Mindanao State University College of Medicine

Department of Pediatrics

CASE PRESENTATION
____________________________________________________
CASE PROTOCOL

RENNE JOY D. RULONA

August 1, 2016

IDENTIFYING DATA: Y.C.C, a 9-year-old, female, Filipino, Seventh Day

Adventist, currently residing at Purok 8, Tipanoy, Iligan City; admitted for the
1st time at Adventist Medical Center last July 20, 2016 at 5:00 PM.
CHIEF COMPLAINT: recurrent seizures for 2 days
INFORMANT & RELIABILITY: Mother, 95%
HISTORY OF PRESENT ILLNESS:
The present condition started 8 years 6 months prior to admission, as
an onset of tonic-clonic seizures with 30-40 second duration, occurring 5-6
episodes per night for 5 nights when the patient is asleep. The parents
consulted a private physician in Cebu City, CT scan of the brain and EEG
findings provided basis for diagnosis of epilepsy, and was prescribed with
valproic acid syrup (depakene) 1.5mL PO OD, which provided relief of
seizures.
Patient was seizure free for 6 months until 8 years prior, seizure
recurred occurring 2-3 episodes per night when patient is asleep with 30-50
seconds duration. Medication was continued, and parents failed to return to
Cebu for follow up checkup.
Patient tolerated the condition until 5 years prior, seizures during sleep
became more frequent occurring 3-5 episodes per night with 30-50 second
duration. Parents thought that the current medication has no effect so they
discontinued treatment for 1 year.
Four years prior, they were referred to a neurologist in Cagayan de Oro
City and was prescribed with Phenobarbital 30mg tab PO OD which provided
relief of seizure.
Patient was seizure-free and apparently well until 5 days prior to
admission, there was onset of cough and colds, productive with yellowish
sputum and clear nasal secretions, associated with undocumented fever and
chills. Patient was given Paracetamol 325mg tab PO every 4hrs which
provided relief of fever.
Patient tolerated condition until 2 days prior, seizures recurred
occurring with a duration of 30-50 seconds with 3-5 seconds interval
occurring all throughout the day. Persistence of symptoms and development
of weakness alarmed the parents. Hence opted for admission.
PAST MEDICAL HISTORY:
Patient had no history of previous hospitalizations, no previous
operations, no history of previous childhood illnesses like typhoid fever,
chicken pox, asthma, or mumps, and no known allergies to food and drugs.
Patient had a history of head trauma when she was 2 months old, after
her father hit her head into the ceiling during play.
BIRTH HISTORY:

Antenatal: Patients mother started prenatal check-up at 3 months of

pregnancy at their Barangay Health Center, with a total of 8 visits. Mother
had a total of 2 doses of tetanus toxoid vaccine. No history of maternal
illnesses such as infections, bleeding, preeclampsia/eclampsia, or UTI during
the course of pregnancy. At 7 months of pregnancy, mother had an accident
and fell into a canal, then at 9 months of pregnancy, mother slipped and fell
flat on her stomach.
Natal: Patient was delivered term via NSVD at home assisted by a
trained hilot. There were no complications during delivery. Birth weight was
unrecalled.
Neonatal: No noted abnormalities and complications. Newborn
screening was not done.
NUTRITION:
The patient was exclusively breastfed for 2 days and shifted to formula
milk (Bona, Bonamil, Bonakid) up to 2 years of age. Complementary feeding
was started at 6 months of age. Current diet includes mainly of rice, fish and
soup with vegetables. Supplement include Vitaplex with good appetite.
DEVELOPMENTAL MILESTONES:
Patients development was delayed compared with peers. The patient
started to hold head at 1 year old, roll over at 2 years old, still unable to
crawl, walk with support at 3 years old and talked mama and papa at 4
years old. First tooth erupted at 7 months.
FAMILY HISTORY:
Patient has a family history of hypertension, diabetes mellitus, asthma
and epilepsy on the maternal side.
IMMUNIZATIONS:
The patient has completed immunizations on BCG, DPT, OPV, Hepa B,
Measles, MMR and rotavirus.
PERSONAL AND SOCIAL HISTORY:
The patient is the eldest of two children of J., a 36-year-old, stay at
home mother, and A., a 39-year-old, electrician father. Patients younger
brother is aged 7 years old and currently a grade 2 student. Patient travels
around the house by rolling around and loves to play with brightly colored
objects.
There are 5 household members, with no history of exposure to
cigarette smoke and PTB. The familys source of drinking water is from a
water refilling station.
REVIEW OF SYSTEMS

General: (+) for weakness, weight loss, and changes in activity

Skin: (-) for discoloration, itchiness, and rashes
Head: (-) for headache, lesions and scars
Eyes: (-) for crossing, redness, and discharges
Ears: (-) for pain, discharges, and hearing loss
Nose and Sinuses: (+) for colds and discharges
Mouth and Throat: (-) for sore throat, hoarseness, dryness, and oral lesions
Respiratory: (+) for cough, (-) for difficulty of breathing
Cardiovascular: (-) for palpitations and chest pain
Gastrointestinal: (-) for abdominal pain, vomiting, LBM, constipation
Genito-Urinary: (-) for frequency, dysuria, hematuria
Neuromuscular: (+) for seizures, lower extremity weakness, (-) for
joint and muscle pains
Hematologic: (-) for bleeding, easy bruising, anemia, and epistaxis
Endocrinologic: (-) for heat/cold intolerance, polydipsia, growth delay
Psychological: (-) for hyperactivity, and sleep problems
PHYSICAL EXAMINATION
GENERAL SURVEY: awake, drowsy, poorly developed, fairly nourished,
small for age, not in respiratory distress
V/S:
T = 36.2C
PR = 75 bpm
RR = 29 cpm
BP =
90/60 mmHg
Ht = 114 cm
Wt = 17 kg
BMI: 27.3
O2 sat: 84%
HC = 49 cm
CC = 57 cm
AC = 49 cm
MAC
= 18 cm
SKIN: no rashes and lesions, warm to touch, good turgor
HEENT: normocephalic, no lesions, pinkish palpebral conjunctivae, anicteric
sclerae, clear nasal discharges, moist and pale lips and oral mucosa, tonsils
not inflamed and enlarged
NECK: supple, no jugular vein distention, no lymphadenopathies
CHEST & LUNGS:
Inspection: no supraclavicular, intercostal or subcostal retractions
Palpation: equal chest expansion
Percussion: resonant lung fields
Auscultation: harsh breath sounds with diminished breath sound over
upper lung fields
HEART:
Inspection: PMI is at 4th ICS, LMCL
Palpation: no heaves or thrills
Percussion: CAD not enlarged
Auscultation: distinct heart sounds with normal rate and regular
rhythm, no murmurs
ABDOMEN:

Inspection: flat, no scars

Auscultation: normoactive bowel sounds
Percussion: tympanitic all over
Palpation: soft, no organomegaly
GU: grossly female
EXTREMITIES: atrophic lower extremities with poor muscle tone, equally
palpable good peripheral pulses, CRT <2 seconds
ANUS: patent
NEUROLOGIC EXAMINAITON
Mental Status: drowsy, not able to communicate, recognizes brightly
colored objects, able to talk mama and papa only, unable to perform
skilled motor skills except grasping
Cranial Nerves:
Olfactory not assessed
Optic unable to assess visual acuity, funduscopic exam normal (positive
red-orange reflex)
Oculomotor, Trochlear, Abducens able to elevate eyelids and move
eyeballs in the 6 cardinal extraocular movements of the eye
Trigeminal brisk corneal reflex, symmetrical facial sensation
Facial symmetric facial expressions when smiling or crying
Vestibulocochlear not assessed
Glossopharyngeal able to elevate palate and uvula at midline, positive
gag reflex
Vagus able to swallow
Accessory unable to shrug shoulders on command, strong trapezius and
sternocleidomastoid muscles
Hypoglossal tongue at midline, no tremors
Cerebellar Function: unable to follow command on finger to nose test and
rapid alternating movements of the hand; unable to stand unsupported due
to weak lower extremities; flaccid posture with poor muscle tone; no tremors
Motor System: upper extremities with fair muscle size, good muscle tone
and muscle strength 5/5; lower extremities are atrophic with poor muscle
tone and muscle strength 3/5; no muscle fasciculations and tremors
Reflexes: 2+ for biceps, triceps, brachioradialis reflexes; 1+ for quadriceps
and Achilles reflexes
Sensory Examination: withdraws extremity to pain, reacts to touch and
vibration
Meningeal Signs: no neck rigidity, Kernig and Brudzinski sings
Autonomic Function: still unable to control urine and bowel movements
PRIMARY IMPRESSION:
Status Epilepticus
Cerebral Palsy
PCAP - C

LABORATORY EXAM RESULTS

July 20, 2016
@ 6:30 PM
CBC & Platelet
Red blood cell
Hematocrit
Hemoglobin
WBC
Segmenters
Lymphocytes
Stabs
Monocytes
Eosinophils
Basophils
Platelet count

Result
4.06
0.35
122.0
10.6
0.59
0.38
0
0.03
0
0
423

Normal Values
4-6 x 10 12/L
0.37-0.47
110-180 g/L
5-10 x 10 9/L
0.50-0.65
0.25-0.35
0.05-0.10
0.03-0.07
0.01-0.03
0.01
140-450 x 10 9/L

@ 6:35 PM
Test
SGPT (ALT)
HGT
Potassium

Result
22.4
67
4.37

Normal Values
5-35 U/L
70-110 mg%
3.5-5.3 mmol/L

Sodium
Calcium

149.4
1.46

135-148 mmol/L
2.2-2.7 mmol/L

@ 7:00 PM
Imaging
Findings
Chest Xray - Minimal streaks densities seen at the right
APL
upper lung.
- No hilar lymphadenopathies.
- The heart and thymus are normal in size
and orientation.
- The diaphragm and costophrenic sulci are
intact.
- The bony thorax is normal.

Impression
PNEUMONIA,
right upper
lung

July 23, 2016

@ 7:37 AM
Urinalysis
Color: Yellow
Transparency: Hazy
Volume: 20 cc
Specific gravity: 1.010
pH reaction: 6.0
Protein: Negative
Sugar: Negative
Acetone: Negative
Blood Occult: +1
Microscopic
WBC: 0-2/hpf

RBC : 3-6/hpf
Epith-Squamou: +2
Epith-Round : Negative
Amourphous Sed: Negative
Crystals : Negative
Casts: 0
Mucus: +1
Bacteria: +1
Routine analysis includes all of the
above
Urobilinogen: Negative
Bilirubin (Bile): Negative

COURSE IN THE WARD

The patient came in at the emergency room due to recurrent seizures
for 2 days. Patient then had 1 episode of tonic-clonic seizure with upward
rolling of eyeballs, and was placed side-lying, with seizure duration of 42
seconds. Post-ictal, patient was unconscious, then regained consciousness
30 sec after, appeared weak with oral salivary secretions. Patient was then
placed on O2 inhalation @ 2LPM via nasal cannula. After 6 minutes, patient
again had another seizure attack which lasted for 38 seconds. Patient was
then admitted and started with D50.3NaCl 500cc to run at 55cc/hr. HGT was
done with a result of 87 mg/dl. The present IV is to be followed with D5NM 1
L at a rate of 55 cc/hr. The patient was given Phenobarbital 170 mg loading
dose IV to be given within 3 minutes, with a maintenance dose of 43 mg slow
IV every 12 hours (6AM 6PM). The laboratory exams ordered were CBC with
platelet, urinalysis, sodium, potassium, calcium, HGT, SGPT and CXR PAL.
Patient was on NPO temporarily, with vital signs to be monitored every 2
hours, input and output to be monitored every shift, O2 inhalation at 1-2 LPM
to maintain O2 sat 95%, and to suction oral secretions.
Six hours post admission, patient had another seizure episode, was
given Diazepam 2 mg IVTT, and was referred to a neurologist for consult.
Patient was maintained on NPO and started with Ranitidine 17mg IVTT every
8hrs. CXR results revealed pneumonia on the right upper lung, and was
started with Cefuroxime 500mg IVTT every 8hrs ANST. Calcium was also
decreased at 1.46 mmol/L and was started with calcium gluconate 10mL +
20mL sterile water very slow IV for 30min to 1hr every 6hrs for 4 doses
under cardiac monitoring, to be deferred if hear rate < 80bpm. Current IVF
rate was reduced to 25cc/hr and vital signs were monitored every 15min
while on calcium gluconate.
On the first hospital day, patient had 2 episodes of seizures with stable
vital signs and occasional cough. Patient was seen by a neurologist and
diagnosis were Status Epilepticus, Seizure Disorder, Cerebral Palsy. Advised
to start another IV antiepileptic (i.e. phenytoin and valproic acid) if still with
seizures. Valproic acid was started at 85mg every 12hrs slow IV (12MN
12NN). Phenobarbital was also revised to 28mg every 8hrs IVTT (2AM 10AM
6PM). Also suggested to subject patient to continuous EEG monitoring.
Calcium gluconate was completed. Other medications were continued, O2
inhalation was maintained at 1-2LMP via nasal cannula, secretions were
secreted, vital signs monitored every 2hrs and intake and output monitored
every shift.
On the second hospital day, patient had 1 episode of seizure, with
stable vital signs and occasional cough. Inserted with NGT Fr. 12 for feeding

and started with milk feeding 100mL every 6hrs, with aspiration precaution,
and placed on moderate high back rest. IVF to be followed with D5NM 1L at
55cc/hr. Other medications were continued, O2 inhalation maintained at 12LPM via nasal cannula, vital signs monitored every 2hrs and input and
output monitored every shift.
On the third hospital day, patient had no episode of seizure for 24hrs,
with stable vital signs and bouts of cough. NGT feeding was increased to
100mL every 3hrs, with aspiration precaution. Patient started with
Salbutamol nebulization 1neb + 2mL NSS every 6hrs. IVF to be followed with
D5NM 1L at 55cc/hr. Medications were continued, O2 inhalation maintained
at 1-2LPM via nasal cannula, vital signs monitored every 2hrs and input and
output monitored every shift.
On the fourth hospital day, patient was seizure-free for 48hrs, with
stable vital signs. Valproic acid IV was discontinued and was started on
valproic acid syrup (250mg/5mL) 2mL BID PO. NGT was removed and oral
feeding with formula milk was increased to 150mL every 3hrs, with
aspiration precaution, to feed in upright position. IVF rate was decreased to
40cc/hr, to be followed with D5NM 1L at 40cc/hr. Other medications were
continued
On the fifth hospital day, patient was seizure-free for 72hrs, with stable
vital signs. O2 inhalation via nasal cannula was discontinued with O2
saturation of 98% room air. Phenobarbital IV was discontinued and was
started on phenobarbital 30mg tablet, 1 tablet BID 1hr apart from valproic
acid. Oral milk feedings were continued, other medications were continued,
IVF to be followed with D5NM 1L at 40cc/hr, vital signs monitored every 2hrs
and input and output monitored every shift.
On the sixth hospital day, patient was seizure-free for 96hrs, with
stable vital signs. Patient was discharged with maintenance medications of
valproic acid syrup (250mg/5mL) 2mL PO BID (6AM 6PM) and phenobarbital
30mg tablet PO BID, 1hr apart from valproic acid (7AM 7PM). Other home
medications include cefuroxime suspension (250mg/5mL) 5mL PO BID for
7days, and guaifenesin+salbutamol syrup (Ventolin expectorant) 5mL PO
TID. Advised for follow up checkup a week after and follow up checkup with a
neurologist. IVF removed aseptically, discharged improved.
Final Diagnosis:
Pediatric Community Acquired Pneumonia C
Status Epilepticus
Seizure Disorder
Cerebral Palsy