1. CASE PRESENTATION Qhasmira Bt Abu Hazir 2008409674 NurAmira Bt MohdAsri 2008409708 Nurjuliana Bt Noordin 2008402524

2. PATIENT DEMOGRAPHIC PATIENT NAME: FATIN AQILAH R/N: SB 00300220 PATIENT’S INITIAL: FA SEX: FEMALE AGE: 2YEARS AND 3 MONTHS ETHNIC GROUP: MALAY INFORMANT: MOTHER/FATHER RELIABILITY: FAIR WARD: 8C DATE OF ADMISSION: 24TH NOVEMBER 2010 DATE OF CLERKING: 29TH NOVEMBER 2010 DATE OF DISCHARGE: 1ST DECEMBER 2010

3. CHIEF COMPLAINT FA, a 2 years old Malay girl was admitted to the Sungai Buloh Hospital on 24th November 2010 due to fever and vomiting for 2 days prior to admission and 3 episodes of fits on the day of admission.

5. Intermittent in nature (on and off)

6. Temporarily relieved by syrup Paracetamol

8. 4 episodes per day

9. Occur after taking food or fluid

10. Vomitus contained stomach content and no blood stained

11. Loss of appetite but not lethargic

13. Went to private clinic

14. Due to poor oral intake, she was given per rectal paracetamol

15. Temperature documented 38.5˚C- Temporarily relieved VOMITING - Same presentation as before 3 EPISODES OF FITS

17. Witnessed by her grandfather. Her mother was away.

18. Was described as generalized stiffness

19. Lasted for 5 minutes

20. Her grandfather failed to explain more regarding on her granddaughter’s condition.

23. Was described as generalized stiffness of both 4 limbs followed by jerky movement.

24. Ass with up rolling of eyes, clenching of teeth and drooling of saliva

27. Appeared weak

28. Not tolerate feeding and feel nauseated

29. No vomiting episodes

31. Witnessed by her father

32. fit was presented like before

33. Lasted less than 1 minute

35. Not able to communicate with her parents

38. PAST MEDICAL HX She had no history of fit before. She also had never been hospitalized or undergone any surgery before. She had no long term illnesses.

39. DRUG HX She had no known drug history

40. ALLERGY HISTORY No allergy noted

41. BIRTH HX She was born full term by spontaneous vertex delivery at SgBuloh Hospital. The birth weight was 3.15 kg. The delivery was uncomplicated and there was no resuscitation required. Antenatal, intrapartum and postnatal period were uneventful.

42. NEONATAL HX Neonatal period was uneventful

43. FEEDING HX She was not breastfed since birth and she was given formula milk instead. She was first introduced to solid foods when she was 6 months old. At that time, she was given Nestum. She started to eat rice at the age of 1 year old. Currently, she is given porridge together with vegetables, fish and sometimes chicken. She is still given the formula milk (DUMEX 123). DUMEX 4 scoops in 4 oz (120ml), 2-3 hourly, prepared by the mother herself.

44. IMMUNIZATION HX Her immunization was completed up to her age. There was no complication developed after each injection. Her latest immunization was MMR which she took when she was one year old.

45. DEVELOPMENTAL HX All of the developmental parameters were appropriate to her age.

46. FAMILY HX She is the only child. There was no history of febrile fits running in both of her parents during their childhood lives. None of them was having fever before the patient even got one. Besides, both of her parents were completely healthy. No history of asthma, hypertension and diabetes mellitus running in her parents. There was also no epilepsy history in the family; including uncles and aunties from both maternal and paternal side. No consanguity noted.

47. SOCIAL HX AND ENVIRONMENTAL HX Her father and mother are working together in nasilemak’s stall owned by family. Both of them are working during the day. Thus, the patient is taken care by her mother’s father (grandfather). The total income of her family is about RM1000 per month. They live in an apartment at Sg Way with complete basic amenities. Her father is not a smoker as well as her mother.

48. HX OF CONTACT There was no significant history contact

49. EFFECT OF THE ILLNESS She became less active ever since she got the fever. Both the parents were worried about her condition and whether these episodes of fits will recur. Her mother had to take leave from work while her father working to earn for the family.

50. Physical examination

51. Physical examination General examination She was sitting comfortably unsupported on her bed, holding marker pen and scribbling Conscious, cooperative, alert to person and place. No respiratory distress, no dysmorphic feature, no abnormal movement and no muscle wasting. well hydrated and well nourished

52. Vital sign Pulse rate: 126 bpm, normal rhythms&vol. Respiratory rate: 36 bpm Temperature : 37 dc Blood pressure: 86/75 mmHg Interpretation:NAD Anthropometry Height: 86 cm (at 50thcentile) Weight: 13 kg (at 50thcentile )

53. CNS EXAMINATION Central nervous system Mental status: She was alert and conscious. Speech: Can speak clearly with no difficulty. Cranial nerves: There was no nystagmus. All her cranial nerves were intact. Muscle tone: There was no hypotoniaand hypertonia Muscle power: all of her muscle power were 5/5

54. REFLEXES EXAMINATION Reflexes- all reflexes were normal

55. Cerebellar signs - she was able to walk steadily without support. Involuntary movement : no presence of any involuntary movement Signs of meningeal irritation : no neck stiffness, negative brudzinski’s and kernig’s sign Sensory function: cannot be tested Impression: no abnormality detected.

56. CVS EXAMINATION NO ABNORMALITY DETECTED

57. RESPIRATORY EXAMINATION NO ABNORMALITY DETECTED

58. ABDOMINAL EXAMINATION NO ABNORMALITY DETECTED

59. Systemic examination CVS, Resp., abdominal, CNS :all NAD Summary FA, a 2 years old Malay girl was admitted to SgBuloh Hospital on 24th November 2010 due to 3 episodes of generalized tonic-clonic fits on the day of admission associated with fever for 2 days and vomiting for 2 days prior to admission with no LP done.

60. Provisional diagnosis Complex febrile fits -points to support: Fever Recurrent seizures in one febrile event Age, febrile fits usually occur in 3 months to 6 years of age.

61. Differential diagnosis

62. Investigation FBC Interpretation: NAD

63. Electrolyte-: normal level of ca2+,Na2+ mg2+, PO42, random glucose indicate that there is no metabolic derangement in this patient hence - rules out fitting due to metabolic derangement

64. RENAL PROFILE normal renal profile and this result exclude any dehydration as she had reduced in oral intake(fluids and solid food)

65. MICROBIOLOGICAL CULTURE there is no presence of bacteremia, or bacteuria

66. LUMBAR PUNCTURE Lumbar puncture is performed to obtain cerebrospinal fluid (CSF) to rule out any CNS infection. However, parents of this patient refused lumbar puncture to be done to her daughter. Therefore, CNS infection was failed to be ruled out.

67. BRAIN IMAGING (CT SCAN) To detect any brain pathology Findings: No intracranial bleeding No focal brain parenchymal lesion No hydrocephalus

68. CHEST X-RAY (not done) Chest x-ray was not indicated as there was no abnormality in the physical examination suggesting infection of lower respiratory tract. Altogether the history, physical examination and investigation had excluded a lower respiratory tract infection.

69. ELECTROENCEPHALOGRAPHY (EEG) to find out abnormal brain function EEG is recommended to be performed on children who are neurologically abnormal or experience a complex seizure.

70. FINAL DIAGNOSIS Complex febrile fits with presumed meningitis

71. DISCHARGED SUMMARY On the day of admission, she had multiple seizures attack: 1st episode occurred at home, lasted for 5 minutes and aborted spontaneously 2nd episode occurred at private clinic, lasted for 5 minutes and aborted spontaneously 3rd episode occurred at Emergency Department of HSB, lasted for 1 minute aborted by suppository Valium (diazepam) 5 mg 4th episode occurred in ward 8c around 3.30pm lasted for 1 minute and aborted by suppository Valium 5mg 5th episode occurred at 6pm in ward 8c, lasted for less than 1 minute and loaded with IV Phenytoin and started maintenance There was total of 5 episodes of fits and patient was febrile at that time No more episode since then. She had good response towards antibiotic given to her.

72. Management Control fever Take off clothing & tepid sponging Anti pyretic eg; syrup/rectal Paracetamol 15mg/kg 6hrly Antipyretic is indicated for patients comfort, but there is no evidence that by using it, it can reduce recurrence rate /risk of febrile convulsion. As for this patient, she was given syrup Paracetamol (200 mg) 6 hourly

73. Vital sign monitoring 4 hourly vital signs monitoring Fit charts

74. Control fits/recurrent fits Rectal Diazepam (valium) 5 mg IV Phenytoin

75. Parents should be advisedon first aid measures during a convulsion; Not to panic, remain calm. Note time of onset of fit Loosen child’s clothing especially around neck Place child in left lateral position with head lower than the body Do not insert any object into mouth even if the teeth are clenched Wipe any vomitus of secretion from the mouth. Do not give any fluids/ drug orally Stay near the child until convulsion is over and comfort the child as she is recovering This is a very important point, as febrile fits can recur. Therefore his parents should be counsel about this upon discharged

76. Patient was treated as presumed meningitis. IV Ceftriaxone for 1/52(complete 7 days) she had good response toward antibiotic given Acyclovir

77. DISCUSSION

78. FEBRILE CONVULSION Convulsion occurring in association with fever in children between 3 months and 6 years of age, in whom there is no evidence of intracranial pathology or any metabolic derangement.

81. Causes of febrile fit Otitismedia (middle ear infection) Respiratory tract infection Urinary tract infection (infection of bladder,urethra/kidneys) Gastroenteritis Viral infection- such as chicken pox or influenza

82. Pathophysiology unclear It is generally believed that a febrile seizure is an age-dependent response of an immature brain to fever. This was postulated due to (80-85%) febrile seizure occurs between 3 months to 6 years of age ,with a peak at 18 months. It is well known that febrile seizure tend to occur in families because of it is an autosomal dominant inheritance.

83. Prognosis in Febrile Seizure it is a benign events with excellent prognosis 30% recurrence after 1st attack 48% after 2nd attack 2-7% develop subsequent afebrile seizure or epilepsy No evidence of permanent neurological deficits following febrile convulsions or even febrile status epilepticus No deaths were reported from simple febrile convulsion

84. Risk factors for subsequent epilepsy Neurodevelopmentalabnormality Complex febrile fits Family history of epilepsy Brief duration between onset of fever and initial convulsions

85. Lumbar Puncture It is also called a spinal tap is a common medical test that involves taking a small sample of CSF for examination. In a lumbar puncture, a needle is carefully inserted into the lower spine to collect the CSF sample.

86. Indications Suspected meningitis, encephalitis Intrathecal chemotherapy for oncology patient In selected patient being investigated for neurometabolic disorder

87. Contraindications Increased intracranial pressure due to space occupying lesions (from signs, symptoms, raised blood pressure, fundoscopic sign) Bleeding tendency (platelet <50, 000/mm3) or prolonged PT/APTT skin infection over site of lumbar puncture

89. Thank you…