Hot Seat #174: 4 year old with febrile seizurePosted on: August 18, 2021, by : Haroon Shaukat MD
Rachel Hatcliffe, MD, Children’s National Medical Center
4.5 year old female with history of prior febrile seizure presents to the emergency room after a 5-10 minute seizure in the setting of one day of fever. Earlier this morning she had one episode of NBNB emesis and was found to have fever to 39.3C. Her father gave a dose of ibuprofen with subjective improvement. Later in the day she was playing with a sibling when she had a generalized tonic-clonic seizure with shaking of bilateral upper extremities and eye deviation to the right. Father gave rectal Diastat and brought patient to the ED. Denies cough, congestion, abdominal pain, diarrhea, or dysuria. Patient is toilet trained and voids independently. Father is concerned patient is not yet at baseline mental status.
PMHx: Febrile seizure x1 in past (2 months ago)
Meds: Rectal Diastat prn
FH: No family hx of epilepsy
SH: Lives with parents and two siblings. Both siblings currently have URI sx.
Imm: Has not received 4 yo vaccines yet, but otherwise UTD
VS: Temp 36.7 HR 109 RR 20 BP 103/78, SpO2 99% on RA
General: Sleepy but arousable
Skin: No rash, warm.
Head: Atraumatic, normocephalic.
Neck: Supple, no nuchal rigidity, no significant lymphadenopathy
Eyes: PERRL, EOMI, normal conjunctiva
ENMT: oral mucosa moist, no pharyngeal erythema
CV: RRR, cap refill <2s in distal extremities
Resp: CTAB, no increased . No crackles, wheezes or rales.
GI: Soft, non-tender, non-distended.
Neuro: CN II-XII intact, moves all extremities. Responds to light touch in all extremities. Patient is arousable but refuses to ambulate.
Father is very concerned and expresses fear about the possibility of repeat seizures at home. He reports patient is still more sleepy than normal and requests more tests to find out the source of the fever.
You obtain CBC, BMP, UA and covid swab. WBC 7, H/H 13.9/39.1, Plt 231, 80% pmns. CMP wnl. Clean catch UA with neg blood/protein, neg ketones, neg nitrites, 3+ LE, 2 RBC, 15 WBC, no epithelial cells, rare bacteria. Covid negative. The patient remains afebrile in ED and returns to neurologic baseline.
The patient is discharged home without antibiotics. No urine culture is added prior to discharge. Father calls the ED a few days later and reports that the child has had persistent fever with Tmax 39.5. No additional seizures. He reports patient has had some congestion, but otherwise denies vomiting, diarrhea, abdominal pain, dysuria. Pt is eating and drinking normally but appears slightly more fatigued than normal.
They return to the ED and on arrival VS: 39.3, HR 115 BP 110/76, RR 24. Pt is alert and interactive, no respiratory distress. Abdomen is soft, non-tender. No neck pain/stiffness. You give Tylenol and obtain repeat Urine testing in the ED. Clean catch UA shows: neg blood/protein, neg ketones, neg nitrites, 2+ LE, 3 RBC, 9 WBC, no epithelial cells, no bacteria.
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