Case Report 4

Simple Febrile Seizure

By :
Erina Puspitasari Priyatna

Supervisor :
M Diana Rahim, MD
Patient Identity
 Name : An.M A
 Age : 3 years old
 Gender : Male
 No. RM :-
 Admission Date : March, 9th 2021
 Address :
Clinical pathway

8/03/2021 09/03/2021
Seizure with febrile Referred to :
Emergency Department
Unit Guntur Hospital
with CC: seizure (+)
febris(+)
Clinical pathway
Subjective

A 3 year old baby boy was brought by his parents to Guntur Hospital with complaints of
seizures approximately 1 day before entering the emergency room at Guntur Hospital.
The seizure only happened once. The duration of the seizures is about 5 minutes.
During a seizure, the patient's hands are clenched into fists and the upper arms and
lower legs vibrate as if someone were shivering. The eyes bulged upwards, and the
patient's mouth was like a grin, but no foam came out of the patient's mouth and the
tongue was not bitten. When a seizure occurs the patient is unconscious and after the
seizure the patient is conscious but his body becomes weak. The patient's mother
admitted that before the seizure the patient had a high fever. Fever occurs since
approximately 1 day before admission to the hospital. Fever appears suddenly. The
patient did not experience cough and diarrhea. only had a cold for 2 days.
Clinical Pathway
EMERGENCY DEPARTMENT UNIT

O : N: 60x/m, RR: 20x/m, T:36,9 SpO2 97% free air,deficit • Advice dr Manan Sp.A
neurologic (-) Acc non-isolation ward
A : observasi konvulsi dd/ simple ferile seizure IVFD RL 40dpm
P: Cefotaxime 2x500mg IV
O2 nasal canule 5 LPM Dexametasone 4x0,8ml IV
IVFD asering 20dpm Valisanbe 4mg IV (febris)
Infus PCT 3x500 mg Paracetamol 3x1 ¼ cth PO
Valisanbe 1x4mmg IV
Clinical pathway
Laboratory examination
Hemoglobin 11.5 gr/dl
Leukosite 8900 /m3
Trombosite 225.000/ mm3
Erythrosite 4.35 million/mm3
NLR 3.19 (<3,12)
Diff count 0/2/3/67/21/7
GDS 116 g/dl

SWAB ANTIGEN NEGATIF

DIAGNOSIS
Simple Febrile Seizure
 Follow Up
March, 10th 2021

S: febris (-)
O: PR: 70 bpm, RR: 20 bpm, S: 36 OC,
SpO2 98%free air
A: Simple Febrile Seizure
P: Discharge
Cefixime 3x1cth PO
Stesolid 5 mg supp