Hot Seat #168: The Toddler who Seized

Posted on: March 21, 2021, by :

HPI:

2-year-old unimmunized male presents after seizure at home. Per parent’s report, the seizure lasted about 30 seconds and self-resolved. The episode was described as generalized shaking of the bilateral upper and lower extremities with eye blinking.

Mother reports that the patient had a fever which started earlier today and has been less energetic since it started. Continues to drink without difficulty. Denies respiratory symptoms, vomiting, diarrhea, rash. Denies sick contacts or recent travel.

ROS:

Constitutional: +fever, decreased energy

HEENT: Denies congestion, rhinorrhea

RESP: Denies SOB, cough

Cardiovascular: Denies peripheral edema

GI: Denies vomiting, diarrhea

GU: Normal urine output

Neuro: +seizure

PMHx/PSHx:

  • Born full term.
  • No past medical or surgical history.
  • Unimmunized by choice. 
  • Does not take any medications.

FamHx: No history of seizures

Social: Lives with parents. No medications at home

Physical Exam:

Vitals:    T: 38.4 C               HR: 145                 RR: 38                    BP: 97/75             O2: 99% on room air      

General: Alert, appropriate for age.

Skin: Warm, dry, intact, no rash

Head: Atraumatic

Neck: Supple, no LAD

Eyes: PERRL, EOMI, normal conjunctiva

Ears, Nose, Mouth, and Throat: Moist oral mucosa. No pharyngeal erythema or exudates. TMs clear

Cardiovascular: Regular rate and rhythm. No murmurs. No rubs. No gallops. <2 second capillary refill

Respiratory: CTAB. Non-labored respirations

GI: Soft, nontender, non-distended.

GU: Circumcised. No diaper rash.

MSK: No swelling. No tenderness. Moves all extremities

Neurological: Alert. Symmetric facies. Normal motor and coordination observed.

While in the emergency department, he has another witnessed seizure with generalized shaking lasting less than a minute and self resolves. He is sleepy afterwards.

Following the lab draw, the patient’s mental status returns to baseline. Just prior to consenting the family for the LP, you get a call from lab that the blood sample needs to be repeated. After relaying this to the family, they decide that they want nothing else done (no repeat labs, no LP).

After a thorough discussion, family continues to refuse further workup. The child remains at their baseline. You let the parent know that you would like to admit the child for observation to the hospital but need to perform a COVID test. The parent becomes more upset and threatens to leave.

After discussion with the social worker, charge MD, charge RN, the parent agrees to labs and admission to the neurology service as a COVID PUI.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Dennis Ren
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