoea.

Vital sign:LOC : Alert, ConsciousBlood pressure : 99/62 mmHgPulse Rate : 128 bpm, regular rhythm, normal volumeRespiratory rate : 30 breaths /min, not tachypnoeicTemperature : 38.5 °C, febrileWeight : 8.7kg (between th-th centile)Length : cm (th centile)Head Circumference: cm

Physical Examination

HeadEyes : conjunctiva not pale, sclera not ictericNose : no nasal flaring, no dischageMouth : mucous membrane moist, no central cyanosis, tongue moist

NeckThyroid gland : no swellingLymph node : no enlargementDeviation of trachea : no deviationJugular venous pressure : not raised

Thorax-Respiratory System

ANTERIOR THORAX Right Left

Inspection

Chest structure

Chest movement

Fusiform

Symmetrical

Fusiform

Symmetrical

Palpation Chest expansion

Tactile fremitus

- -

Percusion - -

Auscultation Breathing sound

Added sounds

Vesicular

-

Vesicular

-

POSTERIOR THORAX Right Left

Inspection

Chest structure

Chest movement

Fusiform

Symmetrical

Fusiform

Symmetrical

Palpation Chest expansion

Tactile fremitus

- -

Percusion Resonance Resonance

Auscultation Breathing sound

Added sounds

Vesicular

-

Vesicular

-

Cardiovascular System

Inspection: no visible apex beat, no pericardial bulge

Palpation : apex beat not displaced at 5 th intercostal space at midclavicular line, no heave, no thrill

Percussion : -Auscultation : normal heart sound S1 and

S2, no murmur

Abdomen

Inspection : symmetry, not distended, no scar, no dilated veins, umbilicus inverted and centrally located

Palpation : soft, not distended, not tender, liver and spleen not palpable

Percussion : no ascites, no shifting dullnessAuscultation: Bowel sound normal

Nervous System

The nervous system for this baby is grossly intact as he can feed breast milk and formula milk normally and for cranial nerves 3,4 and 6 it being proven by the eye movement with the objects surrounding. Motor system including power, tone and reflexes all are normal.

GenitaliaFrom examination the genitalia is male genitalia

with no gross deformity and from palpation , both of testis is palpable and non tender

ExtrimitiesNo pitting edema, No gross deformity

Other systemNormal findings

Summary

Patient, 8 months old malay boy presented with chief complain of cough for x1/52, loose stool x3-4/7, fever for x1/7 and first episode of fitting. Upon examination, patient active and there’s no recurrent of fitting during febrile episode but this child having mild grade temperature. Other than that, all systems are normal.

PROVISIONAL DIAGNOSIS

• Febrile Fit• Epilepsy• Hypoglycemia or other metabolic disorder• Meningitis• Encephalitis• Cerebral palsy (neurological disorder)• Brain Injury

WORKING DIAGNOSIS

• Simple Febrile Fit secondary to acute pharyngitis + viral exanthem

Investigation

1. Full blood count2. BUSE (Ca, Mg, PO4)

3. Random Blood Sugar4. Stool FEME5. Stool Culture and Sensitivity,

Rotavirus6. Urine FEME

Result

Full blood count: - White Blood Cell 25.1x10^9/L ( )- Red blood cell 6.0x10^6/µL ( )- Hemoglobin 10.8 g/dL ( )- Haematocrite 31.3% (N)- Platelet 300x10^3/µL (N)- MCV 52.2 fL ( )- MCH 18.0 pg ( )

Differential: - Neutrophils 8.03x10^3/µL ( )- Lymphocytes

14.81x10^3/µL ( )- Monocytes 2.01x10^3/µL ( )- Eosinophils 0.00x10^3/µL ( )- Basophils 0.25x10^3/µL 61 (

)

Result

BUSE: - Sodium 134 mmol/L ( )- Potassium 5.5 mmol/L ( )- Urea 3.2 mmol/L (N)- Creatinine 19 umol/L (N)- Calcium 2.29 mmol/L (N)- Phosphate 1.90 mmol/L ( )- Magnesium 0.92 mmol/L ( N )

Gluc-Random: 5.8 mmol/L (N)

Urine FEME: normal findings

Plan

1. Supp Valium 2.5mg PRN2. Syrup PCM 125mg 4H/PRN3. Tepid Sponging PRN4. Start Fit Chart5. Zinc Oxide PRN6. Vital Sign and Temperature

monitoring

Follow-Up

02/05/2012 (11.30 PM)

SUBJECTIVE - Still got fever - Throat mild injected

- No fitting - Tolerating orally well

- Not tachypnic - No neck stiffness

OBJECTIVE Alert and conscious

Hydration good, good pulse volume, no edema

BP = 99/62 mmHg

RR=30x/min

PR=128x/min

T=38.5C

DXT: 5.7 mmol/L

SpO2 : 100 %

Lung : clear

CVS :DRNM

Abdomen: soft non tender, macular rash (raised lesion) on anterior chest and abdomen.

ANALYSIS Simple Febrile Fit secondary to acute pharyngitis + viral exanthem

Investigation Full Blood Count, BUSE (Ca, Mg. PO4), Stool C+S, Rotavirus, UFEME

PLAN - Syrup PCM 120 mg 4H / PRN

- Supp. Valium 2.5 mg PRN

- Start Fit Chart

- Vital signs + Temperature monitoring

- Tepid Sponging PRN

- Zinc Oxide PRN

03/05/2012 (1.30 AM)

SUBJECTIVE - Child having fit for second episode, after giving Supp PCM 125 mg, it last for 1 minute

with stiffness and jerky movement of bilateral upper and lower limb ( tonic clonic seizure)

with uprolling of eyeball. There was no drooling of saliva and no bowel or urinary

incontinence.

OBJECTIVE Alert & Conscious. Patient looks lethargic, not tachypnoeic

BP = 110/66 mmHg

RR=28x/min

PR=130x/min

T=38.0˚C

DXT= 5.8 mmol/L

SpO2 : 100 %

Lung : clear

CVS :DRNM

Abdomen: soft non tender, macular rash (raised lesion) on anterior chest and abdomen.

ANALYSIS Simple Febrile Fit secondary to acute pharyngitis + viral exanthem

Investigation Full Blood Count, BUSE (Ca, Mg. PO4), Stool C+S, Rotavirus, UFEME

PLAN - Supp. Valium 2.5 mg Stat

- Tepid Sponging Stat

- Syrup PCM 120 mg 4H / PRN

- Start Fit Chart

- Vital signs + Temperature monitoring

- Zinc Oxide PRN

03/05/2012 (10.35 AM)

SUBJECTIVE - Still got fever- Still cough, mother complain same as before, not much improving- No fitting- Tolerating orally well- No more loose stool- Not tachypnoeic - No neck stiffness

OBJECTIVE Currently sleeping comfortably on bedHydration good, good pulse volume, no edemaBP = 107/66 mmHgRR=30x/minPR=133x/minT=37.6CSpO2 : 100 % Lung : clear CVS :DRNM Abdomen: soft non tender, macular rash (raised lesion) on anterior chest and abdomen. Full blood count: - White Blood Cell 25.1x10^9/L ( high )- Red blood cell 6.0x10^6/µL ( high )- Hemoglobin 10.8 g/dL ( low )- Haematocrite 31.3% (N)- Platelet 300x10^3/µL (N)- MCV 52.2 fL (low)- MCH 18.0 pg (low)

CONT. 03/05/2012 (10.35 AM)

OBJECTIVE BUSE: - Sodium 134 mmol/L ( low )- Potassium 5.5 mmol/L ( high )- Urea 3.2 mmol/L (N)- Creatinine 19 umol/L (N)- Calcium 2.29 mmol/L (N)- Phosphate 1.90 mmol/L ( high )- Magnesium 0.92 mmol/L ( N )

ANALYSIS Simple Febrile Fit secondary to acute pharyngitis + viral

exanthem

Investigation UFEME, Full Blood Picture

PLAN - Syrup PCM 120 mg 4H / PRN- Supp. Valium 2.5 mg PRN- Start Fit Chart- Vital signs + Temperature monitoring- Tepid Sponging PRN

04/05/2012 (9.30 AM)

SUBJECTIVE - No more fever - Cough improving

- No more fitting episode - Tolerating orally well

- Able to sleep well last night - Having normal bowel habit, no more loose stool

- Not tachypnoeic - Child become active as usual

OBJECTIVE Currently active, conscious, pink and not tachypnoeic.

Hydration good, good pulse volume, no edema

BP = 80/56 mmHg

RR=33x/min

PR=130x/min

T=37.0C

SpO2 : 98 %

Lung : clear

CVS :DRNM

Abdomen: soft non tender, macular rash (raised lesion) on anterior chest and abdomen.

Urine FEME: normal findings

FBP:

- RBC: Microcytic Hypochromic with cigar and target cells

- WBC: Leucocytosis with lymphocytosis and reactive lymphocytes. No blast.

- Platelet: Adequate.

ANALYSIS - Simple Febrile Fit secondary to acute pharyngitis + viral exanthem

- TRO Hemoglobinopathy

Investigation Suggest Hb analysis after age 1 year old

PLAN - Syrup PCM 120 mg PRN

- Supp. Valium 2.5 mg PRN

- Start Fit Chart

- Vital signs + Temperature monitoring

- Tepid Sponging PRN

- Hydrocortisone cream 1% LA BD

04/05/2012 (4.30 PM)

SUBJECTIVE - No more fever - Cough improving ( minimal), chesty in nature

- No more fitting episode - Not tachypnoeic

- Tolerating orally well (soft diet) - Having normal bowel habit, no more loose stool

- Child become active as usual - still having rash

OBJECTIVE Currently active, alert and conscious, pink and not tachypnoeic.

Hydration good, good pulse volume, no edema

BP = 90/50 mmHg

RR=30x/min

PR=130x/min

T=37.0C

SpO2 : 100 %

Lung : clear

CVS :DRNM

Abdomen: soft non tender, macular rash (raised lesion) on anterior chest and abdomen.

Urine FEME: normal findings

FBP:

- RBC: Microcytic Hypochromic with cigar and target cells

- WBC: Leucocytosis with lymphocytosis and reactive lymphocytes. No blast.

- Platelet: Adequate.

ANALYSIS - Simple Febrile Fit secondary to acute pharyngitis + viral exanthem

- TRO Hemoglobinopathy

Investigation Suggest Hb analysis after age 1 year old

PLAN - Discharge today

- Discharge with:

Syrup PCM 120 mg 4H/ PRN

Hydrocortisone cream 1% LA BD

- TCA 4 months with FBC, Hb electrophoresis + Iron/Ferritin/ TIBC.

Discussion – My Patient, 8 months old malay boy presented with chief complain

of cough for x1/52, loose stool x3-4/7, fever for x1/7 and first episode of fitting.

– From detail history taking , there are history where the child develop fitting, stiffness with jerky movement of bilateral upper and lower limb ( tonic clonic seizure) with uprolling of eyeball. There was no drooling of saliva and no bowel or urinary incontinence. The fitting duration was around 5 minutes and associated with post-ictal drowsiness.

– For more investigation to diagnose febrile fit and to eliminate other differential diagnosis, we can do some examination to confirm the febrile . the first one by physical examination , no neck stiffness, no trauma and no evidence of intracranial pathology or metbolic derangement.

– The treatment of febrile fit is divided into two which are diazepam 0.5 mg/kgBW if in fit and symptomatic (control fever) with antipyretic if not in fit.

Thank You