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Pedia HX Seizure 1
Pedia HX Seizure 1
Pedia HX Seizure 1
SWU-MHAM gr 19
Informant: pt’s Mother
Reliability: 80%
General data:
A case of JRC, 5 y.o., male, filipino, Roman catholic,
born Feb 9, 2012, currently residing at Pahina San Nicolas,
Cebu City, admitted for the first time at VSMMC on July 14,
2017 at 6pm.
Chief Complaint:
o Seizure
o (“mag seizure sya basta
hilantan”) -mother
History of Present Illness:
Gestational History:
Prenatal:
Mother was 20 y.o. at pregnancy,
OB score was G1P0(0000)
1st prenatal visit at 8 wks AOG at the Health
Center on regular visits per schedule.
Given caltrate & ferrous sulfate as prenatal
supplements, received tetanus toxoid, 2 doses.
During pregnancy, mother was not diabetic,
hypertensive, non smoker & doesn’t drink
alcohol.
On 28 weeks, she had UTI, given w/ an
unrecalled antibiotic taken for 1 week at the
health center.
Natal:
Pt was premature on delivery at 32 weeks AOG
via NSD attended by a physician at Miller
Hospital. Birth weight was 1800 grams.
Neonatal:
According to the mother, pt had delayed
crying at birth and required resuscitation, OGT
was placed for feeding and was on incubator for 1
week.
Feeding history:
Pt was exclusively fed w/ breast milk via
OGT for 1 month then breastfed for another
month, then given w/ formula milk.
Complimentary feeding starts at 6 months
w/ cerelac, mashed vegetables, fish and am
until 2 yrs old when solid foods were
introduced.
Pt has good appetite. Usual diet consists of
rice, vegetables, meat, fish & dairy.
Multivitamins: Ferlin and Tiki-tiki syrup once
daily, unrecalled dose.
Developmental / Behavioral History:
Previous Hospitalizations:
2013 – Velez Hospital due to Gastroenteritis, 1 week
confinement.
2014– Velez Hospital due to Pneumonia
Seizure history:
2014 – 1st seizure episode associated w/ fever and
cough, seek consult in a private clinic, prescribed w/
phenobarbital 30 mg 1 tab/day for 60 days but with
poor compliance. Only given w/ 30 tabs.
Parents:
Mother is 25 y.o., housewife, and the primary
caretaker. Father is 26 y.o., unemployed. Both
parents are healthy.
Siblings:
pt is the only child
Familial Illnesses:
HFD includes DM & HPN on paternal side. No
family history of epilepsy.
Socioeconomic History:
Family lives on a 2 story house made of mixed
wood & concrete w/ 3 rooms, 1 restroom. There
are 8 persons living in the house. Extended
family setting.
The financial support of the family came fr the
pt’s paternal grandparents. In varying amounts.
Environmental History:
Pt is not exposed to cigarette smoke. Observe
Proper garbage segregation. They have their own
septic tank. Water for drinking is purified water,
while water for bathing/washing is fr MCWD.
REVIEW of SYSTEMS:
Cutaneous: no pruritus
Head:
Eyes: no abnormal lacrimation observed
Ears: no discomfort observed
Nose: runny nose w/ watery discharge, no
epistaxis
Cardiovascular: easy fatigability
Respiratory: no difficulty of breathing
Gastrointestinal: no vomiting, normal bowel
movement
Genitourinary: clear light yellow urine, no itching
Endocrine: no cold/heat intolerance
Nervous/ behavioral : hx of convulsions (3x), gets
upset when hungry and no food was offered
Physical Exam
General Survey:
Examined a conscious, afebrile, weak looking
child, not in respiratory distress w/ the ff V/S
of:
T- 36.9’C
CR-98 bpm
RR- 24 cpm
BP- 90/60
O2 sat- 96%
Anthropometric Data:
Wt: 23 kg
Ht: 98cm
Hc: 47cm
Cc: 75cm
Ac: 83cm
BMI: 23.9
WHO: wt for ht: overweight
BMI for age: overweight
Ht for age: Normal
Skin: fair complexion, -rashes, -edema, -jaundice,
good turgor except lower extremities dry, cracked
Head: Normocephalic, no lesion, hair- normal
texture, no lice/ nits
Face: symmetrical, no unusual facies, no deformities
Eyes: no redness, PERRLA, -discharges, visual acuity
not assessed.
Ears: No lesion, no discharges, responds when called
Nose: no alar flaring, septum at midline, watery
discharge fr runny nose
Mouth and throat: dry pinkish lips, milk teeth- plenty
of dental carries
Neck: no venous engorgement, no rigidity, no visible
swelling.
Chest & Lungs: no lesion, equal chest expansion, n
adventitious breath sounds
Heart & Vascular System: adynamic precordium, PMI not
visible, regular rhythm, distinct S1&S2
Abdomen: no lesions, distended w/ visible veins (AC 83cm)
Genitalia: not assessed
Extremities: no clubbing of fingers, no cyanosis, CRT
<2secs, small hands and feet
Spine: no deformities
Neurologic:
Behavior: pt had limited focus, mostly didn’t follow
commands
Mental Status: awake, oriented to person, not cooperative
most of the time
Motor: no involuntary movts
Reflexes: not assessed.
Cranial Nerves:
History:
5 yo, male
Fever(unrecalled), runny nose, weakness
-recent hx multiple episodes of febrile convulsions
lasting (1) 5 mins, (2) 30-45 secs.
Prior hx of febrile convulsions
PE:
1. Bacterial Meningitis:
Rulled in : +fever, +seizures
Rulled out: -nuchal rigidity, -brudzinski
sign, - kernig’s sign
2. Colds
r/i : +fever, +runny nose, + weakness
r/o : -seizures
3. Epilepsy
r/in : +seizures
r/o: seizure present only on febrile
state, -family history of epilepsy
Diagnostic Procedures: