CAGAYAN STATE UNIVERSITY

CARIG CAMPUS
COLLEGE OF MEDICINE AND SURGERY

PEDIATRICS 2
LABORATORY

CASE NO. 2

Submitted by:
MD 3B – GROUP 2

ACEBEDO, KATHRYN
BALMORES, JOANNA MAE
BAYQUEN, ARCHIMEDES
CAUILAN, BERNADETTE
JOSE, VASILLE LEIF
MALAMUG, ADRIAN PAOLO
MANGABAT, ALLISON MAE
PALATAN, JOANA MARIE
ROLLON, PRINCESS
SANTOS, RUTH ANNE SHARMAINE
TAMAYAO, ARLENE

Submitted to:

DR. MARIA CONSUELO M. MANUEL

SEPTEMBER 01, 2020

 GENERAL DATA

This is the case of patient C.D., 3 years old, male, Filipino, Roman Catholic, born on June
12, 2017 from Buntun, Tuguegarao City, admitted for the first time at Cagayan Valley Medical
Center on August 26, 2020 at around 5:00 PM.
The patient’s informant was his mother, with a 90% reliability.

CHIEF COMPLAINT: SEIZURE

HISTORY OF PRESENT ILLNESS:

Two Days prior to admission, patient C.D. experienced colds, but is not yet feverish to
touch as described by the mother. No consult was done at this time since the mother thought it
was just a normal process as she herself is having cough.
However, the mother observed her baby to have moderate to high grade fever few hours
prior to admission. She gave her son a teaspoonful of paracetamol suspension every 4 hours
which helped lower his fever however to a limited degree.
Few minutes prior to admission, patient C.D. had seizure characterized as generalized
tonic-clonic with upward rolling of eyeballs estimated to last for about less than 5 minutes. The
mother recalled rolling her son to his side during his attack, giving no specific medical treatment
to him. She then rushed her son to Cagayan Valley Medical Center prompting admission of the
child.

PAST HEALTH HISTORY

The patient’s mother recalled that she also rushed her son to the ER of Tuguegarao City
People’s General Hospital, when he was a year old, due to an incidence of seizures. As recalled by
the mother, he initially had colds and then during the night he was feverish and started to exhibit
seizure movements like rolling of the eyeballs and shaking of the body, lasting for less than 5
minutes. He was admitted for further evaluation but didn’t have any other episodes of seizures
and was sent home after two days. Other than that, there were no other previous
hospitalizations, surgeries, and trauma/accidents.

The child is not taking medications other than his daily multivitamins, Ceelin Plus which
is given orally once a day at 2.5 mL and Growee syrup also given orally, once a day at 5 mL. The
patient has no known allergies to any food or medication. The mother recalled that he was given
BCG vaccine and Hepa B a week after the delivery. All his vaccines were given by the designated
midwife and nurse in the barangay. The mother does not recall the names of the vaccines, but
she remembers the midwife saying that her child is fully immunized and his last vaccination was
when he was 1 year old. Patient’s mother noted that fever never happened after vaccine
administration.

FAMILY HISTORY:

Father, age 27, is alive and well with a history of convulsion when he was 18 months old
while the mother, age 24, is also alive and well with no known history of any medical illness.
Paternal grandfather is suffering from hypertension. Paternal grandmother on the other hand, is
alive and well with no known medical illness.
 Maternal grandparents are both diagnosed with hypertension but are strictly complying
in their maintenance medications. There is no known history of cancer, neurological and
respiratory diseases or other health related conditions not mentioned above.

SOCIAL HISTORY:

Patient C.D. is living with his parents and are currently residing in Buntun, Tuguegarao
City. His father is a tricycle driver and his mother is a public school teacher. His usual physical
activity is playing around the house with his toys. He usually sleeps at 8 in the evening and
wakes up at 6 or 7 in the morning. The patient’s mother describes their house as a concrete
bungalow which includes one living room, and three bedrooms.
Their source of drinking water is from mineral water they bought from the water refilling
station. Their garbage disposal is through garbage collection. They have 3 dogs and 3 cats at
home as pets. The mother described the community they reside in as peaceful and calm.

PREGNANCY AND BIRTH HISTORY:

Patient was born at 38 weeks gestation via normal spontaneous delivery, cephalic and
delivered by a midwife in a birthing center. There were no complications during the delivery
process.
Patient’s mother was a 24-year-old G1P1 and was generally healthy during the pregnancy
with no known illnesses or infections. Patient’s mother had 3 prenatal checkups and on the 1 st
checkup, the RHU doctor prescribed the patient’s mother ferrous sulphate with folic acid 200mg,
once a day, and vitamin C for 500mg, once a day for the first trimester. No other medications
were taken during the pregnancy. Patient’s birth weight was 3.0 kg, but the mother did not
remember the length. APGAR score is unknown, but the baby had spontaneous cry and did not
have problems during delivery.

DEVELOPMENTAL MILESTONES:

The patient attained social regard and began startling to sound at 1 month and social
smile at 2 months. He was noted to roll over at and starts to babble at 4 months. He was able to
sit without support at 6 months and began to stand when he was 9 months. Also, he said his first
word “mama” around 9 months. He was noted to feed with spoon when he was 1 year old and
ran well when he was 1 year, 2 months old. At present, he was able to name pictures and
flashcards.

FEEDING HISTORY:

The patient started breastfeeding right after delivery then was able to have
complementary feeding with squash and potatoes at 8 months of age. The patient then switched
to milk formulas at the age of 2 years old. As stated, the patient is taking his vitamins namely,
Ceelin Plus and Growee syrup.
 REVIEW OF SYSTEMS
Constitutional (+) fever, (-) weight gain/ loss, (-) chills, (-) fatigue
Integumentary (-) color change, (-) itching, (-) dryness, (-) lumps
Head (-) trauma, (-) headache
Eyes (-) mild pain, (-) lacrimation, (-) redness, (-) swelling, (-)
conjunctivitis
Ears (-) earache, (-) ear discharge, (-) tinnitus
Nose and (-) nasal stuffiness, (-) discharge, (-) itching, (-) nose
Sinuses bleeding
Mouth and (-) mouth sores, (-) bleeding gums, (-) toothache, (-)
Throat difficulty swallowing
Neck (-) pain, (-) lumps, (-) stiffness
Respiratory (-) cough, (-) colds, (-) difficulty of breathing
Cardiovascular (-) chest pain, (-) edema, (-) cyanosis,
(-) pale lips
Gastrointestinal (-) abdominal pain, (-) vomiting, (-) nausea, (-) diarrhea,
(-) constipation, (-) blood in stool (hematochezia)
Renal (-) pain in urination, (-) frequent urination, (-) blood in
urine, (-) tea-colored urine, (-) low-output urine
Genitalia (-) pain, (-) swelling, (-) discharge, (-) ulcers, (-) itching
Musculoskeleta (-) muscle weakness, (-) stiffness
l
Neurologic (-) numbness, (-) loss of consciousness, (-) paralysis, (-)
memory loss, (+) seizures
Hematologic (-) easy bruising, (-) bleeding
Endocrine (-) heat intolerance, (-) thirstiness, (-) excessive sweating
Psychiatric (-) anxiety

PHYSICAL EXAMINATION
General: The patient, a 3-year old boy, is well-developed, well-nourished and in no
apparent distress. He was awake, conscious, and coherent. Mood and affect are congruent.
Vital Signs:
 BP- 90/60
 Temperature- 38.9°C axillary (102°F)
 Pulse rate- 110 bpm
 RR- 58 cpm (tachypneic)
 SpO2-98% on room air

Anthropometric Measurements:
 Weight- 11 kg
 Height- 70 cm
 Head circumference- 47 cm
 Chest circumference- 51 cm
 Abdominal circumference- 54 cm

Skin and Nails: Normal in appearance and texture. No swelling or edema, cyanosis, or
scaling. No bruises or jaundice.
Head: Normocephalic, symmetric and atraumatic. No tenderness and lumps noted.
 Eyes: Symmetrical, anicteric sclera, pink palpebral conjunctiva. No discharge or
conjunctivitis. Pupils equal, round and reactive to light and accommodations. No ptosis.
Ears: Symmetrical with no external swelling. No discharges. Clear external auditory
canals. Pinna is normal in shape and contour. No periauricular tag/pits. No erythema or bulging.
Nose: Symmetric with no signs of deformity. No sinus tenderness, congestion, discharge,
and lesion.
Mouth/ Throat: Lips symmetrical without lesions. Oral hygiene properly maintained
with 20 primary (milk) teeth. No cyanosis. Pink and moist oral mucosa. Uvula and tongue in
midline, tonsils not enlarged. No evidence of cleft.
Neck: Grossly non-swollen. No stiffness. No lymphadenopathy, goiter or masses detected.
No tracheal deviation.
Chest and Lungs:
Inspection: Rounded chest cavity. Diaphragm moves well with respiration. No obvious
spine or chest deformity.
Palpation: Symmetric chest expansion, no retractions and tenderness.
Percussion: No dullness
Auscultation: Lungs are clear bilaterally. No stridor, wheezes, crackles, or rubs. Good air
movement.
Heart:
Inspection: No noticeable bulges, lesions, and heaves by inspection of precordium.
Palpation: PMI is at 4th ICS MCL. Left and right carotid palpable, regular rhythm, normal
amplitude. No palpable thrills and friction rub
Auscultation: S1 and S2 present
Abdomen:
Inspection: No irregular contours and scars. No discoloration. No discharge seen on
umbilicus.
Auscultation: Normoactive
Percussion: Tympanic sounds on four quadrants
Palpation: Soft, non-tender, non-distended. No noted splenomegaly and hepatomegaly. No
masses.
Genitalia: Uncircumcised, normally placed urethral meatus. Bilaterally descended testes.
No hernia, hydrocoeles and hypospadias.
Extremities: Warm, no clubbing, cyanosis, or edema. No gross deformities. No tremors.
With full and equal peripheral pulses.
Back: Symmetrical. No lordosis, and kyphosis.
Neurologic: Mental status: Alert and cooperative.
Cranial Nerves:
 CN I: intact sense of smell
 CN II: 4-5mm reactive to light
 CN II, III: Pupillary constriction normal
 CN III, IV, VI: Normal, intact EOM movements
 CN V: (+) corneal reflex, intact muscle of mastication
 CN VII: No facial asymmetry, can raise both eyebrows
 CN VIII: Able to respond to sounds
 CN IX, X: Normal swallowing
 CN XII: Protruded tongue in midline

Cerebellar: Not assessed dadagdagan daw po tomo hehe awit zzzz

Pathologic reflex: (-) Brudzinski, Kernig sign (-) Babinski sign
DIFFERENTIAL DIAGNOSIS:

Rule In Rule Out

1. Bacterial or Viral (+) fever (38.9 °C) (-) photophobia & headache
Meningitis (+) convulsions (-) sleepiness, confusion, and
(+) URTI (colds) irritability, change in behavior
(-) change in feeding
behavior, nausea & vomiting
(-) Kernig’s sign, Brudzinski
sign, & nuchal rigidity
(-) neurologic deficits
2. Viral Encephalitis (+) fever (38.9 °C) (-) headache
(+) convulsions (-) muscle or joint pains,
body stiffness, fatigue or
weakness
(-) nausea, vomiting &
change in feeding behavior
(-) irritability, confusion,
agitation or hallucinations, &
change in behavior
(-) neurologic deficits
(-) skin rash
3. Epileptic Seizures (+) convulsions (-) 2 or more seizures
without fever
4. Electrolyte (+) convulsions (-) nausea, vomiting or
imbalance diarrhea
(-) fatigue, lethargy,
irritability, & confusion
(-) headaches, muscle
tingling & numbness
(-) fast heart rate & irregular
heartbeat
(-) muscle and abdominal
cramping, muscle weakness

SALIENT FEATURES

Impression: Simple Febrile Seizures

Salient Features:
(+) 3-year-old male with a family history (paternal side) of convulsions
(+) 1st seizure at the age of 1
(+) fever (38.9 °C)
(+) colds
(+) convulsions that lasted for less than 5 minutes within 24 hours of the onset of fever
(+) Generalized Tonic-Clonic movements of the limbs with upward rolling of eyes

FINAL DIAGNOSIS:
 Simple Febrile Seizures

CASE DISCUSSION:

Febrile seizures are the most common seizure disorder in childhood, affecting 2% to 5%
of children between the age of 6 and 60 months. These seizures occur with a temperature of 38
0
C (100.4 0F) or higher, that are not the result of central nervous system infection or any
metabolic imbalance, and that occur in the absence of a history of prior afebrile seizures. Febrile
seizures are subdivided into two categories: complex and simple.
A complex febrile seizure is more prolonged (>15 minutes), is focal, and/or reoccurs
within 24 hours. Complex febrile seizures may have an approximately two-fold long-term
increase in mortality, as compared to the general population, over the subsequent two years,
probably secondary to coexisting pathology.

A simple febrile seizure is a primary generalized, usually tonic-clonic attack associated

with fever, lasting for a maximum of 15 minutes, and not recurrent within a 24-hour period.
Most patients with simple febrile seizures have very short postictal state and usually return to
their baseline normal behavior and consciousness within minutes of the seizure.
In relation to the case above, the patient has manifested almost all common symptoms
presented by a child having simple febrile seizure. Our patient had a moderate to high grade
fever measuring 38.9 0C with seizure characterized as generalized tonic-clonic movements of the
limbs with upward rolling of the eyes. His seizure lasted for less than 5 minutes and has not
recurred within the 24-hour period upon onset of the attack
Neurologically healthy infants and children may experience at least one, usually simple,
febrile seizure. There are no long-term adverse effects of one or more simple febrile seizures and
do not have an increase in mortality even though they are concerning to parents when they first
witness them.

ETIOLOGY:

The direct cause of Febrile Seizure is unknown, but the most important associated factors
are fever, epilepsy, hypoglycemia, hypocalcemia, head injury, poisoning and drug overuse,
respiratory infection, or gastroenteritis. The fevers that trigger febrile seizures are usually
caused by a viral infection, and less commonly by a bacterial infection. Influenza and the virus
that causes roseola, which often are accompanied by high fevers, appear to be most frequently
associated with febrile seizures. The risk of febrile seizures may increase after some childhood
immunizations. These include the diphtheria, tetanus and pertussis or measles-mumps-rubella
vaccinations. A child can develop a low-grade fever after a vaccination. The fever, not the
vaccination, causes the seizure.

EPIDEMIOLOGY:
Febrile seizure (FS) is the most common neurological disorder observed in the pediatric
age group. It has been reported that one in every 25 children in the population will experience at
least one FS during their childhood. Although febrile seizure is seen in all ethnic groups, it is
more frequently seen in the Asian population.
The important viral or bacterial infection causes of FS’ are recent upper respiratory
infection 42.3%, gastroenteritis 21.5% and otitis media infections 15.2% respectively. The
pooled prevalence rate of FS among other childhood convulsions was 47.9%.
Prevalence of simple and complex febrile seizure were 69.3% and 28.3%, respectively.
Approximately 50% of the recurrences occur within 6 months of the initial seizure; 75% occur
within 1-2 years.
 CLINICAL MANIFESTATIONS:

In most cases, febrile seizures occur within the first day of fever with most children
having a temperature of ≥ 38°C. These attacks are known to be hereditary in nature, occurring
without the involvement of any central nervous system infection. Febrile seizures can be
classified as either simple febrile seizures or complex febrile seizures. The former presents
with a generalized tonic-clonic movement of limbs and rolling back of the eyes, lasting for 1-2
minutes up to 15 minutes (usually less than 5 minutes), followed by a brief postictal period of
drowsiness with no recurrence within the 24-hour period. It accounts for almost 80-85% of all
febrile seizures. Foaming of the mouth, difficulty of breathing, pallor, or cyanosis may also occur
during this attack, affecting both facial muscles and even respiration of the infant. The latter is
less common, noted to last for more than 15 minutes, presenting with a temporary weakness
after the episode of the attack. Seizure is usually focal, limiting the movement to one limb or one
part of the body, with possible recurrence within 24 hours at the onset of seizure. It may also
have a longer postictal period of drowsiness or may be associated with postictal transient
hemiparesis or Todd’s Palsy. (Leung et al., 2018)

DIAGNOSTICS:
 no specific studies are indicated for a febrile seizure
 focus on carefully examining and appropriately investigating for the cause of the
fever and to rule out meningitis
 electroencephalography is not routinely ordered for neurologically healthy children
who have a simple febrile seizure
 Computed Tomography, Magnetic Resonance imaging are not necessary in a child
with a simple febrile seizure
 In many cases the diagnosis of a seizure is based solely on clinical grounds — the
examination and laboratory studies are often normal
o CBC
o serum electrolytes (particularly sodium) and toxicology screening (evidence of
dehydration)
o glucose determination – if the seizure is longer than 15 minutes in duration or
ongoing, depressed level of consciousness for a prolonged period following the seizure
o blood urea nitrogen = <35mmol/L – recurrent febrile seizures
o screen for toxins in blood and urine
Further testing may be needed if:
 The child younger than 9 months or older than 5 years
 The child has a brain, nerve, or developmental disorder.
 The seizure was confined to one part of the body.
 The seizure lasted longer than 15 minutes.
 The child had more than one febrile seizure in 24 hours.
 The child has abnormal findings when examined
Lumbar tap may also be done IF the patient has signs and symptoms suggestive of
meningeal irritation. Such indications include nuchal rigidity, back pain, positive, Kernig and
Brudzinski Sign. This diagnostic test is necessary IF there is occurrence of seizures on patients
<6 months old at the onset of the attack. It is also an option if the child was noted to be deficient
in Haemophilus influenzae type B and Streptococcus pneumoniae immunization or if the child’s
history of immunization is unknown. (Kliegman, 2016)
 PATHOPHYSIOLOGY

PRECIPITATING FACTORS PREDISPOSING

FACTORS

VIRAL FEVER
AGE AT GENETICS
INFECTION (> 380C)
EXOGENOUSLY INITIAL (FAMILY HISTORY
ELEVATED BRAIN VACCINE SEIZURE OF EPILEPSY /
TEMPERATURE (DTP, MMR) FAMILY HISTORY OF
(HOT BATH) FEBRILE SEIZURE)
INCREASED
METABOLIC
DEMANDS
GABAA SODIUM INCREASED
RECEPTOR CHANNEL PRODUCTION
SUBUNIT SUBUNIT OF FEVER
HYPERVENTILATION MUTATION MUTATION MEDIATORS
(IL-1ß)

SYNTHESIS OF IL-1ß IN FEVER

HIPPOCAMPUS (> 380C)

ELEVATED
TEMPERATURE IMPACTS
ION CHANNELS

↓ GABA
and / or
↑ GLUTAMATE

↑ EXCITABILITY AND
SYNCHRONIZATION OF
ACTIVITY

SIMPLE FEBRILE
SEIZURE

GENERALIZED TONIC-CLONIC
SEIZURE WITH NO FOCAL
 TREATMENT AND PATIENT MANAGEMENT:

NON-PHARMACOLOGICAL MANAGEMENT
1. Maintain clear airway.
2. Protect the child from injury.
3. Place the child in a side lying position.
4. Loosen clothing or remove excess clothing.
5. Give oxygen if available.
6. Apply suction for nasal or oral secretions if facility available.
7. Address the benign orientation of seizure and orient the family about the relative risks
of recurrence of both FS and epilepsy, its occurrence, and other ways to manage seizures.

PHARMACOLOGICAL MANAGEMENT
As soon as it is appropriate, antipyretic medication should be administered to reduce the
child’s temperature.
 Paracetamol may be given 15 mg/kg every 4-6 hours.
It is important to note that administration of antipyretics does not reduce the risk of febrile
seizure’s recurrence neither does using it as a prophylaxis is effective to prevent the occurrence of
FS. Giving antipyretics only aids in decreasing the discomfort on the child, brought about by fever.
Based on risk/benefit analysis, neither long-term nor intermittent anticonvulsant therapy is
indicated for children who have experienced 1 or more febrile seizures. If, however, the parents of
the child are very anxious and/or the seizure attack lasted for more than 5 minutes, antiepileptics
may also be used to settle the child in comfort (Kliegman, 2016):
 Intermittent oral diazepam (0.33 mg/kg per dose, every 8 hours throughout the febrile
illness, until the child was afebrile for 24 hours.) would be the treatment of choice.
 Intermittent rectal diazepam (0.5 mg/kg rectal suppository every 8 hours). Given at
recurrence of seizures lasting for more than 5 minutes.
Antiepileptic therapies stated above help reduce but do not eliminate the risks of recurrence
of febrile seizures. In managing simple febrile seizures, it is not justified to use continuous therapy
owing to the risks of its side effects and its lack of demonstrated long-term benefits. (Kliegman,
2016).

COMPLICATIONS

The most common complication is the possibility of more febrile seizures. The risk of
recurrence is higher if:
 The child’s first seizure resulted from a low fever
 An immediate family member has a history of febrile seizures
 The child was younger than 18 months at the time of the first febrile seizure
 Febrile seizure occurring within an hour of recognized fever
 A febrile seizure as the first sign of an illness
 PREVENTION

 In most cases, treatment to prevent future seizures is not recommended; the risks and
potential side effects of daily antiseizure medications outweigh their benefit. In addition, giving
medication (eg, acetaminophen or ibuprofen) to prevent fever is not recommended in a child
without fever (eg, if the child has a cold but no fever) because it does not appear to reduce the risk
of future febrile seizures. Treatment for fever (temperature greater than 100.4ºF or 38ºC) is
acceptable but not always required.

For the child’s fever, give fever medicine if prescribed. Give plenty of fluids to
prevent dehydration. Don't bundle up or overdress the child. The body loses heat through the skin.
If the child is bundled up, the excess heat cannot escape. Take seizure precautions. Counsel the
guardian to avoid letting the child be alone in water and high places or be in any dangerous place.

PROGNOSIS

Clinicians and parents/caregivers are often concerned about the recurrence of FS, particularly
about the risk of the onset of epilepsy. Simple FS may slightly increase the risk of developing
epilepsy, but have no adverse effects on behavior, scholastic performance, or neurocognition. The
risk of developing epilepsy is increased further in children with a history of complex FS.

One third of children who present with one FS will present with a second episode during a
future febrile disease. Risk factors for the recurrence of FS are a positive family history of FS, a first
FS before 18 months of age, the occurrence of a first FS less than one hour after the start of a fever,
and FS at a body temperature of less than 38 °C. Febrile seizures will recur in 4% of children with
no risk factors but in 75% of the children with previously described risk factors. It is important to
know the risk factors for FS recurrence to counsel the child’s parents or caregivers and to
administer rescue antiepileptics to children with a strong risk of recurrence.

REFERENCES

Febrile seizure - Symptoms and causes. (2020). Accessed on August 27, 2020. Retrieved
from https://www.mayoclinic.org.

Febrile Seizures Fact Sheet | National Institute of Neurological Disorders and Stroke.
(2020). Accessed on August 27, 2020. Retrieved from https://www.ninds.nih.gov.

Kliegman, R. (2016). Nelson Textbook of Pediatrics, 20th Edition. Elsevier: Philadelphia.

Leung, A., Hon, K., and Leung, T. (2018). Febrile Seizures: An Overview. Drugs in Context, 7,
212536. DOI: 10.7573/dic.212536.