Transcript Family History

• V.Z.O.P.
• 2 month old Male
• 1073 K. Tayabas St, Tondo, Manila
• Chief Complaint: Seizure
Prenatal History
• Patient’s mother had regular prenatal checkup at a private clinic starting at 8 weeks AOG.
• Took Folic Acid, Natal Wiz, Iveret, Calcium, and
An Mum milk.
• No immunization and screening done.
• She denied illicit drug use, alcoholic intake,
exposure to viral exanthema, teratogenic
drugs, cigarette smoke and radiation.
• During the 4th month of gestation, the
patient’s mother had cough and colds to
which she took cephalexin for 1 week.
• She had no maternal fever, no pruritus and no
discharge before labour.
Postnatal history
• Patient was born to a 25-year old, G1P0,
receptionist, living with 30-year old
unemployed man.
• He was born live, term, singleton, male, via
NSD at a lying-in clinic with a BW of 3.8kg and
an unrecalled BL, attended by a doctor.
• He had delayed cry at delivery, spontaneous
respiration, and was meconium-stained.
On the 3rd day of life
Patient was noted to have multiple episodes
of seizures characterized as :
• Upward rolling of the eyes accompanied by
crying
• Flexion of the upper extremities with
twitching and rigid extension of the lower
extremities.
• The episodes would last for about 4050seconds.
No medications and consult were done.
On the 5th day of life
The frequency of seizures increased which
prompted consult (USTH CD to JRRMMC)
On admission,
Work ups done:
• Cranial UTZ = normal
• EEG = abnormal negative spikes
• Cranial CT scan = leptomeningeal enhancement
with no hydrocephalus
• Lumbar tap = normal
He was managed as a case of CNS infection
Medications given were Cefotaxim and amikacin for
21 days.
On the 18th HD
The patient had no episodes of seizure until the 18th
HD. He was given Phenobarbital 25mg OD and
Levetiracetam 65mg/pptab twice a day.
On the 45th
HD,
Few hours prior
to consultation,
At the USTH
CD ER
He was discharged even with seizure episodes. The
parents were just instructed to continue giving
Phenobarbital and levetiracetam 65mg twice a day and
record the duration and time when the patient would
have seizure episodes.
He was brought back to the same institution for follow
up check-up. Upon seeing the frequency of the seizure
episodes (>10/day), the patient was advised to be readmitted, however, the parents opted to seek a second
opinion and was brought to our institution.
He had 2 episodes of seizures characterized as upward
rolling of eyeballs, generalized tonic-clonic seizure of
about 40 sec. The patient was subsequently admitted.
Review of Systems
• General: (-) weight loss (+)poor suck, (-) diminished activity
• Cutaneous: (-) diaper rash, (-) jaundice, (-) pigmentation
• HEENT: (+) nasal discharge, (-) epistaxis, (-) increased
salivation
• Respiratory: (-) dyspnea
• Cardiovascular: (-) cyanosis (-) fainting spells
• Gastrointestinal: (-) abdominal distention, (-) vomiting
• Musculoskeletal: (-) pain, (-) limitation of movement
• Hematopoietic: (-) pallor, (-) bruises
• Endocrine: (-) heat/cold intolerance, (-) polyuria
• Nervous/Behavior: see HPI
Feeding History:
• He was breast fed for only one day.
• The mother claims that she shifted to formula
milk due to the insufficient amount of her
breastmilk.
• He was started on Enfalac, milk with 1:1
dilution, ½ ounce of milk every three hours.
Then on the 6th week of life, the patient was
given S26 with 1:1 dilution, 2 ounces every
three hours.
Developmental History:
• Delayed
– Spontaneous motor activity
– Head lags on pull to sit
– Does not follow objects to midline
– Does not smiles and coos socially
Past Medical History
• Sepsis Neonatorum
• No allergies
Immunizations:
• Mother claims that the patient did not have
any immunization
Family History:
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(-) seizure disorder
(+) HPN – maternal and paternal grandparents
(+) CA of the bone – maternal grand uncle
(+) paternal grandfather – kidney disease
Family Profile
Name
Age
Relation
Educational
Attainment
Occupation Health
Rochelle
Ann
25
Mother
2 year certificate Receptionist Healthy
course on
Associate
Tourism
Victoriano
30
Father
2nd year college
unemployed Healthy
Personal, Socioeconomic and
Environmental History
• Patient lives with her parents in a one-storey,
wooden house.
• Drinking water is distilled water.
• Garbage is collected once a week, not
segregated.
• The family lives near a dirty creek.
• There are cats, rats and cockroaches around the
area.
• Patient is not exposed to cigarette smoke.
Physical Examination
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Awake, not in cardiorespiratory distress, well nourished, no dehydration
VS: CR 160 bpm, regular RR 24 cpm, regular T 36°C;
Lt::60 cm (z-score: above 0) Wt:4.25 kg (z-score: below 0)
BMI= 11.8 (z-score:below -3)
Warm, moist skin, no active dermatoses, no jaundice
No gross head deformities, HC = 38.5 cm (z-score: above 1), no lesions on
the head, equally distributed fine black hair, no bulging fontanels
Pink palpebral conjunctivae, pupils 2-3 mm ERTL, anicteric sclerae
No tragal tenderness, no ear discharge, non-hyperemic external auditory
canal
Midline septum, no nasal discharge, no alar flaring
Moist buccal mucosa, no oral ulcers, nonhyperemic posterior pharyngeal
wall
Supple neck, no palpable cervical lymph nodes, no masses, thyroid gland
not enlarged
• Adynamic precordium, AB at 4th LICS MCL, S1 and S2
normal, no thrills, no murmurs
• Symmetrical chest expansion, no use of accessory
muscles, clear breath sounds
• Flat, abdomen, everted umbilicus, normoactive bowel
sounds, liver span: 2 cm below costal margin
• No limitations in range of motion, no joint swelling,
• Grossly male genitalia
• Pulses full and equal, no cyanosis, no clubbing
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Neurologic Exam on Admission
Awake, alert
No asymmetry, no gross deformities, no bulging fontanels
Spontaneous muscle movements, no involuntary movements, no tremors
Cranial Nerves:
CN2- blinks with bright light
CN3, 4, 6- no ptosis, pupils 2-3 mm ERTL
CN5- blinks upon gentle air blowing
CN7- no facial asymmetry
CN8- turns head to stimulus
CN9, 10- normal suck and swallowing
CN 11- symmetry of SCM muscle bulk
(-) Involuntary movements
(-) Nuchal rigidity, (+) Babinski
Salient Features
• Subjective
• multiple episodes of
seizures characterized as
upward rolling of the eyes
accompanied by crying,
flexion of the upper
extremities with twitching
and rigid extension of the
lower extremities. The
episodes would last for
about 40-50seconds
• (-) seizure disorder
• Objective
• 2mos/ Male
• VS: CR 160 bpm, regular
RR 24 cpm, regular
T36°C;
• EEG which showed
abnormal negative spikes
• Cranial CT scan showed
leptomeningeal
enhancement with no
hydrocephalus
• (+) Babinski