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HISTORY TAKING

PATIENT DETAILS
Name

: Nur Hayati Bin Mohamad Ridwan

Date of birth : 13 June 2014


Age

: 7months

Gender

: Female

Religion

: Muslim

Race

: Malay

Address

: TBG 333, Jalan Sg. Betik, Teluk Gadong, 41000 klang, Selangor.

Informant

: Mother (reliable)

ADMISSION DETAILS
Bed no.

: 20

Ward no.

: 6B

Registration no.

: HTAR 1525546

Date of admission

: 13 January 2015

Date of clerking

: 14 January 2015

CHIEF COMPLAINTS
A 7 months old girl presented with fever for 3 days and 1 episode of fits on the day of
admission at Hospital Tengku Ampuan Rahimah (HTAR).

HISTORY OF PRESENTING ILLNESS


According to mother, the child was apparently well 3 days prior to admission until she
developed fever. Patient has fever for 3 days of duration, characterized as high
grade fever of sudden onset and intermittent in nature which associated with chills,
cough, and diarrhoea. It was not associated with vomiting or rashes. The
temperature documented at home was 38C. Mother brought the child to Klinik
Kesihatan Teluk Gadong on the next morning after the onset of fever. The child was
given antipyretic (ibuprofen) and antibiotic. Fever subsided with sweating. However,
fever does not subside completely and the child developed fever and one episode of
fits yesterday (13/01/2015) for the first time and her parents immediately brought her
to Klinik Kesihatan Teluk Gadong.
Patient developed 1 episode of fit in the evening (4.00 p.m.) which lasted for 5
minutes. During pre-ictal phase, the child was lying on the bed. During the ictal
phase, both the upper and lower limbs had jerky movement, up rolling of eyes,
presences of drooling of saliva, had bluish discolouration over the face and no
urinary and bowel incontinence. Post-ictal phase, the child appears lethargic and
eyes were closed. After 5 minutes the child cried and responds to mother`s call. At
Klinik Kesihatan Teluk Gadong, her temperature was 40.3C and rectal diazepam
was given. Then fever subsides to 38C when brought to Emergency Department of
HTAR.
Cough and running nose was associated by fever for 3days. Cough is more frequent
when the child cries and during sleep. Cough is characterizes as productive cough
with whitish sputum which worsen in the morning. The cough is not associated with
post tussive vomiting and noisy breathing. It is not a prolonged cough and no forced
expression present. Regarding running nose, it was whitish mucus with no blood
stain present and no nose block or difficulty in breathing present.
Patient has diarrhoea for 2 days of duration. The frequency of diarrhoea was 3 times
in a day. Diarrhoea was characterized as small quantity, watery and mucous stools.
No blood stain present. Colour of diarrhoea was yellowish and no foul smelling.
Diarrhoea not associated with vomiting.

The child tolerates less orally where she does not even complete 3 ounce of milk
and usually she drinks 8-10 ounce of milk a day. However, there was no significant
weight loss. She was less active as well.
There was no sick contact at home. Recently travelled to Banting to relatives house,
there was a sick child with fever and cough.

SYSTEMIC REVIEW
General
Respiratory system

No rashes or weight loss. Less active.


No shortness of breath and no noisy breathing or rapid

Cardiovascular

breathing.
No bluish discolouration on feeding and no history of murmur.

system
Ear, nose & throat
Gastrointestinal

No ear discharge or earache and no sore throat.


No vomiting, constipation or abdominal pain.

system
Genitourinary

Not crying on micturition. Less urine output (only changes

system
Muscular

pampers twice a day). Urine colour was yellowish.


skeletal No limb swelling and no functional abnormalities.

system

HISTORY OF PAST ILLNESS


This was her first hospitalization.
Past medical history: No any significant past medical history.
Past surgical history: No history of surgery.
Trauma: No history of trauma.
Medication: Currently, patient is on syrup paracetamol and antibiotic to reduce
fever and suppository rectal diazepam to prevent recurrent episodes of
seizure. She is not on any long-term medications.

BIRTH HISTORY
a)

Antenatal:

This was 4th gravida and 3rd parity. Health of mother during pregnancy was good
as she had supervised antenatal check-ups and antenatal follow-ups. Antitetanus toxoid injection was given once at 2 nd trimester. There was no fever with
rash during pregnancy. The result of serological test for Hepatitis B, VDRL and
HIV was not reactive. Mother is a known case of asthma and she was
hospitalised once for 1day, in 2 nd trimester due to acute exacerbation of Bronchial
asthma. She was given nebulization twice and discharged on the same day. She
does no consume any other medication apart from vitamin and iron
supplementation that doctor provided. During pregnancy there was no exposure
to radiation, alcohol or smoking. There was no history of trauma during
pregnancy and the growth of baby was normal. There was no antepartum
haemorrhages, no gestational diabetes mellitus and no pregnancy induced
hypertension.
b)

Natal:

This was a term baby of 40 weeks of gestation. The mode of delivery was Normal
Spontaneous Vertex Delivery (NSVD). The duration of labour was 1 hour. Place
of delivery was at HTAR. No premature rupture of membrane (PROM), no
meconium stained liquor and no chorioamnionitis.
c)

Post natal:

The infant cried vigorously and breathe immediately after birth. The birth weight
was 3.2kg. There were no breathing problems and normal heart beat was noticed
at birth. The child was given to mother for breast feeding within 1 hour. The baby
passed out urine and meconium on the same day.
d)

Neonatal:

The infant had jaundice on day 2 of life which lasted for 2 days and was not on
phototherapy. There were no other complications such as pneumonia or
meningitis.
FEEDING/DIETARY HISTORY
There was no pre-lacteal feeding given to the child. The baby was exclusively
breast-fed for 2 months, and then started to give Dumex formulated milk because

mother started to work. Usually 4 scoops with 6 ounce of water for every 2-3 hours.
Currently, 2 ounce of milk of 2 scoops for 8 times a day. Complementary feeding
started on 6 months of age, porridge with mashed chicken, carrot and potato.

IMMUNIZATION
Immunization is up-to-date as per scheduled in National Immunization schedule for
Malaysia. Below stated as in immunization record book:
i)

BCG: 1st dose given at birth

ii)

Hepatitis B: 1st dose at birth and 2nd dose at first month of age

iii)

DTap, IPV and Hib: 1st dose was given at 2 months old, 2nd dose was given

at 3 months old and 3rd dose was given on 5 months old.


iv)

Hepatitis B: 3rd dose given at 6 months of age.

There are no optional or additional vaccines were given.

DEVELOPMENTAL HISTORY
Gross motor:

Sits with support. Bears weight on legs.

Prone - Supports weight on hand of chest, upper abdomen off couch. Rolls
prone to supine and rolls from supine to prone.

Vision and Fine motor:

Palmar grasp of cube, ulnar approach. Moves head, eyes in all directions. No

squint.
Feeds self with biscuits.
Transfer objects from one hand to the other.
Rakes at pea.

Hearing, Speech and Language:

She able to babble in single syllables.

Social, emotional and behavioural:

She has stranger anxiety.

DRUGS AND FOOD ALLERGY


No known drugs and food allergy.

FAMILY HISTORY

Both the parents are 27 years old. She is the last child out of 2 children. Her brother
is 2 years old. It is a non-consanguineous marriage. Her eldest brother has history of
febrile seizure at the age of less than 1 year old and hospitalised for 1 day. Mother is
a known case of asthma and maternal uncle passed away due to Tuberculosis.

There is no history of hypertension, diabetes mellitus, malignancy and other genetic


illness in the family.

SOCIAL HISTORY
The primary caretaker is the babysitter together with her brother. Both parents
education until secondary school level. Father working as despatch and mother is a
general worker in Gardenia Company. Income is RM2500. House has adequate
basic amenities. No pets or carpet at home. No smoker in the family.

PHYSICAL EXAMINATION
GENERAL INSPECTION

The child was pink in the room air, alert and conscious. The child was sleeping in the
supine position with one pillow supported and not on respiratory distress. The R/N
tag was on her left dorsum of hand and cannula on the right hand.

VITAL SIGNS
Temperature = 37C (afebrile)
Pulse rate

= 159 beats/minute (Mild tachycardia)

Blood pressure

= 102/74mmHg (Normotensive)

Respiratory rate

= 35 breaths/minute (Normal)

Oxygen saturation = 98%

ANTHROPOMETRIC MEASUREMENT
Weight

= 8 Kg (

percentile)

Height

= 72 cm (

percentile)

Head circumference = 44 cm (

percentile)

GENERAL EXAMINTION
a) EXTREMITIES
The peripheries are warm and moist.
Capillary filling time (CFT) is less than 2 seconds.
No deformity, oedema, cyanosis or clubbing
b) SKIN
No rashes.
c) HEAD
Shape of the head is normal.
Anterior frontanel is opened.

d) EYES
No icterus on sclera.
The conjunctiva not pallor.
e) EARS
No discharge and inflammation of ear canal.
f) NOSE
Has watery coryza discharge. No bleeding.
Nasal septum is symmetrical.
g) MOUTH
Tongue: Red smooth tongue, symmetrical.
No teeth. No enlargement of tonsils. No oral ulcer.
Lips are pink.
Throat mildly injected.
h) NECK
No neck swelling.
i) LYMPH NODES
No lymphadenopathy.

SYSTEMIC EXAMINATION
a) NERVOUS SYSTEM
Inspection
- Alert.
- Position at rest is frog position in hypotonia.
- No dysmorphic signs.
- Normal movements. No fasciculations.
- Base of spine: No sacral dimple or tuff of hair.
Palpation:
- No bulging frontanelle.
Motor examination
- No muscle bulk.
- Tone:
Easy to move joints freely.
At supine position, baby lies in frogs leg position (hypotonia).
At prone position, head and shoulders raised.
On pull to sit, head lag (hypotonic).

On axillary suspension, baby bears weight.


- Power: Sub-maximal movement against resistance.
- Coordination: Not done.
Reflexes
- Upper Limbs:

Lower Limbs:

Meningeal Irritation Test


- Kernigs sign: Negative
- Brudzinki sign: Negative
Sensation: Not performed.

Impression: Physiologically normal.

b) CARDIOVASCULAR SYSTEM
Inspection: The chest wall is symmetrical and normal in shape. There

was no scar, no precordial bulging and no abnormal pulsation.


Palpation: The apex beat was located in the 4 th intercostal space, at the
mid-clavicular line. There was no thrill and heave. The peripheral

pulses were present with normal rhythm and volume.


Auscultation: The first and second heart sounds were normal. There
were no murmurs heard. Increased heart rate was noted.

Impression: Physiologically normal.

c) RESPIRATION SYSTEM
a) Inspection: The chest moved symmetrically with respiration with no
deformity seen. There was no sign of respiratory distress. There were
no scar, prominent dilated.
b) Palpitation: Trachea centrally located. The chest expansion was equal
anteriorly and posteriorly at all three zones of the lungs. No area of
tenderness.
c) Percussion: The lung was resonant bilaterally, anteriorly and
posteriorly. There were normal liver and cardiac dullness.
d) Auscultation: Bilateral air entry was noted. There were vesicular breath
sound anteriorly and posteriorly at all three zones. No added sounds
heard.
Impression: Lungs clear.

d) ABDOMEN
Inspection: No surgical scar. No abdominal distension. No jaundice.
Palpation: Soft and non-tender. No splenomegaly or hepatomegaly. No

groin hernias.
Percussion: Not done.
Auscultation: Not done.

Impression: Physiologically normal.


e) GENITALIA
Not examined.

SUMMARY
A 7 months old, Malay girl is hospitalized for first time. Patient presented with fever
for 3 days which developed 1 episode of fits which lasted for 5 minutes. Also,
presented with cough and running nose for 3 days and diarrhoea for 2 days. Patient
has poor bottle feeding and decreased activity.

Upon physical examination, patient has no stiffness of the body and no muscle bulk
on extremities. Easy to move joints freely. The power was sub-maximal movements
against resistance. Babinski reflex was negative. The vital signs were normal.

PROVISIONAL DIAGNOSIS
Simple febrile seizure
Fever associated with fits, temperature above 38C, intermittent fever and
tachycardia (RR=159 beats/min). The seizure of one episode characterized as
generalized tonic-clonic and lasted for 5 minutes. No recurrent episodes of seizure.

DIFFERENTIAL DIAGNOSIS
a) Meningitis
Points supporting: Acute generalised tonic-clonic seizure, up-rolling of eyeball,
drooling of saliva, cyanosis (mouth area) and associated by fever.
Points against: No neck stiffness. Kernigs sign, Brudzinki sign and Babiniski
reflex are negative.
b) Complex febrile seizure
Points supporting: Fever and seizure. Age of the child between 3 months to 6
years.
Points against: No recurrent seizure in one febrile event. No nausea or
vomiting.

INVESTIGATION
a) Full Blood Count
WBC

5.7

6.0-15.0
(x100)

Low

RBC
distribution
width

32.3

30.0100.0

Normal

Hemoglobin

12.0

10.5-14.0

Normal

Hematocrit

36.4

33.0-42.0

Normal

Mean cell Hb

25.7

25.0-31.0

Normal

Mean cell
volume

72.0

70.0-74.0

Normal

Mean cell Hb
concentratio
n

34.8

28.0-34.0

Normal

Platelets

435

110-450

Normal

Calcium

2.54

2.20-2.67

Normal

Magnesium

0.86

0.7-1.1

Normal

Phosphate

1.43

0.14-1.52

Normal

Interpretation: Normal
b) Electrolytes

Interpretation: Normal level of ca2+,Na2+ mg2+, PO42, random glucose


indicate that there is no metabolic derangement in this patient.
c) Renal Profile
Urea

4.8

1.7-6.4

Normal

Sodium

137

135-150

Normal

Potassium

3.7

3.5-5.0

Normal

Creatinine

45.0

27.0-62.0

Normal

Chloride

105.0

98.0-107.0

Normal

Interpretation: Normal renal profile and this result exclude any dehydration as
she had reduced in oral intake (fluids and solid food).
d) 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.

PLAN OF MANAGEMENT
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)

Fits chart
Suppository paracetamol (PMC) stat
Syrup paracetamol
Strict urinary input/output chart
Stools for inspection
Monitor vital signs for temperature spikes
Start IV fluid (37cc/hour) with full maintenance.
Parental education on First aid measures during seizure.

DISCUSSION
Definitions:
Febrile fits (F.C.) are defined as fits 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 metabolic derangement that could be the cause of the fit. Febrile fits,
febrile convulsions and febrile convulsions are synonymous terms. Children with
previous afebrile fits are excluded from this definition.
Magnitude of Problem:
There is no comprehensive local epidemiological data. Studies in Western Europe
quote a figure of 3-4 % of children 5 years experiencing febrile fits with higher
figures of up to 8% in Japan. This makes febrile fits the single most common
problem in paediatric neurology.
Types of Febrile Fits:
Febrile fits are classified as either simple or complex. Simple febrile fits are short,
less than 15 minutes, generalised fits that do not occur more than once in a febrile

episode. Febrile fits that are either prolonged ( 15 minutes) unilateral or recur within
a single febrile episode are classified as complex.

Issues in management of Febrile Fits:


The major issues are:a Risk of recurrent febrile fits.
b Risk of subsequent afebrile, unprovoked fits or epilepsy.
c Prognosis for neurological, motor, intellectual and behavioural outcomes.
d Need for admission.
e Investigations for the individual child.
f

Need for electroencephalogram (EEG).

g Need for prophylactic treatment.


h Type of prophylactic treatment to be used.

Current Recommendation:
Based on the above discussion, the following approached is recommended:
a Parents of children with febrile fits should be counselled on the benign nature of
this condition.
b They should be taught effective measures of temperature control such as tepid
sponging with tap water and antipyretic administration. Paracetamol is still the
safest antipyretic and can be given at a dose of 15 mg/kg 6 hourly. Alternately
NSAIDs can also be used. The mechanism of action of tepid sponging namely
heat loss from the body surface should be explained to the parents.
c

The parents should also be advised on first aid measures during a fit, if this was
to recur namely:

i) Do not panic, remains calm. Note time of onset of fit.


ii) Loosen the childs clothing especially around the neck

ii

iii) Place the child in the left lateral position with the head lower than the body.

iii iv) Wipe any vomitus or secretion from the mouth


iv v) Do not insert any object into the mouth even if the teeth are clenched

vi) Do not give any fluids or drugs orally

vi vii) Stay near the child until the fit is over and comfort the child as he/she is
recovering.
vii viii) The caregiver of children with a high risk of recurrence, ie more than 3
risk factors, should be supplied with a preparation of diazepam rectal solution at
0.5 mg/kg of the childs weight. They should be advised on how to administer this
in case the fit last more than 5 minutes.
viii ix) Rectal Diazepam solution is a list C item in the Ministry of Healths drug
list and hence should be available in all government health facilities.
ix x) In the event that the fit is not aborted by rectal diazepan they should seek
urgent medical help to stop the fit before status epileptics develops.
x

xi) If the fit is aborted, they should also seek medical advice to determine the
cause of the fever.

These recommendations apply both to children who have had a simple or a complex
febrile fit.

REFERENCE
1. Clinical examination by Nicholas J Tally and Simon OConnor, 6 th edition,
2010, published by Elesvier.
2. Paediatrics and Child health, 2 nd edition by Mary Rudolf and Malcolm Levene
published by Blackwell on 2006 of pages 17 to 41.
3. http:// emedicine.medscape.com/article/978654-overview
4. http://www.adhb.govt.nz/starshipclinicalguidelines/_Documents/Convulsions
%20-%20Febrile%20.pdf
5. The New England journal of Medicine, Seizure Recurrence after a First

Unprovoked Seizure W. Allen Hauser, M.D., V. Elving Anderson, Ph.D., Ruth


B. Loewenson, Ph.D., and Stella M. McRoberts, B.R.N.N Engl J Med 1982;
307:522-528August 26, 1982DOI: 10.1056/NEJM198208263070903