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Patient’s Record
PATIENT’S IDENTITY
Register number : 49.XX.XX
Patient’s name : MAG
Date of birth : 13th March, 2017
Age : 5 month
Gender : Male
Nationality : Indonesia
Date of admission : 15th August
2017
3
Parent’s Identity
FATHER MOTHER
Name : LG AM
Age : 28 years 25 years
Occupation : Private employee Nurse
Education : College degree Diploma degree
4
History
(alloanamnesis on the parent’s and medical record)
6
PERSONAL/ SOCIAL HISTORY
10
PATIENT’S HOSPITAL
ADMISSION SUMMARY
Prior to initial observation (15th - 17th
August 2017)
BW : 6.2 kg, BL : Leucocyte :
63cm 10.470/mm3
Shortness of
RR: 78x/m, S: CRP : 12
breath, fever,
cough 38.5oC Chest radiograph :
Thorax: infiltrate on both
Seizure
retractions, ronchi lungs
(+) EEG : abnormal 11
Diagnosis :
Frontal Lobe Epilepsy
with Global Delay Development
and Severe Bronchopneumonia
Therapy :
• cefotaxime and gentamycine injection,
• dexamethasone injection,
• valproic acid 25 mg/kg/day,
• paracetamol
• diazepam suppositoria prn
12
PHYSICAL EXAMINATION
(18th August 2017)
General condition : looked ill, compos mentis
Antropometric status
Body weight : 6.2 kg Body length : 63 cm
Based on the WHO Z-score weight for length curve : Between -1 and -2 SD
Nutritional status: good nutritional status
General condition : Looked ill Consciousness : Compos mentis
Pulse rate : 95 times/minutes, regularly
Respiratory rate : 28 times/minutes
Temperature : 37°C
13
Head and neck
Head : LK 41 cm normocephaly, black colour hair, not easily pulled out,
head lag (+)
Eyes : Conjunctiva was not anemic, sclera was not icteric. Pupil was round,
isocoria, 3-3 mm, light reflex normal
Ears : Clear meatus acusticus externus, normal ear drums, no discharge
Nose : There was no discharge and no nasal flaring.
Mouth : There was no cyanosis, tonsils T1/T1 without inflammatory sign,
pharynx no inflammatory sign
Neck : There was no lymph node enlargement, trachea position was in the
midline, no thyroid enlargement
14
Head circumference
Normocepha
l
15
Thorax
Heart : within normal limit
Lung :
- Inspection : symmetrical respiration
movement on the both side hemithorax,
with subcostal retractions
- Palpation : equal vocal fremitus right = left
- Percussion : sonor percussion right = left
Diagnostic
• Waiting for result of blood culture and
susceptibility test.
19
MANAGEMENT PLANS
• O2 1-2 L/m
• IVFD KAEN 4B (maintenance rate according to Holliday Segar) = 15 micro
drops per minute
• Cefotaxime injection 3 x 300 mg iv
• Gentamycine injection 1 x 30 mg iv
• Dexamethasone injection 3 x 1 mg iv
• Paracetamol syrup 3 x cth ½
• Depakene syrup 2 x 1.5 mL (dosage 25 mg/kg/day)
• Stesolid suppositoria 5 mg prn seizure
20
Pediatric nutritional assessment
and care
Determination of nutritional status
Body weight : 6.2 kg Body length : 64 cm Nutritional status: good
nutritional status
Nutritional requirement : based on Recommended Daily Allowance (RDA)
Calories = 108 x 6.2 = 669.6 kcal/day
Protein = 2.2 x 6.2 = 13.64 gram/day
Fluid = maintenance rate according to Holiday Segar = 620 ml/day
Administration route : parenteral and enteral
Monitoring and evaluation : tolerance, adverse reaction, body weight
monitoring. 21
Monitoring plans
23
19th August 2017
(Observation day - 2, 5th day
P : of hospitalization)
IVFD KAEN 4B (maintenance
rate according to Holliday Segar)
= 8 micro drops per minute
S : Fever (-), seizure (+) twice, the Cefotaxime injection 3 x 300 mg iv
seizure was described as left hand and (4)
left feet was lifted up slowly, intake (+) Gentamycine injection 1 x 30 mg iv
O : General condition : look sick (4)
Conciousness : compos mentis Dexamethasone injection 3 x 1 mg
Vital sign : HR : 108 x/m, regular iv (4)
RR : 38 x/m S : 36.4°C Paracetamol syrup 3 x cth ½
Thorax : Symmetrical chest expansion, Depakene syrup 2 x 1.5 mL
no retractions (dosage 25 mg/kg/day)
Stesolid suppositoria 5 mg prn
A : Bronchopneumonia (J18.0) + seizure
Frontal lobe epilepsy (G40.209) + Monitoring : clinical symptoms,
Global delay development (R62.50) vital signs. 24
Nutritional care : RDA
Plan: wait for blood culture
20th – 22nd August 2017
Consultation to Child Development
(Observation day 3 – 5, 6th – 8thPday
Division (23rd August 2017)
IVFD of hospitalization)
KAEN 4B (maintenance
rate according to Holliday Segar)
Developmental delay :
= 8 micro drops per minute
Personal social : according to 2
Smonths
: Fever (-), seizure (+) twice, the Cefotaxime injection 3 x 300 mg iv
seizure was described as left (5-7)
Language : according to hand
4 and
left feet was lifted up slowly, intake (+) Gentamycine injection 1 x 30 mg iv
months
(5-7)
OFine
: General condition :: look
motoric/adaptive sickyet
had not
Dexamethasone injection 3 x 1 mg
developed
Conciousness : compos mentis iv (5)
HRGross
: 94motor
x/m RR : 30 : had
x/mnotSyet: 36.4°C Paracetamol syrup 3 x cth ½ prn
developed
Thorax : Symmetrical chest expansion, Depakene syrup 2 x 1.5 mL
Suggestion :
no retractions (dosage 25 mg/kg/day)
TORCH tests
: Bronchopneumonia (J18.0) +
ARehabilitation Stesolid suppositoria 5 mg prn
seizure
Frontal lobe epilepsy
Blood culture: (G40.209)
No bacterial growth+
Monitoring : clinical symptoms,
Global delay development (R62.50)
vital signs. 25
Nutritional care : RDA
Plan: wait for blood culture
23rd – 25th August 2017
(Observation day 6 – 8, 9th – 11th day of hospitalization)
• Ad vitam : bonam
• Ad functionam : dubia ad malam
• Ad sanationam : dubia ad malam
28
29
30
DISCUSSION
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Frontal lobe epilepsy (FLE)
• Unilateral clonic seizures
• Tonic asymmetric seizures with preserved consciousness
• Hypermotor seizures
• Brief (30”- 2’)
• Begin with screaming, severe agitation, stiffening and
kicking, or bicycling movements of the legs.
32
The Patient
• Recurring tonic seizure since 3 weeks the left hand and
leg was stiff throughout the seizure episode and the right
extremities was flaccid
• Happened while asleep
• 3 times/day
• < 1 minute
• Fully alert between seizures
33
Electroencephalogram (EEG)
Recording on the sleep phase 2-3 Hz delta wave on the
background, high amplitude, symmetrical and reactive.
Spikes was often found on the independent bilateral
frontopolar area, the right area was more than the left
area, with 2-2.5 Hz high amplitude focal deceleration.
Conclusion : abnormal EEG, supporting a diagnosis of
frontal lobe epilepsy, possibly a symptomatic epilepsy
34
Diagnosis
35
Problem
• Seizure control
• Developmental delay present in this patient :
• 5 mo head lag (+)
• Delay of personal social and language development, and a
significant or almost no development on the fine and gross motor
development
Continuous rehabilitation
36
Discussion
• Fever
• Cough All
• Increased work present in
of breathing this
• Chest patient
indrawing/cyan
osis
38
Laboratory evaluation
• Leucocyte
This
• CRP patient :
• Procalcito Increased
nin CRP
39
Frontal Global
Lobe Delay
Epilepsy Developmen
t
Pneumoni
a
40
Berg et al
Causes and risk of death in children followed from onset of
epilepsy and to contrast the risk of seizure-related death with
other common causes of death in the population
Seizure related
recommendation)
Concern : The Development
Relationship between cortical brain morphology and cognitive
functioning in a cohort of children with FLE and healthy controls.
Thirty-four children and 41 healthy age-matched controls underwent
neuropsychological assessment and structural brain MRI. The group of
cognitively impaired children with FLE had significantly
smaller left temporal cortex volumes , specifically middle
temporal grey matter volume and entorhinal cortex thickness. These
findings might well explain the broad scale of cognitive domains
affected in children with FLE complicated by cognitive impairment and
highlight that FLE impacts on areas beyond the frontal lobe
Braakman. Acta Neurol Scan. 2014
(Level of evidence 2b, B 43
recommendation)
Concern : The Development
Executive functioning deficits that might differentiate children with
frontal lobe epilepsy (FLE) from children with temporal lobe epilepsy
(TLE) 19 youth with intractable FLE and 47 youth with intractable TLE.
Participants completed the Wisconsin Card Sorting Test (WCST), verbal
fluency, Trail Making Test (Trails A and B), Digit Span Forward (DSF),
and Digit Span Backward (DSB). Overall, the results indicated that
youth with FLE had significantly greater difficulty with
concept formation compared to children with TLE. Both groups
performed significantly below the normative sample
Longo et levels &
al. Epilepsy onBehaviour.
attention
and working memory tasks. 2014
(Level of evidence 2b, B 44
recommendation)
Concern : The Development
Cerebral network characteristics are associated with epilepsy and
cognitive comorbidity. 37 children with FLE and 41 healthy age
matched controls. Cognitive performance was determined by means of
a computerized visual searching task. FLE patients displayed a
higher modularity, implying that subnetworks are less
interconnected. Impaired cognition was associated with higher
modularity scores and abnormal modular organization of the brain,
which was mainly expressed as a decrease in long-range and an
increase in interhemispheric connectivity in patients.
Vaessen et al, Cerebral Cortex,
2013
(Level of evidence 2b, B 45
recommendation)
Challenges
Minimize complication
Proper education to the
family
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