case presentation
DESCRIPTION
CASE PRESENTATION. Maria Angelica U. Veloso. Identifying Data. Name: MV Age: 1 Sex: Male Nationality: Filipino Religion: Roman Catholic Address: Taguig Chief informant: Mother and Father Reliability: Fair. Chief Complaint. Seizure (Few mins PTA, lasting approximately 5 mins). - PowerPoint PPT PresentationTRANSCRIPT
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CASE PRESENTATION
Maria Angelica U. Veloso
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Identifying Data
Name: MVAge: 1Sex: MaleNationality: FilipinoReligion: Roman CatholicAddress: TaguigChief informant: Mother and FatherReliability: Fair
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Chief Complaint
Seizure (Few mins PTA, lasting approximately 5 mins)
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History of Present Illness
1 week PTA
•Coughing episodes, productive
•No dyspnea, wheezing, colds
•Consult done Salbutamol nebulization 3 times a day and Prednisone 3 mL OD, which offered some relief
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HPI
Day of admission
•Cough still present
•Fever– (T max = 38.2 C) – Temporarily lysed with paracetamol– Still with good activity and good appetite
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HPI
Few minutes PTA•Seizure
– Sudden onset without aura– Upward rolling of eyeballs, stiffening of extremities,
pooling of saliva, frothing around the mouth and generalized cyanosis
– No vomiting, loss of consciousness or incontinence– Lasted around 5 minutes– Post ictally upward staring– No recurrence
•Immediate consult and subsequent admission
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Review of Systems
(-) Weakness, loss of appetite, colds, dyspnea, vomiting, diarrhea or urinary changes
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Past Medical History
• No history of head trauma
• First seizure occurrence
• Asthma– Ventolin nebulization– With previous hospitalizations last year
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Past Medical History
Previous hospitalizations: - URTI x 2 (Aug 2010)
- AGE (2011)
Previous surgeries: None
Allergies: None
Immunization history:- BCG, Hepa B x 3, DPT + OPV x 3, Measles
- No HiB, MMR, Varicella, Pneumococcal, Rotavirus
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Family History
• Asthma Maternal aunt
• Brother had a cough few days before which was treated with antibiotics
• No history of febrile seizures, epilepsy
• No HTN, DM, heart disease
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Birth and Maternal History
• Born full term via NSD to a 31 y/o G3P3 (3003)– Unrecalled BW; No complications; Good
activity, cry and color– NBS done
• Planned pregnancy
• Regular PNCU
• No maternal illnesses/vices during pregnancy
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Nutritional History
• Breastfed until 1 month then began taking formula (Enfalac)
• Not yet weaned
• Currently on pure formula milk diet
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Developmental History
Gross Motor: Walks well alone
Adaptive Fine Motor: Throws toys, drinks from cup
Language: Obeys commands or requests, can say mama and dada
Personal Social: Does nursery games, helps dress himself, does not attempt to feed himself with a spoon
At par for developmental age
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Environment and Social History
• Lives with 4 others in a well lit but not well ventilated home, which is quite small
• Water source: Delivered mineral water• Daily garbage collection• No smokers at home but some neighbors burn wood for
cooking• No pets but some neighbors raise pigs• Mother is a housewife• Father is a TMC employee• Patient is active and playful despite being asthmatic
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Physical Exam
General Survey: Awake, Alert, Irritable, Not in cardiorespiratory distress
Vital Signs: HR - 161, RR - 40, BP – 90/70, Temperature – 38.6 degrees C, Height – 80 cm, Weight – 12 kg, HC – 46 cm, CC – 50 cm, AC – 53 cm
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Physical Exam
HEENT: Normocephalic, Closed fontanelles; Anicteric sclerae, Pink palpebral conjunctivae; No nasal discharge; Dry lips, moist buccal mucosa, and tongue; No TPC, (-) CLAD, Supple neck
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Physical Exam
Chest/Lungs: Equal chest expansion, No retractions, Harsh breath sounds, Bibasal rales
CVS: Adynamic precordium, Tachycardic, Regular rhythm, Distinct heart sounds, Good S1 and S2; (-) Murmurs, (-) S3 or S4; PMI at 5th ICS MCL
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Physical Exam
Abdomen: Globular without any visible masses or scars; Normoactive bowel sounds; (-) Obliteration of Traube’s space; Soft, (-) Masses or organomegaly upon palpation, (-) Tenderness
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Physical Exam
GU: Grossly normal male external genitalia
DRE: Not done
Skin/Extremities: Good skin color and turgor; (-) Pallor, (-) Cyanosis, (-) Jaundice (-) Edema; Full and equal pulses; Good capillary refill
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Physical Exam
Neurologic:
GCS 15, Irritable
VII – No facial asymmetry
VIII – Lateralizes/Localizes sound
IX, X – Intact gag reflex and swallowing
XI – Moves shoulders
XII – Tongue midline
Cranial nervesI – Not assessedII, III, IV, VI – Pupils 3 mm equally brisk and reactive to light, Able to track objects, No ptosisV – Able to bite down hard on tongue depressor
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Physical Exam
Motor: Spontaneous active movement on all extremities
Sensory: Intact
Absent Babinski, No ankle clonus, DTRs ++
(-) Nuchal rigidity, (-) Brudzinski, (-) Kernig’s
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Salient Features
• 1/M• 1 week of productive cough• Fever• 1 seizure episode lasting 5 minutes without recurrence• First occurrence and no family history of febrile seizures
or epilepsy• Bilateral rales• Essentially normal neurologic exam without nuchal
rigidity or meningeal signs
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Working Impression
Benign Febrile Convulsion secondary to Pneumonia
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Differentials
• Complex febrile seizure
• CNS Infection
• Electrolyte imbalance
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Diagnostics at the ER
CBC Hgt 90 mg/dL
Na 136
K 3.9
Ionized Ca 5.36
O2 sat 93% 98%
CXR
Consider interstitial pneumonia, bilateral
133605
0.3918.3
0.77/0.16/0.07/0
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Treatment
• Admit• Diet as tolerated• Monitor VS q 4 and I&O q shift• IVF: D5IMB 500 mL x 10 hours
(maintenance + 10%)• Paracetamol 120mg/5mL, 5
mL every 4 hours for T >/= 37.8 C
• Salbutamol nebulization once every 6 hours with chest clapping after every other nebulization
• Standby diazepam 3 mg IV for frank seizures > 5 mins
• Ampicillin 300 mg IV every 6 hours
• Zinc 10mg/5mL twice a day for 14 days
• Standby O2• Seizure precaution• Refer to neurology
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Course in the Wards – Day 1
Subjective Objective Assessment Plan
- Afebrile (last fever 4:40 am)
- No seizure reoccurrence
- Occasional cough- No dyspnea- Good activity and
appetite
- Awake, alert, irritable
- HR 120s, RR 30s, Afebrile
- No alar flaring, retractions
- Bilateral rales- GCS 15- Supple neck
BFCPneumonia
- Continue present medications but revise paracetamol to 100mg/mL, 1.5 mL every 4 hours for T >/= 37.8
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Course in the Wards – Day 2
Subjective Objective Assessment Plan
- Afebrile - No seizure
reoccurrence- Occasional cough- No dyspnea- Good activity and
appetite
- Awake, alert, less irritable
- HR 120s, RR 30s, Afebrile
- No alar flaring, retractions
- Harsh breath sounds, occasional wheezes
- GCS 15- Supple neck
BFCPneumonia, resolving
- Continue present medications but revise paracetamol to 100mg/mL, 1.5 mL every 4 hours for T >/= 37.8
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Seizures
• Transient occurrence of signs and/or symptoms resulting from abnormal excessive or synchronous neuronal activity in the brain
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Seizures
• Either:
1.Focal (partial) initial activation of a system of neurons limited to part of one cerebral hemisphere
• Generalized synchronous involvement of all of both hemispheres
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Febrile Seizures
• Occur between the age of 6 and 60 months
• Temperature of 38°C or higher
• Not the result of central nervous system infection or any metabolic imbalance
• Occur in the absence of a history of prior afebrile seizures
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Simple or Complex?
Simple •Primary generalized•Usually tonic-clonic, attack associated with fever•Lasts for a maximum of 15 min•No recurrence within 24 hours
Complex •More prolonged (>15 min)•Focal •Recurs within 24 hours
Febrile status epilepticus febrile seizure lasting >30 min.
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Febrile Seizures
• Between 2% and 5% of neurologically healthy infants and children experience at least 1
• Do not have an increased risk of mortality• No long-term adverse effects of having ≥1
simple febrile seizures (No brain damage)• Only 2-7% of children who experience febrile
seizures proceed to develop epilepsy later in life
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All in the family
• In many families, the disorder is inherited as an autosomal dominant trait
• Multiple single genes causing the disorder have been identified
• In most cases the disorder appears polygenic, and the genes predisposing to it remain to be identified
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Genes, genes, genes
• Identified single genes include FEB 1, 2, 3, 4, 5, 6, and 7 genes on chromosomes 8q13-q21, 19p13.3, 2q24, 5q14-q15, 6q22-24, 18p11.2, and 21q22
• Only the function of FEB 2 is known: it is a sodium channel gene, SCN1A
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Some syndromes
• Almost any type of epilepsy can be preceded by febrile seizures
• A few epilepsy syndromes typically start with such
• Generalized epilepsy with febrile seizures plus (GEFS+)
• Severe myoclonic epilepsy of infancy (SMEI, also called Dravet syndrome)
• And, in many patients, temporal lobe epilepsy secondary to mesial temporal sclerosis
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Work Up
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Lumbar Puncture
• Recommended in children <12 mo of age after their first febrile seizure to rule out meningitis
• Especially important if the child has received prior antibiotics mask clinical symptoms of the meningitis
• The presence of an identified source of fever, such as otitis media, does not eliminate the possibility of meningitis
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Lumbar Puncture
• Seizures are the major sign of meningitis in 13-15% and 30-35% of such children have no other meningeal signs
• American Academy of Pediatrics (AAP) strongly recommends LP in infants <1 yr of age because other signs of the infection might not be present
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Lumbar Puncture
• A child between 12 and 18 mo of age should also be considered Clinical symptoms of meningitis may be subtle in this age group
• For children >18 mo of age indicated in the presence of clinical signs and symptoms of meningitis (e.g., neck stiffness, Kernig sign, Brudzinski sign) or if the history and/or physical examination otherwise suggest intracranial infection
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Electroencephalogram
• Not needed if the child is presenting with his or her first simple febrile seizure and is otherwise neurologically healthy
• Would not predict the future recurrence of febrile seizures or epilepsy even if the result is abnormal
• Spikes during drowsiness are often seen in children with febrile seizures, particularly those >4 year old, and these do not predict later epilepsy
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EEG
• Often have nonspecific slowing, if performed within 2 weeks usually posteriorly. Thus, in many cases, if an EEG is indicated, it is delayed until or repeated after >2 weeks have passed
• Generally restricted to special cases in which epilepsy is highly suspected
• Should be used to delineate the type of epilepsy rather than to predict its occurrence
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EEG
• Should be performed for at least 30 min in wakefulness and in sleep avoid misinterpretation and drawing of erroneous conclusions
• At times, if the patient does not recover immediately from a seizure, it can help distinguish between ongoing seizure activity and a prolonged postictal period -- nonepileptic twilight state (NETS).
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Neuroimaging
• According to the AAP a CT or MRI is not recommended after a first simple febrile seizure
• Patients with febrile status epilepticus have been reported to have swelling of their hippocampus acutely and subsequent long-term hippocampal atrophy. These patients may be candidates for neuroimaging, because they may be at risk for later temporal lobe epilepsy
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Remember…
• The work-up of children with complex febrile seizures needs to be individualized
• This can include EEG and neuroimaging, particularly if the child is neurologically abnormal
• Patients with febrile status epilepticus swelling of their hippocampus acutely and subsequent long-term hippocampal atrophy which puts them at risk for later temporal lobe epilepsy
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Treatment
• In general, antiepileptic therapy, continuous or intermittent, is not recommended for children with one or more simple febrile seizures
• Counseling on the relative risks of recurrence of febrile seizures and recurrence of epilepsy, how to handle a seizure acutely plus emotional support
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Treatment
• If the seizure lasts for >5 min acute treatment with diazepam, lorazepam, or midazolam – Rectal diazepam is often prescribed – Buccal or intranasal midazolam may be used
and is often preferred by parents– IV benzodiazepines, phenobarbital,
phenytoin, or valproate may be needed in the case of febrile status epilepticus
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Treatment
In the vast majority of cases it is not justified to use these medications for intermittent therapy Risk of side effects and lack of demonstrated long-term benefits, even if the recurrence rate of febrile seizures is expected to be decreased
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Treatment
Antipyretics
•Can decrease the discomfort of the child but do not reduce the risk of having a recurrent febrile seizure (seizure often occurs as the temperature is rising or falling)
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Treatment
• Chronic antiepileptic therapy may be considered for children with a high risk for later epilepsy
• Currently available data indicate that the possibility of future epilepsy does not change with or without antiepileptic therapy
• Screen for iron deficiency, as it has been shown to be associated with an increased risk of febrile seizures
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Prognosis
• Benign events with excellent prognosis
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THE END