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Case Illustration

Identity of Patient

Name : F

Gender : Male

Age : 4 years, 2 months, and 17 days

Address : Duren Sawit

Religion : Moslem

Date of hospital admission : 22nd of August 2010

Identity of patients parents

Father

Age : 30 y.o

Occupation : driver

Education : high school

Mother:

Age : 31 y.o

Occupation : housewife

Education : high school

Anamnesis (Alloanamnesis with mother and medical record)

Chief Complaint

Seizure that was accompanied by high fever 5 hours PTHA (prior to hospital admission)

Present Disease History

5 hours PTHA, the patient got a high fever, then his mother brought him to Puskesmas. In the way toPuskesmas, the patient got seizure, his eyes opened and moved to the top, and his mouth was stiff.

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There was no cough, cold, diarrhea, dyspnea, vomit, and bleeding. After arriving at the Puskesmas,

he got anti seizure supposutoria (stesolid). The seizure was stopped afterwards. His seizure lasted

for 20 minutes. Afterwards, the patient slept. He still got fever (temp 38.9o

C).

He was reffered to RSCM. When he arrived at RSCM, there was still fever. However, the seizure did

not occur anymore.

One day PTHA, he also got high fever, although his mother does not measure the temperature. He

took paracetamol syrup, and the fever was relieved.

Past History of Disease

He has ever got seizure 1 year PTHA, which was also accompanied by fever.

History of urinary tract infection (+)

Family History of Disease

Epilepsy (-)

Seizure accompanied by fever (-)

Allergic reaction to medication (-)

Social , and Growth and Development History

- Birth: he was born trough Caesarean section due to long labor. Birthweight: 3600grams,birthlength: 52 cm. He cried directly.

- He is the only child in the family.- He has got complete immunisation. (BCG, campak, 4x polio, 4x HepB, 4x DPT)- Growth and development: within normal limits

o 1st tooth : 7 month oldo

Prone position : 4 month oldo Sitting : 6 month oldo Standing : 10 month oldo Walking : 14 month oldo Talking : within normal limit

- Nutrition: he ate 3-4 times a day. Good appetite. He got ASI until 2 years old. Additional foodstarted at the 5th month.

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Physical Examination (23rd of August 2010)

General condition :looked mildly ill

Consciousness : CM

Pulse : 110x/minute, reguler, good filling

Respiratory : 25 x/minute, reguler, deep

Temperature : 36,30C

Blood pressure : 100/60 mmHg

Body height : 105 cm

Body weight : 14 kg

Nutritional status :

BW/age: 14/16 x 100% = 87.5%

BH/age : 105/105 x 100% = 100% wasted (gizi kurang)

BWact/BWheight : 14 /17 x 100% = 82%

General Status

Head : no deformity, closed fontanel. Head circunference = 52cm

Hair : pull test (-), black hair

Eyes : anemic conjunctiva -/-, icteric sclera -/-, round pupil, isochor 3mm

Direct/indirect reflex +/+, hollow eyes -/-

Ears : secrete (-)

Nose : secrete (-), nose bridge (+), epistaxis (-)

Throat : tonsil T1/T1, hiperemic (-)

Teeth and mouth : caries (+), ulcer/stomatitis (+)

Neck : lymph nodes enlargement (-)

Lung : symetrical static and dynamic

vesiculer +/+, ronchi -/-, wheezing -/-

Heart : 1st and 2nd HS normal, gallop (-), murmur (-)

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Abdomen : seemed flat, supple, liver and spleen not palpable,

no pain on palpation, good turgor

Extremity : within normal limit, multiple scar tissue on both legs with diameter 5mm each

CRT 70/>70

Kernig >135/ >135

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d. Cranial Nerve

N. III, IV, VI

Eye ball position Eye ball movement

Ptosis : -/- Right Lateral : good

Strabismus : -/- Left Lateral : good

Eksoftalmus : -/- Up : good

Down : Good

Around : Good

N. V

Motorik

Jaw movement: symmetric

Biting : no weaknes in masseter muscle and temporalis dextra sinistra

Sensorik

V1-2-3

Light touch +/+

N. VII

Mouth condition during resting : closed

Smiling with teeth showing : symmetric

N.VIII

N. Koklearis

Whispers : good/good

Finger sound :good/good

Rinne : was not done

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Weber : was not done

Schwabach : was not done

N. IX, X

Pharyng : symmetric

Disfagi : -

Cough : -

N. XI

Head movement (right left down) : good and symmetric

N. XII

Tounge inside : middle

Tounge outside: middle

Tounge movement: symmetric and

strong

e. Motoric

5555 5555

5555 5555

f. Sensibility : touch normal

g. Reflex:

Physiological reflex Right Left

Tendon Biseps normorefleks (+2) normorefleks (+2)

Patella normorefleks (+2) normorefleks (+2)

Pathological Reflex Right Left

Babinski (-) (-)

Supporting Examination

Urinalysis (22nd of August 2010)

Epitel +

Leuko 2-3

RBC 0-2

Cylinder (-)

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Crystal (-)

Bacteria (-)

Density (BJ) 1.030

pH 5.0

Protein (-)

Glucose (-)

Keton (++)

Bil (-)

Urobilinogen (-)

Leucocyte esterase (-)

Complete Blood Count (22nd of August 2010)

Hb: 11.2

Ht: 35

Leucocyte: 12,100

Thrombocyte: 312,000

MCV: 71

MCH: 23

MCHC: 32

DiffCount: 0/0/4/84/10/2

List of Problems

1. Complex Febrile Seizure2. Poor Nutritional Status

Management

- Diet: 1610 kcal/day- Paracetamol 150-200mg/day (divided into 4-6 dosage)if he gets fever- Diazepam 150mg when he gets fever >38OC- Cefixime 2x100 p.o.- Monitor general condition, vital sign, seizure.

Prognosis

- Prognosis ad vitam : bonam- Prognosis ad functionam : dubia ad bonam- Prognosis ad sanactionam : dubia

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Literature Review

Febrile seizure

Definition

Seizure that is occured when body temperature (rectal) increases (38OC), which usually happened

among babies and children between 6 month old and 5 years old, which is caused by an

extracranium process, without any specific cause. It should be differed from epilepsy which have

other seizure events without fever.

Ferbrile seizure is divided into 2 types:

1. Simple febrile seizurelast less than 15 minutes, general, single2. Complex febrile seizure last more than 15 minutes, or focal, or multiple (more than 1

seizure in 24 hours). It may indicate more serious diseases such as meningitis, abcess, or

encephalitis.

Risk factors for developing febrile seizures

Family history of febrile seizures High temperature Neonatal discharge at an age greater than 28 days (perinatal illness that need

hospitalization)

Children with delayed development Children under suspicion Low sodium level

If a child has 2 of these risk factors, then the probability of a first febrile seizure increases about

30%. Maternal alcohol intake and smoking during pregnancy increases the risk by 2-fold.

Interestingly, there is not any data which show that a rapid increase in body temperature causes

of febrile seizures.

Risk factors for recurrent febrile seizures include the following:

Age at time of first febrile seizure

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Family history of a febrile seizure in a first-degree relative Short duration between fever onset and initial seizure Multiple initial febrile seizures during same episode Family history of epilepsy

Patients who have 4 risk factors have >70% possibility of recurrence, while those with no risk factors

have

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Other possible causes of seizure should be omitted, including possibility of encephalitis or meningitis

(lumbal puncture might be indicated, especially for baby younger than 12 month old, since

meningeal signs are difficult to be detected). Laboratory examinations are also indicated (those

which are suitable to define the cause of seizure)

Management

1. Manage acute phaseAnti-pyretic : acetaminophen (10-15mg/kgBW/day, every 4-6 hours)

Or ibuprofen 5-10mg/kgBW/day, every 4-6 hours)

Anti convulsant: oral diazepam (0.3 mg/kg/day every 8 hours)Rectal diazepam (0.5mg/kg/time every 12 hours whenever fever >38

OC)

2. Search and treat the causal3. Prophylaxis treatment for reccurent seizure (intermitten and continuous). Continuos

prophylaxis is not recommended due to it good prognosis. Only in certain cases,

phenobarbital 3-5mg/kgBW/day or valproic acid 15-40mg/kgBW/day are given for a year,

then taping off in 1-2 years.

Continuous treatment are given to:

a. Children with febrile seizure more than 15 minutesb. Prominent neurological deficit, before of after seizure (cerebral palsy or mental

retardation)

c. Focal febrile seizured. History of epilepsy in the familye. First febrile seizure before 12 month old, or multiole seizures within 24 hours

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Discussion

The diagnosis of febrile seizure was made based on anamnesis and physical examination. The child

got seizure when his temperature reach 39.8OC, and the seizure was preceeded by the fever.

Moreover, he has no history of seizure without fever. Based on the physical examination, it was

found that there was no remaining symptoms from the seizure.

The management for this patient were paracetamol 150-200 mg/day (divided into 4-6 dosage) in

order to reduce the fever, oral diazepam 4mg/day (divided into 3 dosage, only when the fever reach

>38OC) to prevent recurrent seizure, and cefixime 2 times 100mg per day in order to treat the

possible cause of the fever. Monitoring of vital sign and seizure are necessary. Moreover, based onthe nutritional status, he needs (his ideal bodyweight based on height) 17 x 90 kcal, which is 1610

kcal per day.

Prognosis ad vitam of this patient is bonam, since his condition is stabile, and his disease does not

endanger his life. Furthermore, his prognosis ad functionam is dubia ad bonam, since he does not

show any abnormal post recovery symptoms, although precise effect of the seizure is unknown.

However, his prognosis ad sanactionam is dubia, since he has a history of previous seizure. Therefore

his possibility of getting another seizure attack is questioned.

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References

1. Tumbelaka, Alan, Partini P.Trihono, Nia Kurniati, Dwi Putro Widodo. Penanganan Demampada Anank Secara Profesional. 2005. Jakarta: Departemen Ilmu Kesehatan Anak FKUI.

2. Panduan Pelayanan Medis Departemen Ilmu Kesehatan Anak.2007. Jakarta: RSUP. NasionalDR. Cipto Mangunkusumo.

3. Tejani, Nooruddin R. Pediatrics, Febrile Seizure. Updated on the 25th of August 2010.Downloaded from:http://emedicine.medscape.com/article/801500-overview.