CASE PRESENTAION :

CASE NO. 1
Diagnosis:
FEBRILE FITS
Logbook Case#: 20

Patient Identification & Demographics

Patient Name: XYZ Hospital: LRH Ward :CWA

Bed#: 6 Address: Peshawar Occupation: child

Gender: female Age: 1/1/2 year

DOA: 28 NOV ,18 TOA: 12:00 am MOA: emergency DOD: 1/12/ 18

Chief Complaints:
Fever with Fits
History of Present Illness:
According to patient attendant child got fever along with one episode of fits
for 10 min .
Fever is continuous in nature ( mild - moderate )
Past Medical History: Nill
Past Surgical History: no past surgery history

Family History: Nill

Social History: Poor Socioeconomic status

Allergies (Non-drug): no known allergies

MEDICATION HISTORY
Drugs Purpose of use Duration Status Respons U-eff Complia
e nce

PANADOL FEVER TID ,1 day l Discontinue N/S N/A FAIR

SYRUP d
Other History :
Pregnancy : normal ,Complication : nill
Place : hospital ,Type of delivery : normal ,
Development history : normal

PHYSICAL EXAMINATION (only relevant positive findings)

General: Vital Signs: PR 76 b/min TEMP : 99
Systemic:
Cardiovascular: S1 +S2 +0
Gastrointestinal: Normal
Respiratory: normal
Nervous system: normal
Skin: normal
Genitourinary: normal
Other:

RESULTS OF RELEVANT LABORATORY

TESTS
HEMATOLOGICAL TESTS

TESTS Normal ranges 28/11/18

Hgb test gm/dlt 11.5-17.5 10.9↓
WBC x10.e3/micro lt 4- 11 18↑
Neutrophils % 40-75 70
Lymphocytes % 20-45 25
Monocytes % 2-10 1↓
Eosinophils % 0-6 4
PLT % 150-450 332
MCV fl 76-96 72.8↓
MCH pg 27-33 25.8↓
MCHC g/dl 33-35 35.4↑
RBC x10.e6/micro lt 4-6 4.23

LFTs
Bilirubin Total mg/dlt 0.1-1.0 0.34
ALT/ SGPT U/L 10-50 11
ALP U/L 40-129 96
Creatinine
0.64-1.2 0.6
mg/dl

RFTs
urea mg/dlt 18-45 31

ELECTROLYTES

Na mmol/lt 135-150 140

Cl mmol/lt 96-112 102.7

K mmol/lt 3.5-5.1 4.53

RBS mg/dlt 70-140 174↑

CSF TEST
PHYSICAL EXAMINATION :
Volume : 2ml
Turbidity : nill
Clot : nill
Colour : straw
CHEMIMICAL EXAMINATION:
Protein : 23 mg/dl
Glucose : 56 mg/dl

MICROSCOPIC EXAMINATION :
WBC 5 mg/dl
RBC 45mg/dl
Differential leukocyte count
Neut 0%
Lymp 100%

Gram stain nill

Zn stain no AFB seen

DIAGNOSIS: FEBRILE FITS

TREATMENT AT HOSPITAL
Start- Dosage-Form, Brand (Generic), Dose, Route, Frequency & Stop-
Date Duration Date

28/11/18 Inj ceftriaxone 1.5gm IV OD in 20 mg N/saline 1/12/18

28/11/18 Inf dextrose /S 450 mg 30/1/18

28/11/18 Inf provas (paracetamol ) 20 mg IV SOS 1/12/18

28/11/18 Inj valium (diazepam )1cc IV SOS 1/12/18

29/11/18 Syp brufen (ibuprofen )100 mg 1TSP TDS 1/12/18

DISCHARGE MEDICATIONS
Dosage-Form, Brand (Generic), Dose, Route, Frequency & Advice / Remarks (If
Duration any)

Inj rocephin 1gm 4 days

Syp brufen 100 mg 1TSP TDS SOS

Syp vidylin -M

DAILY PROGRESS REPORTS (DPRs)

DATE 28/11/18
10:20 AM
SHIFTED TO CONCERNED WARD
Patient with febrile convulsions

DATE 29/11/18
Fever with fits
1 episode 10 min
O/E vitals are stable and A febrile
CNS intact
CVS S1+S2-0
CHEST B/C
DATE 30/11/18
R/E
cough and fearful jurking
O/E
Chest not clear , Abdomen soft .HR 100 RR 35 ,TEMP 99F
Patient was stable now and no new episode of fits were seen

CASE ANALYSIS/DISCUSSION
SIGNIFICANT FINDINGS OF MEDICATION HISTORY (Medications used before
admission to hospital):

Number of drugs before admission to hospital: 1

Names of Drugs used:
Panadol syp
Allergy:
NILL
Response:
WHEN USED SATISFACTORY
Compliance: fair

MEDICATIONS:
Number of drugs in hospital treatment Chart: 5

DRUG#1: Inj ceftriaxone 1.5gm IV OD in 20 mg N/saline

AVAILABILTY/STRENGHT:
IM inj 250 ,500 mg ,1 gm ,2 gm in vial
IV inj 250 ,500 mg ,1 gm ,2 gm in vial
INDICATION :for prevention of of meningicoccal meningitis
RECOMMENDED DOSE:
For adults 1-2 gm 0D ,For children 20- 50 mg / kg OD

DRUG#2: Inf provas (paracetamol ) 20 mg IV SOS

AVAILABILTY/STRENGHT:
Tab 500 mg ,Inf 1 gm
Sus/elixer/liq 120 mg 125 mg 150 mg 160 mg 250 mg
Suppositories 80 mg 125 mg 250 mg 300 mg 650 mg
INDICATION : analgesic and used for fever
RECOMMENDED DOSE: 10-15 mg /kg/dose

DRUG#3: Inj valium (diazepam )1cc IV SOS

AVAILABILTY/STRENGHT:
Inj/ ml 5mg/ ml 10 mg/ml
Solution per 5 ml 10 /5 /2 mg
Rectal suppositories 10mg/5mg
INDICATION : for febrile convulsions
RECOMMENDED DOSE: for children 0.25 mg/kg

DRUG#4: Syp brufen (ibuprofen )100 mg 1TSP TDS

AVAILABILTY/STRENGHT:
Susp 100 mg /5 ml
Tab 200 mg 400 mg 600 mg 800 mg
Cap 100 mg 200 mg 400 mg
INDICATION : Mild to moderate pain Pyrexia with discomfort
RECOMMENDED DOSE: for children age 1 -3 ,100 mg 3 times a day

DRUG INTERACTIONS
VALIUM - PROVAS
Valium decrease the concentration of provas by increasing the metabolism
Minor /significance unknown
By increase metabolism will increase levels of hepatotoxic metabolites

COMPLIANCE: good
PATIENT EDUCATION/COUNSELING & DRUG INFORMATION
Educated regarding discharge medications and their use .
DISCUSSION/COMMENTS (If any)
Patient was now stable and was discharged with home base treatment .