Case file: A, 2 year 3 months old boy

with fever and seizure

History of present illness:
3 days prior to admission: cough and colds. Other
complaints (-) Meds: OTC cough and colds remedies
2 days prior to admission: cough and colds (+), still
given the same meds. Other complaints (-)
1 day prior to admission: cough and colds (+), fever (+).
Meds: cough and colds remedies, panadol syrup.
Few hour prior to admission: fever (+), developed
seizure with upward rolling of eyeballs and drooling of
saliva, associated with movements of all extremities,
lasted for 3 minutes, then seizure subsided. After
seizure, patient was awake and cried. Then he was
brought to our hospital.

Case file: A, 2 year 3 months old boy

with fever and seizure
History of past illness:
(-) previous seizure with fever
(-) previous hospitalization

Family history:
Mother: (+) seizure with fever in
childhood
1st sibling: (+) seizure with fever at 2 y.o
(-) history of allergy

Case file: A, 2 year 3 months old boy

with fever and seizure
Birth & maternal history:
Born term to a 28 y.o. G2P2A0, via normal
delivery, (-) illness during pregnancy. Took
multivitamins from Obgyn. Routine ANC

Immunization history:
Completed primary immunization on BCG,
DPT, Polio, Hep. B, measles.

Nutritional history:
Fully breast-fed until 6 months, started on
solid foods around 6-7 months.

Case file: A, 2 year 3 months old boy

with fever and seizure
Presently: 3x meals, 2x snacks, 2x glass of milk.
Various diet.

Growth and development history:

1st tooth around 7-8 months
Gross motor:
Rolled over 3 months, sat with support 6-7 months,
sat without support 9 months, crawled 8-9 months,
walked by himself 13-14 months.

Fine motor:
Hands to mouth 4 months, grabbed on object 5
months, reached and hold and object 6-7 months,
finger food 9-10 months.

Case file: A, 2 year 3 months old boy

with fever and seizure
Language
Social smile 1 month, laughed 2-3
months, cooed 3 months, babbled 7-8
months, waved bye-bye 11-12 months

Presently: runs, steps up and down

stairs, scribbles, drinks from glass and
bottle, eats by himself using hands and
spoon, messy (+). Tells story with 2-3
words, fair pronounce.

Case file: A, 2 year 3 months old boy

with fever and seizure
PE

Awake, slightly irritable

T 38.6 oC, HR 135 bpm, RR 26x/min
BW 12.5 kg, height 90 cm, HC 49 cm
HEENT: normocephaly, (+) nasal discharge,
moist lips and oral mucosa, (+) hyperemic
pharynx, tonsils T1/T1
Neck: (+) palpable cervical lymph nodes, (-)
tenderness
Chest: symmetrical chest expansion, normal
breath sound, (-) additional breath sound.
Normal 1st and 2nd heart sound, (-) additional
heart sound

Case file: A, 2 year 3 months old boy

with fever and seizure
PE
Abdomen: flat, soft, (-) tenderness, liver and
spleen not palpable, normal bowel sound
External genitalia: testis +/+, (+) phimosis
Extremities: (-) deformity, warm extremities,
good peripheral pulses