Grand Conference

Clinical Clerks
Openiano, Oquendo, Pasaporte, Pangandian
Chief complaint

 This is a case of a 1 year female child who came in due to stiffening of

extremities
General Data

 A.M
 1 year and 4 months
 Female
 Child
History of Present Illness

 8 hours PTC: patient had onset of non-productive occasional cough. No other

associated symptoms.
 5 hours PTC: onset of fever (>39C), given paracetamol 100mg/ml drops, 1ml q4h
with temporary relief. Patient was still able to play with her siblings. No decrease
of appetite observed.
 2hrs PTC, patient had continued fever around 38 C. Another dose of 1ml of
paracetamol 100mg/ml was given and the mother placed the child on the bed and
started wiping her with wet cold towel. Patient was still active, awake but
irritable and was crying. Patient had sudden onset of stiffening and straightening
of all extremities, fisting of both hands and jerky movement ofextremities, bluish
discoloration of the lips, appeared to be gasping for air land upward rolling of
eyeballs which lasted for for 20-30 seconds. After the seizure episode, mother
observed that the patient’s extremities are relaxed, looked tired and she
proceeded to sleep continuously for 20 minutes. Patient woke up hungry, irritable
and return in the same previous state of sensorium. Mother did not observe any
paralysis, motor weakness or worsening of sensorium. Patient was then brought to
WVSUMC-ER.
PAST MEDICAL HISTORY
Allergies to Food, Drugs etc
Injuries, Trauma, Falls
Past Hospitalization/Illness
None known
None
MAY 2017 (1 month old) onset of cough and
undocumented fever associated with sudden onset
of upward rolling of eyeballs and stiffening of
extremities approximately <10s. Private physician
was consulted and cranial ultrasound result was
unremarkable.
PAST MEDICAL HISTORY

JANUARY 2018 (8 months old): onset of cough and

Past Hospitalization/Illness undocumented fever associated with sudden onset of
upward rolling of eyeballs and stiffening of extremities
approximately <10s. Patient was admitted in the Mission
Hospital for 4 days. Patient was discharged well.

JULY 2018 (1 yo, 2mos) Admitted due to upward rolling

of eyeballs. History of intermittent fever relieved by
paracetamol Associated with 3 episodes of loose stools.
There was 1 episode of upward rolling of eyeballs
associated with fever, <30s duration. Diagnosed as Benign
Febrile Seizure secondary to PCAP-B; Acute
Gastroenteritis with no dehydration S/P Lumbar Puncture
PERSONAL HISTORY

Prenatal: Started prenatal check up at 4 mos AOG, with monthly regular check-
ups. Mother had asymptomatic UTI diagnosed with routine urinalysis treated with
antibiotics.
Natal: Born to a G2P3(3003) 31 year old mother via repeat cesarean, no
complications. Patient was born full term, with good active, cry and good suck.
Meconium passed within 24 hours.
Post-natal: BCG, Hep B vaccine was given. Negative new born screening results,
no illnesses, no complicatons. Patient was discharged in the hospital after 48
hours.
Feeding History

 Exclusively breastfed for 1 month then given complementary formula milk

(Bona 1:2 dilution then switched to Lactum milk with 1:2 dilution after 1 year
of age)
 Started eating solid foods at 6 months, starting with soft/mashed vegetables
and rice
 Loves eating junk food Water from a water refilling station
 Good appetite
Socioeconomic and Environmental
History
 Patient lives with her mother, two 7 year-old twin siblings, maternal
grandmother in a 2-bedroom bungalow house made out of mixed plywood and
concrete. There is single flush-type toilet shared by the household.
 Mother is a housewife while the father is a seaman apprentice currently in
training in Manila.
 House is located near the main highway (approx. 30 m) and in close proximity
with other houses.
 Source of drinking water: local water refilling station
 Source of water for daily use: NAWASA
IMMUNIZATION RECORD

1st 2nd 3rd 4th 5th 6th

BCG at 4/24/18
birth (At birth)
Hepatitis 4/23/17
B (At birth)
DPT 6/7/17 8/1/17 9/6/17
(6 weeks) (10 we
OPV 6/7/17 8/1/17 9/6/17
Measles 4/23/18
(9
months)
PCV 6/7/17/ 9/6/17 10/4/17
IPV 10/4/17
MMR 6/20/18
Developmental Milestones

9 mos – stands with support

12 mos – walks without support; Starts saying “mama” and incomprehensible
sounds pertaining to different things
2 mos – Head control, smiles and regards face
4 mos – turns head to sound, prone
6 mos – sits alone steadily, turns head when called by name
INTERPRETATION:
AT PAR WITH AGE
Vital signs at ER

Vital Signs Results Int. Normal Values

Temperature 39.6◦ C Febrile 36.5 - 37.5 C
Heart Rate 170s to Tachycardic 70-110 bpm
120s bpm
Respiratory Rate 28 bpm Tachypneic 20-30
Blood Pressure 110/70 Hypertensive 90-110/55-70
Vital signs at Wards

Vital Signs Results Int. Normal Values

Temperature 37.6◦ C Afebrile 36.5 - 37.5 C
Heart Rate 120 bpm Tachycardic 70-110 bpm
Respiratory Rate 28 bpm Normal 20-30
Blood Pressure 90/60 Normal 90-110/55-70
Anthropometric Measure

Growth Indicator Z-score Interpretation

Data Input
Weight-for-Age 0.08 Normal
Height 85 cm
Height-for-Age -1.82 Stunted

Weight 10kg Weight-for-Height -1.50 Normal

BMI 13.6 BMI-for-Age -1.82 Underweight

Growth Charts

Weight for Length Weight for Age:

Growth Charts

Length for Age BMI for Age

Physical Exam

Mental Status
 Fully awake patient, standing on the bed, vocalizes “mama”, irritable mood,
cries occasionally, well-groomed, uncomfortable with strangers around
Physical Exam

A. Skin and Nails

I The color of the skin is even light brown all throughout the body.
The finger and toe nails cover the entire nail bed, with no lesions noted.
Nails are short trimmed with NO clubbing and NO cyanosis present.

P Skin is warm, with good skin turgor and not dry to touch.
Capillary refill of less than 2 seconds

B. Head

I Normocephalic
Atraumatic
No lesions or masses noted.
P Hair is fair slightly fine texture.
Fused fontanels both anterior and posterior
Physical exam

C. Face
I Facial features are bilaterally symmetrical. Facial bony contours are prominent.

D. Eyes
I Pupils are equally round with brisk reaction to light. Follicular lesions, discharges and ptosis are not
present.
White sclera. Pink conjunctiva.
No pigmentation, hemorrhages or exudates
E. Ears
I Ears are bilaterally symmetrical. Superior auricular attachments are in line with the outer canthus
of the eyes.
Discharges and skin tags are not present.
Ear skin smooth with no lesions.
Ear cartilages present and well-formed.
Canal walls pink, smooth and without nodules.
P Auricles are firm with instant recoil. Tenderness not noted.
Physical exam

F. Nose
I Midline with patent nostrils.
Septal deviations and discharges are not present.
Alar flaring not noted.
G. Mouth, Throat and Tonsils
I Lips are light pink. Lip cracking not noted. Oral mucosa is pink and moist.
Tongue is pink, moist
No dental caries found on the teeth
Non hyperemic, non-enlarged tonsils
H. Neck
I Neck is symmetrical.
P No neck vein engorgement, no masses or lesions noted.
Trachea is midline and thyroid gland is normal size
No lymphadenopathy
Physical Exam

I. Chest and Lungs

I Chest is bilaterally symmetrical
P Chest expansion assessment is symmetrical.
No retractions, masses or lesions noted
No tenderness on palpation
P All lung fields are resonant in percussion.
A Symmetrical breath sounds
Clear breath sounds
Physical Exam

J. Heart and Blood Vessels

I Adynamic precordium.
No precordial heaves, lifts, or bulge observed.
P Peripheral pulses are present (+2)
A no murmurs noted.
Heart is regular in rate and rhythm

K. Abdomen
I The abdomen is symmetrical without distention.

P Smooth and sharp liver edge. Spleen nonpalpable

P Soft non tender abdomen
A Bowel sounds are normal in quality and intensity in all areas 12 bowel sounds per minute.
Physical exam

L. Extremities
I No clubbing or cyanosis noted.
All flexors and extensors 5/5 with good muscle tone
P Peripheral pulses +2 radial artery, +2 on popliteal, posterior tibial
Pitting edema +1 on both legs and feet
Capillary refill less than 1-2 seconds

M Genito-Urinary
I Patient wearing diapers.
Phenotypically female

N. Spine
I Not assessed

O. Lymph nodes
P No lymphadenopathy
Cranial nerves

Cranial Nerves Assessment Method Patient’s Response

1 Sensory: to close eyes and identify different mild Not assessed
aromas e.g. coffee, orange, or chocolate
Olfactory
2 Sensory: ask to point a toy, or an object preferably Visual acuity: Able to follow colorful object when presented.
colorful
Optic Visual field: Able to turn to the direction of an introduced colorful object
at the periphery.
Ophthalmic findings:
Pupils (3mm in size) are equally round and reactive to light and
accommodation.
Positive red orange reflex, media is clear and disc borders are distinct.
3 Motor: assess six ocular movements and pupil reaction Able to move medially upward, and downward ocular movements.
Oculomotor PERRLA
4 Motor: assess six ocular movements (downward and
lateral)
Trochlear
6 Motor: assess directions of gaze (lateral)

Abducens
 Cranial nerves
Cranial Nerves Assessment Method Patient’s Response

5 Sensory: while patient looks upward, lightly touch lateral Sensory: Able to feel cotton wisp on forehead, both cheeks
Trigeminal sclerae of eyes to elicit blink reflex.
To test Light Sensation, have patient close eyes, wipe a
and jaw. Able to feel blunt edge of neurohammer on
wisp of cotton over forehead and paranasal sinuses. To test forehead, both cheeks and jaw.
Deep Sensation, blunt end of an object over areas. Assess
skin sensation.
Motor: ask to clench teeth
Motor: Corneal reflex intact. Patient blinked when a cotton
wisp was applied.
Able to clench teeth and chew food without difficulty.
7 Motor: ask to smile, raise eyebrows, frown, puff out cheeks Motor: Able to smile, raise eyebrows,frown, and close eye
Facial and close eyes tightly.
Sensory: ask to identify taste placed on tip and sides of
tightly without difficulty,
tongue; sugar, salt, lemon juice, quinine; identify areas of
taste. Sensory: Patient enjoys eating sweet food. Able to appreciate
chocolate.
8 Sensory; Romberg’s Test; Whisper Test, Rinne’s Test and Able to turn to the directions of the snapping fingers from
Acoustic Weber’s Test
behind.
 Cranial nerves

Cranial Nerves Assessment Method Patient’s Response

9 Sensory: apply taste on posterior tongue for Sensory:

Glossopharyng identification. Motor: Able to swallow food. Intact gag
eal Motor: ask to move tongue from side to side and reflex. Able to stick tongue out. Symmetrical
up and down. Assess for gag and swallowing
movement of the uvula and soft palate. Able
reflex.
to pronounce the word, “Ma”.
10 Motor and Sensory: assess for hoarseness of voice,
Vagus gag and swallowing reflex

11 Motor: ask client to shrug shoulders and turn head Able to shrug and turn head from side to side
Accessory to sides against resistance from SN’s hands. against resistance.
12 Motor: ask to protrude tongue at midline and Able to protrude tongue without dificulty
Hypoglossal move from side to side.
 Primitive Reflexes
Reflex Age at Disappearance Remarks
Rooting Reflex 4 months Absent

Palmar Grasp Reflex 6 months Absent

Plantar Grasp Reflex 15 months Absent

Moro Reflex 2 months None

Babinski Reflex 1 – 2 years old Absent

Reflexes
Reflex Age at Disappearance Remarks
Knee reflex +2 Normal
•Sensory Exam

Sensory Function

SENSORY FUNCTION
Parameter Results
Pain and Temperature Able to identify pain and temperature
on all extremities
Light Touch Able to identify light touch on all
extremities
Motor and Cerebellar Function

MOTOR FUNCTION
Parameter Results
Condition and movement of muscles All flexors and extensors 5/5 with good muscle tone

Gait and Stance Stands unsupported

Waddling gait

CEREBELLAR FUNCTION
Parameter Results
Ability to stand with eyes closed (Romberg) Done

Tremors, ataxia None

COURSE IN THE EMERGENCY ROOM
 8/19/2018
1:00 AM
 S/O:BP: 90/60; CR: 170 to 120; RR: 28; TEMP: 39.6; WT: 10 KG; HT:85
 02 SAT: 98%; CBG: 106; LAST SEIZURE 8/18 AT 10 PM
 Awake,alert, coherent, not in CPD, AS, PC, PERRLA, moist lips and buccal
mucosa, nonhyperremic tonisls, symmetric chest expansion, Harshbreath
sounds, adynamic precoridum, (-) murmur, soft non- distended abdomen,
gross normal extremities, CRT <2 seconds, full pulses
 8/19/18
1:00 am

 A: SIMPLE FEBRILE SEIZURE SECONDARY TO PCAP B

 P:IVF: D5 0.3 NACL 50 cc/hour (30/6)
 Labs: CBC Now, platelet, Na, K, Ca, Urinalysis, CXR-PAL
 Meds: Paracetamol 100 mg/ampule q 4 hours RTC for T >37.8 C (10.5 mkdose)
 Ceftriaxone 750 mg IVTT OD
 8/19/18
10:10 AM

 S/O: Patient had upward rolling of the eyeballs, stiffening of the upper and lower
extremities and generalized jerky movement which lasted for 1 minute, (+)
circumoral cyanosis

 A: Complex Febrile Seizure Secondary to PCAP-B

 P:Treatment: Start 02 at 2 lpm via nasal prongs

Midazolam 1 mg IVTT now
Continue Paracetamol RTC
Phenobarbital 15 mg/tab, 1 3/4 tablet BID; May use phenobarbital 60
mg/tablet, prepare 25 mg/tab 1 pptab BID
Midazolam 1 mg IVTT for frank seizure
 8/19/18
11:00 AM

 S/O: Patient had harsh breath sounds, and occasional wheezing, symmetrical
chest expansion

 A: Complex Febrile Seizure Secondary to PCAP-B

 P: PAI with salbutamol 1 nebule Q8 hours

Refer for any recurrence of seizure
Start phenobarbital now
8/20/2018

 T-39.7
 HR: 147
 RR: 40
 BP: 90 systolic
 02 saturation- 99%
 A: Complex Febrile Seizure Secondary to PCAP-B
 FOR ADMISSION
 IVF: D5 LR NACL 1L x 42 cc/hour (MR)
 CHEST X-RAY
8/19/2018

BRONCHOPNEUMONIA WITH
REGRESSION
CLINICAL CHEMISTRY

EXAMINATION 8/19/2018

SODIUM 134.60

POTASSIUM 4.34

CALCIUM 2.39
 HEMATOLOGY

COMPLETE BLOOD COUNT 8/19/2018

Hemoglobin 116
Hematocrit 0.34
Red Blood Cell 4.29
White Blood Cell 9.41
DIFFERENTIAL COUNT
Neutrophil Number Faction
Segmenters 0.68
Lymphocyte 0.17
Eosinophil 0.06
Monocyte 0.09
Basophil
BLOOD INDICES
MCH 27.10
MCV 78.30
MCHC 34.50
Platelet 274
COURSE IN THE WARD
 8/20/2018 HD

SUBJECTIVE OBJECTIVE
 LAST SEIZURE AT 2 PM 8/19/18,  AWAKE, ALERT, COHERENT NOT IN
FEBRILE CP DISTRESS, NO SKIN LESIONS,
EVEN SKIN COLOR, AS, PC, PERRLA,
NNVE, NCLAD, SCE, HBS, (-)
MUMURS, NCRRR, CRT <2 SECONDS,
NEURO PE- UNREMARKABLE
A: COMPLEX FEBRILE SEIZURE SECONDARY TO
PEDIATRIC ACQUIRED PNEUMONIA-B

PLANS SPECIAL ORDERS

 P: TPR Q 4 HOURS AND RECORD  MONITOR NEURO VS Q 4H AND
 IVF: D5 0.3 NACL 1L X 42 CC/HR (MR) RECORD
LABS: CHEST XRAY PAL, S. NA, S. K, S. CA, CBC,

PLATELET, URINALYSIS  MONITOR INTAKE AND OUTPUT Q
SHIFT AND RECORD
 MEDICATIONS: PARACETAMOL 100 MG IVTT Q 4H
RTC FOR 24 HOURS THEN PRN FOR FEVER (T>37.8
C)
 02 AT 2 LPM VIA NASAL CANNULA
 CEFTRIAXONE 1 GM IVTT OD ANST  WATCH OUT FOR FEVER
 MIDAZOLAM 1MG IVTT FOR FRAN SEIZURE RECURRENCE OF SEIZURE
 PHENOBARBITAL 60 MG/TAB TO MAKE 25
TACHYPNEA, DYSPNEA,
MG/PPTAB GIVE 1 PPTAB BID DESATURATIONS OR ANY
 AMIKACIN 150 MG IVTT OD NST (15MKDAY) UNTOWARD SIGNS AND SYMPTOMS
 PAI WITH SALBUTAMOL NEBULES Q 8 HOURS
 8/21/2018 HD 3

SUBJECTIVE OBJECTIVE
 AFEBRILE, AWAKE, IRRITABLE, NOT  NO SKIN LESIONS, EVEN SKIN
IN CPDE COLOR, AS, PC, PERRLA, NNVE,
NCLAD, SCE, CBS, (-) MURMURS,
SOFT NON DISTENDED ABDOMEN,
NCRRR, CRT <2 SECONDS, NEURO
PE- UNREMARKABLE
A: COMPLEX FEBRILE SEIZURE SECONDARY TO
PEDIATRIC ACQUIRED PNEUMONIA-B
PLANS
 02 AT 2 LPM
 FOR LP AT 10 30 AN TIDAY
 GIVE MIDAZOLAM 1 MG IVTT NOW
POST LP ORDER
 FLAT ON BED FOR 4 HOURS
 NPO X 4 HOURS UNTIL FULLY AWAKE
 MONITOR VS Q 15 MIN X HOUR, THEN Q 30
MINS X HOUR THEN Q HOURLY UNTIL STABLE
 SEND CSF SPECIMEN FOR THE FOLLOWING:
TT1-CSF GS/CS
 TT2- CSF- AFB, KOH, INDIA INK, CELL CT, DIFF
CT, SUGAR
 TT3- CSF- PROTEIN
 TT4- SAVE CSF
 WATCH OUT FOR BLEEDING AT LP SITE
CSF ANALYSIS 8/21/2018
BODY FLUIDS 7/9/2018 8/21/2018
SPECIMEN CSF CSF
PROTEIN 35.56 (5-40) 27.12 MG/DL (15-45)
PHYSICAL PROPERTY
AMOUNT ABOUT 5
COLOR XANTOCHROMIC
TRANSPARENCY SLIGHTLY HAZY
MICRO
CELL COUNT 4 2
RBC COUNT 2 248
DIFFERENTIAL COUNT
LYMPHOCYTES 100% 100
FLUID
SUGAR 2.88 3.11
SERUM
SUGAR 6.66 5.79
GRAM STAIN (-) 0-1 PUS CELLS, 0
KOH (-) FOR FUNGUS (-) FOR FUNGUS
INDIA INK (-)FOR CRYPTOPCOCCUS (-)FOR CRYPTOPCOCCUS
AFB (-) FOR ACID FAST BACILI (-) FOR ACID FAST BACILI
 8/22-24/2018 HD

SUBJECTIVE OBJECTIVE
 (-) SEIZURE  STABLE VITAL SIGNS, AFEBRILE,
ASLEEP, COMFORTABLE, , ADYNAMIC
PRECORDIUM, NCRRR, SOFT
ABDOMEN, CRT<2 SECONDS,
A: COMPLEX FEBRILE SEIZURE SECONDARY TO
ACUTE BACTERIAL MENINGITIS; PCAP B

PLANS
CONTINUE ANTIBIOTICS
CASE DISCUSSION
Seizure

 A sudden, uncontrolled electrical disturbance in the brain.

 May cause changes in behavior, movements or feelings, and in levels of
consciousness.

 Symptoms:
o Temporary confusion, staring spell, uncontrollable jerking movements, of the arms
and legs, loss of consciousness or awareness, cognitive or emotional symptoms such
as fear, anxiety or déjà vu.
Differential Diagnoses

Pediatric status epilepticus

Encephalitis
Meningitis
Febrile seizure
1. Pediatric Status Epilepticus (SE)

 Defined as a recurring and unpredictable seizure that lasts longer than 5

minutes, or having more than 1 seizure within a 5 minute period, without
returning to a normal level of consciousness between episodes.

 Medical emergency that may lead to permanent brain damage or death.

Types of SE

 Convulsive SE – more likely to lead to long-term injury. May involve jerking

motions, grunting sounds, drooling, and rapid eye movements.

 Nonconvulsive SE – appear confused or look like they’re daydreaming. May be

unable to speak and may be behaving in an irrational way.
Symptoms of SE

 Muscle spasms
 Falling
 Confusion
 Unusual noises
 Loss of bowel or bladder control
 Clenched teeth
 Irregular breathing
 Unusual behavior
 Difficulty speaking
 “Daydreaming” look
 STATUS EPILEPTPICUS PATIENT’S HISTORY

• Recurring and unpredictable • Fever (Tmax 39 C)

• Acute onset nonproductive cough
seizure that lasts longer than 5 • Multiple seizure lasting 20-30 sec, with body
minutes, or having more than 1 stiffening, 12 hours apart with return to
seizure within a 5 minute period, normal state of consciousness
without returning to a normal
level of consciousness between
episodes
• Muscle spasms
• Falling
• Confusion
• Unusual noises
• Loss of bowel or bladder control
• Clenched teeth
• Irregular breathing
• Unusual behavior
• Difficulty speaking
2. Encephalitis

 Inflammation of the brain most commonly caused by a viral infection.

 2 main types
o Primary encephalitis – when an etiologic agent directly infects the brain.
o Secondary encephalitis – results from a faulty immune system reaction to an
infection elsewhere in the body.
Presentation of Encephalitis

 Mildflu-like symptoms: fever, headache, aches in muscles or

joints, fatigue or weakness.

 Severe symptoms: confusion, agitation, hallucinations, seizure,

loss of sensation or paralysis in certain areas of the face and
body, muscle weakness, problems with speech or hearing, loss
of consciousness.

 Infants
and young children: bulging fontanels, nausea and
vomiting, body stiffness, poor feeding or not waking for a
feeding, irritability.
 ENCEPHALITIS PATIENT’S HISTORY

Fever • Fever (Tmax 39 C)

• Acute onset nonproductive cough
Headache • Multiple seizure lasting 20-30 sec, with body
Aches in muscles or joints stiffening
Fatigue or weakness
Bulging fontanels
Nausea and vomiting
Body stiffness
Poor feeding or not waking for a
feeding
Irritability
Meningitis

 Inflammation of the meninges surrounding the brain and spinal cord

 Swelling from meningitis triggers the symptoms of:

o sudden high fever o difficulty concentrating

o stiff neck o seizures
o severe headache that seems o sleepiness or difficulty waking
different than normal o sensitivity to light
o headache with nausea or vomiting o no appetite or thirst
o confusion o skin rash
 Signs in newborns
o High fever
o Constant crying
o Excessive sleepiness or irritability
o Inactivity or sluggishness
o Poor feeding
o Bulging fontanel
o Stiffness in a baby’s body and neck
Febrile seizure

 A convulsion in a child caused by a spike in body temperature, often from an

infection.
 Usually harmless and typically don’t indicate a serious health problem.
 Most often occur within 24 hours of the onset of a fever.

 Symptoms:
o Fever higher than 38.0 C
o Loss of consciousness
o Shaking or jerking arms and legs
Classification of Febrile Seizure

 Simple febrile seizure – most common type. Lasts from a few seconds to 15
minutes. Do not recur within a 24-hour period and are not specific to one part
of the body.

 Complex febrile seizure – lasts longer than 15 minutes, occurs more than
once within 24 hours or is confined to one side of the child’s body.