Febrile Convulsion

Casebank History
1

Where you are:
You are an FY2 working in the Paediatric Department.

Who the patient is:
Mrs. Sari Knowles has brought her 2-year-old son Alex Knowles. Alex had a fit at home.

Other information:
Jenny had a fit at home which lasted 2 minutes. Her temperature is 38.5 C. On examination, there is redness over the left eardrum. The rest of the nose and throat are normal.

Special note:
None

What you must do:
Please talk to Mrs Knowles, take a focused history, discuss management with her, and address her concerns.

Patient Information:

  • Your name is Sari Knowles. You are a 30-year-old lady.
  • You have brought your 2-year-old child because the child had a fit at home 2 hours ago. This is the first time it has happened.
  • You have got 2 children at home.
  • You were in the kitchen and the 2 children were in the living room.
  • Then the older child who is 6 years old called you to say that Alex was having a fit. After the seizure, the child went floppy and pale.
  • In the last 24 hours, Jenny has been touching the ear vividly and there has been discharge from the ear.
  • The child is up to date with all immunisations.
  • The child was pulling and touching the ear but not crying.
  • There is no other past medical history, no allergies, and no regular medications.
  • You are worried about meningitis because your neighbour’s child had meningitis / you read in the news that there are many children now getting meningitis.

Questions:

  • Is febrile convulsion dangerous?
  • What caused it?
  • Will it happen again?
  • What should I do if it happens again?
  • Can I prevent it?
  • Could it be a meningitis doctor?

Before:

  • Can you please tell me what happened in detail?
  • What happened just before the fit?
  • Did he have his food as usual? (hypoglycaemia)

During:

  • How long ago did he have the fit?
  • How long did it last?
  • Did he (LOC/ wet himself/ bite his tongue)
  • Has h e ever had s u c h a fit before?

How is he in general?
Is he normally fit and well?

DDs for convulsions:
Head from outside to inside

  • Head injury
  • Meningitis (fever + rash)
  • SOL (early morning vomiting + limb weakness)
  • Hypoglycaemia (drowsy + sweating)
  • Epilepsy (jerky movement + LOC)
  • Febrile convulsion: FEVER Discharge from (ear - nose - eye)

Data Gathering

Introduction:
D: Hello my name is dr.), one of the junior doctors in the department,
can I confirm Alex’s full name, your relation to him and his age, please?

Confirmed
Paraphrase:
D: I can see from my notes that your son is here because he had a fit, can you tell me more about it? Yes

P1 (BEFORE - DURING - AFTER)
D: Can you tell me more about that? I was in t h e kitchen when his older brother called m e because his brother w a s ‚having a fit; h e was jerking and moving all of his limbs and h e fainted.
D: Did he bite his tongue? No.
D: How long did this last? 2 mins.
D: Did he hurt his head by any chance? No.
D: Has he been eating as normal? Not really
D: Have you noticed anything else wrong with him? Well, In the last 2 4 hours, h e was touching his left ear a lot, a n d I noticed there was some discharge coming out of it. (+ve finding)
D: Have you noticed any fever? I am not sure.
D: After the fit, did he regain his consciousness? He was floppy and pale.

DDS:
Head to toe
D: Did you notice any rash? (meningitis) No.
D: Any early morning vomiting? (sol) No.
D: Any family history of epilepsy? No.

P2
D: Has he had this problem before? No.
D: Has your baby been diagnosed with any medical condition? No.

BIRD DDD

  • B: Birth
    • Is he full-term or preterm?
    • How was his birth?/ Any problems during or after birth?
  • I: Immunisation
    • Is he up to date with his jabs?
    • When was his last jab? / What?
  • R: Red book
    • Does he have a red book?
    • When you take him to the doctor any concerns about his red book?
  • D: Development
    • How is his development?
    • Is it okay in comparison to others of his age?

Don’t forget IMMUNIZATION

HERE. Dehydration
D: is your baby active and playful? H e h a s not been himself the last 24 hours (+ve finding)
D: Does he wet his nappies as usual? Yes.

DIET:
D: What do you feed him? Everything we eat a s a family he eats with us.
D: Any changes to your diet? No.
D: So, you said he’s not feeding well? No, he is not feeding well in the last two days.

NAI
D: Who do you live with other than Alex? My husband and my other 2 children.
D: Is your husband, Alex’s dad? Yes.
D: And is everything ok at home? Yes, everything is fine.

MAF
D: Is he on any medication including OTC medicines? D: Any allergies? No.
D: Any family history of a similar problem? No.

ICE:
No.

Concern
D: Other than this, is there anything else worrying you? I am worried that it’s meningitis.
D: Is there any specific reason for that? My neighbour’s daughter had meningitis 5 weeks ago.

(Exclude meningitis symptoms + contact hx)
D: I am sorry to hear that, how is she doing right now? I think she is better.
D: Have any of you come into contact with your neighbour’s girl? No

Examination:

  • Observations: Temp 39
  • Ear: red inflamed tympanic membrane
  • Head to toe

Provisional Dx:
Firstly, let me assure you Alex does not have meningitis, but I do suspect he has a condition called febrile convulsions; Which is a type of fit that happens when the child gets a high temperature.

Q: Is it serious?
Short-lasting seizures are not harmful to the child. Most febrile seizures stop on their own within 2 to 3 minutes without any treatment. About 1 in 3 children wil have another febrile seizure. The risk of febrile seizures reduces with age as the brain matures, and they are rare beyond 6 years of age.
Q: Would it happen again with any infection?
Not all illnesses and episodes of fever will provoke a febrile seizure
Q: What’s causing the fever?
I suspect the fever is due to an ear infection we examined his ear, and we found his eardrum to be swollen and inflamed.

Management:

  1. We’ll put the child under observation.
  2. Senior.
  3. Investigations
    a. Blood: all + infection markers
    b. Urine: dipstick
  4. Symptomatic (fever)
    i.Calpol (paracetamol)
    ii. Keep him lightly dressed.
    ii. Plenty of fluids
  5. Safety netting:
    • Continuous fever
    • Fit> 5 minutes
    • Rash & neck stiffness
  6. Leaflets.
    When he has a fit:
    • Remove dangerous things away from the child.
    • Lay him on his side with his face turned to the side.
    • Don’t put anything in his mouth, including medications Sit & watch:
      • less than 5 minutes no need to bring him
      • more than 5 minutes call the a m b u l a n c e

Q1: Dr, is febrile convulsions a type of epilepsy?
Well, no, febrile convulsions are due to infection, whereas epilepsy is due to abnormal electrical activity in the brain.
Q2: Dr, will it lead to epilepsy?
Febrile seizures are not the same as epilepsy, and the risk of a child developing subsequent epilepsy is low.
Q3: Dr, will you give m e some medication for him?
Well, there’s no medication to treat this condition.