Case Presentation

Febrile Seizure
Supervisor: dr. Ulynar Marpaung, Sp.A
Created by: Bening Irhamna (1102013057)
 CASE
ILLUSTRATION
 PATIENT’S IDENTITY
Name : Child Z
Birthdate : 29th August 2017
Age : 11 months
Gender : Male
Nationality : Indonesian
Race : Javanese
Religion : Islam
Address : East Jakarta
Date of Admission: 29th July 2018
Date of Discharge : 1st August 2018
 PARENT’S IDENTITY
Father Mother
Name Mr. A Mrs. Z
Age 23 years old 17 years old
Gender Male Female
Nationality Indonesian Indonesian
Religion Islam Islam
Occupation Employee Housewife
Last Education Primary School Primary School
Relationship with patient: Biological parents
 COMPLAINT
Chief Complaint:
Seizure in the last 1
hour prior to hospital
Additional Complaint:
admission
Fever, cough
 HISTORY OF PRESENT ILLNESS
1 day prior to hospital admission, the patient has a fever, sudden
high fever, a fever that occurs continuously. Fever ranges from
38C - 39C. Patient also have complaints of cough. Cough was
not phlegm, cough was rare and erratic.
1 hour prior to hospital admission, the patient experienced a
seizure. Seizures occur 1 time. The duration of seizure is
around 5 minutes. The patient clenched both hands when
seizure occurred, both upper arms and lower limbs trembled
like shivering, the patient's eyes glared up. No foam comes out
of the patient's mouth and the tongue does not bite.
Other complaints such as runny nose, stomach ache, nausea,
vomiting, ear pain and fluid coming out of the ear are denied.
No complaints in defecation and urination
 MEDICAL HISTORY
Past Medical History:
No past medical history to date. Mother denied any
sickness, accidents and injuries.

Allergy History:
No known allergies were reported.
 PREGNANCY HISTORY

Antenatal Pregnancy Drug

Care Illness Consumed
•Mothers •No history •Mother
check up of regularly
regularly problem drink
in an disease vitamin
maternity during and folic
clinic pregnancy acid
 BIRTH HISTORY
Labor Maternity Clinic
Birth attendants Midwife
Mode of delivery Pervaginam
Gestation 38 weeks
Infant state Healthy
Birth weight 3300 grams
Body length 49 cm
There were no complications at delivery, APGAR score was
unknown but the mother said Child Z breathed spontaneously at
birth and he did not require any respiratory support or
phototherapy
DEVELOPMENTAL HISTORY
Social Personality Language Psychomotor development
• Slant : 5 months
• Smile : 3 months • Screaming : 11 months
• Speech initiation : 6 months
• Reaching toys : 6 months • Laughing : 6 months • Sitting : 8 months
• Clapping hands : 6 • Crawling : 8 months
• Turn one’s head : 3 months
months • Standing : 9 months

Conclusion: developmental is within the

normal limits and appropriate according to the
patient’s age
 FEEDING HISTORY

Breast milk : Exclusively 6 months

Formula milk : None were given

Baby biscuit : Milna and promina

Fruit and vegetables : Banana and papaya

 IMMUNIZATION HISTORY

Immunization Frequency Time

BCG 1 times 1 month old
Hepatitis B 4 times 0, 2, 3, 4 months
old
DPT 3 times 2, 3, 4 months
old
Polio 4 times 0, 2, 3, 4 months
old
Measles 1 times 9 months
 FAMILY HISTORY

There are not any No complaints are

congenital disease, the same as patients
significant illnesses or when the patient's
chronic illnesses in parents are still
the family declared children
 PHYSICAL EXAMINATION
• Patient is a well-developed with good
General
nutrition. Appears to be well hydrated.

• Body Temperature : 39,2oC

• Respiratory Rate : 25 breaths per
minute Vital Sign
• Heart Rate : 120 beats per
minute

• Weight : 9 kg
Growth
• Height : 73 cm
Parameter
• Head Circumference : 45 cm
CDC Growth Chart

• Weight for age : 9/10 x 100% =

90% (Gizi Baik)
• Height for age : 73/74 x 100% =
98,6% (Normal)
• Weight for height : 9/9,8 x 100% =
91,8% (Gizi Baik)

Conclusion:
The patients is within
good nutritional status
 PHYSICAL EXAMINATION
Head
• Normocephalic, atraumatic with thick hair.

Eyes
• Pupils equal, round and reactive to light. Extraocular
muscle appeared intact. No discharges, conjunctivitis or
scleral icterus. No ptosis. Pallor were not detected for both
eyes.
Ears
• Clear external auditory canals. Pinnae shape and contour
was normal. No pre-auricular pits or skin tags. No erythema
or bulging. No bleeding, secretion or serumen.
 PHYSICAL EXAMINATION
Nose
• Normal pink mucosa, no discharge or blood visible. Normal
midline septum.
Mouth
• Moist mucous membrane. Tongue no dirty.
Pharynx
• Tonsil T1/T1, pharynx shows hyperemia.
Neck
• Grossly non-swollen. No tracheal deviation. No decrease in
ROM. No lymphadenopathy, goitre or masses detected.
 PHYSICAL EXAMINATION
Thorax
• symmetric when breathing, rectraction (-). ictus cordis is not
visible, fremitus tactile right=left, sonor on both of lungs, cor
regular S1-S2, murmur (-), gallop (-), pulmo vesikular +/+,
wheezing -/-, rhonchi -/-
Abdomen
• convex, normal bowel sound, bruit (-), the entire field of
tympanic abdomen, shifting dullnes (-), liver and spleen not
palpable, abdominal mass (-)
Extremities
• Warm, no cyanosis or oedema. No gross deformities. Good
skin turgor with no tenting.
DOCUMENTATION
NEUROLOGICAL EXAMINATION
Power Physiologic Reflex
- Hand 5555/5555 Upper extremities
- Feet 5555/5555 - Biceps +2 / +2
Tones - Triceps +2 / +2
- Hand Normotonus/ Normotonus Lower extremities
- Feet Normotonus / Normotonus - Patella +2 / +2
Trophy - Achilles +2 / +2
- Hand Normotrophy / Normotrophy - Pathological Reflex -
- Feet Normotrophy / Normotrophy - Meningeal Sign -
LABORATORY FINDINGS
Hematology July 29th, 2018

Results Normal Value

Hemoglobin 11,2 13 – 16 g/dl
White blood cells 17.000 5.000 – 10.000 u/l
Hematocrit 24 40 – 48 %
Platelet count 253.000 150.000 –400.000
/ul
 ASSESEMENT

WORKING DIAGNOSIS
Simple Febrile Seizure
Normal Growth Development
Normal Nutritional State

DIFFERENTIAL DIAGNOSIS
Complex Febrile Seizure
MANAGEMENT
• Fluid Maintenance • Antibiotics
• Intravenous hydration: • Cefotaxime intravenous 450
Ringer Lactate 900 ml for mg two times daily.
24h. • Anticonvulsant prophylaxis
• Symptomatic drugs • Diazepam syrup 1mg per
• Paracetamol syrup 1 ml per oral three times daily.
oral three times daily.
• Ambroxol syrup 2.5 ml per
oral two times daily
PROGNOSIS
• Quo ad vitam : bonam
• Quo ad functionam : bonam
• Quo ad sanationam : bonam
FOLLOW UP
July 29th 2018, first day of admission, 2nd day of illness July 30th 2018, second day of admission, 3rd day of illness
S Mild fever (+), Seizure (-), Cough (+) Mild fever (+), Seizure (-), Cough (+)
Consciousness : Compos Mentis
Consciousness : Compos Mentis
General condition : Moderately ill
O General condition : Moderately ill
Temperature : 38 °C
Temperature : 37,7 °C
Pulse :110 x/min
Pulse :110 x/min
Respiratory rate : 25 x/min
Respiratory rate : 25 x/min
Pharynx shows hyperemia
Simple Febrile Seizure
Normal Growth Development
A
Normal Nutritional State
Ringer Lactate 900 ml for 24h
Cefotaxime intravenous 450 mg two times daily.
P Paracetamol syrup 1 ml per oral three times daily.
Ambroxol syrup 2.5 ml per oral two times daily
Diazepam syrup 1mg per oral three times daily.
FOLLOW UP July 31th 2018, third day of admission, 4th day of illness
S Mild fever (+), Seizure (-), Cough (-)

Consciousness : Compos Mentis

Hemoglobin 13 g/dl
O General condition : Moderately ill
White blood 10.500 u/l
Temperature : 37,5 °C
Hematocrit 40%
Pulse :110 x/min
Respiratory rate : 25 x/min
Platelet count 260.000/ul

Simple Febrile Seizure

Normal Growth Development
A
Normal Nutritional State

Ringer Lactate 900 ml for 24h

Cefotaxime intravenous 450 mg two times daily.
P
Paracetamol syrup 1 ml per oral three times daily.
Diazepam syrup 1mg per oral three times daily.
FOLLOW UP August 1st 2018, fourth day of admission, 5th day of illness

S Fever (-), Seizure (-), Cough (-)

Consciousness : Compos Mentis

O General condition : Moderately ill
Temperature : 36,7 °C
Pulse : 102 x/min
Respiratory rate : 24 x/min

Simple Febrile Seizure

Normal Growth Development
A
Normal Nutritional State

- Azithromycin suspension 100 mg per oral once daily.

P
- Plan to discharge
LITERATURE REVIEW
FEBRILE SEIZURE
DEFINITION
Febrile seizure is a seizure occurring in childhood after 1 month
of age associated with a febrile illness not caused by an infection
of the central nervous system (CNS), without previous neonatal
seizures or a previous unprovoked seizure, and not meeting the
criteria for other acute symptomatic seizures.1
EPIDEMIOLOGY
• Among children with febrile seizures, about 70-75% have only simple
febrile seizures, another 20-25% have complex febrile seizures, and
about 5% have symptomatic febrile seizure.2
• Febrile seizures occur in all races, some studies demonstrate a slight
male predominance. Simple febrile seizure occur most commonly in
children aged 6 month to 5 years.
 RISK FACTOR
DEVELOPING RECURRENCE EPILEPSY

•Family history of febrile •Young age at time of •Complex febrile seizure

seizure first febrile seizure •A family history of
•High temperature •Relatively low fever at epilepsy
•Parental report of time of first febrile •An initial febrile seizure
developmental delay seizure before 12 month of age
•Perinatal illness •Family history of a •Neurologic impairment
(Especially affecting the febrile seizure in a first prior to the febrile
CNS) degree relatives seizure
•Brief duration between
fever onset and initial
seizure
•Multiple initial febrile
seizures during same
episode
ETIOLOGY
• The etiology of febrile seizure to date has not been known.
• Febrile seizure usually begin with a viral or bacterial infection.
The most common diseases that accompany febrile seizure are
respiratory infections, otitis media and gastroenteritis.3
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
CLASSIFICATION1,4,5
CLINICAL MANIFESTATION
• Febrile seizures can begin with a sudden
contraction of the muscles on both sides of
the child's body.
• Contractions generally occur in the
muscles of the face, body, hands and feet.
• Eventually the contractions stop and are
replaced by short relaxation.
• Then the child's body starts to beat
rhythmically (in clonic seizures), or stiff (in
tonic seizures).
• Some children do not breathe and can
show symptoms of cyanosis
 DIAGNOSTIC APPROACH
Supporting
Anamnesis Physical Examination
Examination
•History of •Temperature body •Laboratory findings
neurological •Examination to •Lumbar puncture
disorders, previous determine the •Electroencephalogram
seizure underlying disease for (EEG)
•History of fever fever •CT Scan
•Determine the •Pathological reflex
underlying disease for examination
fever •Examination of
•History of seizure meningeal excitatory
•Trauma signs
THERAPEUTIC
APPROACH
THERAPEUTIC APPROACH
Antypiretics and
Anticonvulsant Prophylaxis
Antibiotics
•Paracetamol 10- •Oral diazepam •Intermittent
15 mg / kg / day at a dose of 0.3 •Continuous
every 4-6 hours mg / kg every 8
•Ibuprofen 5-10 hours
mg / kg / day
every 4-6 hours
•Antibiotics to
treat infections
that are the basic
etiology of fever
PREVENTION
Educate Parents
• Ensure that febrile seizures generally have a good prognosis.
• Notify how to handle seizures.
• Provide information about the possibility of a seizure again.
• Provision of drugs to prevent recurrence is effective but it must be
remembered that there are side effects.
Things to do if the seizure return:
• Stay calm and not panic.
• Loosen tight clothing especially around the neck.
• If unconscious, position the child on his back with his head tilted.
Clean up vomit or mucus in the mouth or nose. Even though the
tongue might be bitten, don't put something in the mouth.
• Measure the temperature, observation and note the length and
shape of the seizure.
• Stay with the patient during seizures.
• Give rectal diazepam. And do not give if the seizure has stopped.
• Bring the doctor or hospital if the seizure lasts 5 minutes or more
PROGNOSIS
Prognosis for normal neurologic function is excellent.
• About one third of children who experience a single simple febrile
seizure will have another.
• The lifetime rate of epilepsy in these children is slightly above that of
the general population.
BIBLIOGRAPHY
1. Guidelines for Epidemiologic Studies on Epilepsy. Commission on
Epidemiology and Prognosis. International League Against Epilepsy.
Epilepsia. 1993.Jul-Aug. 34(4);592-6.
2. Chung B, Wat LC, Wong V. Febrile Seizures in Southern Chinese
Children: Incidence and Recurrence. Pediatr Neurol. 2006. Feb.
34(2):121-6.
3. W Hay, William. Current Diagnosis and Treatment of Pediatrics. 19th
Edition. United States of America: Mc Graw Hill. 2009. p.697-98.
4. Nelson KB, Ellenberg JH. Prognosis in Febrile Seizure. Pediatr 1978;
61:720-7.
5. Berg AT, Shinnar S. Complex Febrile Seizure. Epilepsia 1996;37:126-33.