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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.
http://emedicine.medscape.com/article/801500-overviewhttp://emedicine.medscape.com/article/801500-overviewhttp://emedicine.medscape.com/article/801500-overviewhttp://emedicine.medscape.com/article/801500-overview