Quiz 19: First Seizure

Front 1

You are working overnight call in the ED when Charlie, a 3-year-old male infant, arrives after his parents witnessed an episode of convulsions at home. His parents report that Charlie was in his usual state of good health until three days ago when he developed fever, cough, and rhinorrhea. This evening they found him in bed with his eyes rolled upward, jerking all four of his extremities uncontrollably. He was unarousable from this state, which self-resolved after about two minutes. This has never happened before. Currently, Charlie is sleepy but arousable and complains of nausea. His vitals include T 103.2 F, P 112 bpm, BP 100/60 mmHg, RR 22 bpm, O2 sat 99% on room air. Aside from rhinorrhea and erythematous mucous membranes, the remainder of his physical exam is unremarkable. What is the next best step in management?

Back 1

Workup for source of fever

Front 2

When to do EEG?

Back 2

recurrent, focal, or complex seizures

Front 3

T/F: treat febrile seizure with valproic acid?

Back 3

This answer is incorrect, because the majority of patients with febrile seizures do not require treatment with anticonvulsants. This is especially true if this is Charlie’s first febrile seizure. Anticonvulsants such as phenobarbital or valproic acid may rarely be indicated, but generally these drugs are not recommended in the setting of febrile seizures because they are associated with serious side effects.

Front 4

A previously healthy and developmentally normal 16-month-old male comes to the urgent care clinic with his father with a chief complaint of his first reported seizure. The child was reported to have dropped to the floor with loss of consciousness and had sporadic twitchy movements of his legs and arms that lasted for five minutes. The child has had URI symptoms for the past two days, with a fever to 103 degrees F without any changes in mental status. Neither parent has a seizure disorder, but the child’s mother reports having a single seizure as a young girl once after developing a high fever after a cold. What is the most likely diagnosis?

Back 4

Simple febrile seizure

Front 5

Simple febrile seizure

Back 5

self limited

triggered by acute febrile illness

< 15 min

generalized

Front 6

Complex febrile seizure

Back 6

> 15 minutes

more than once in 24 hour period

being focal

Front 7

Absence seizure

Back 7

recover consciousness much more quickly, usually within 30 seconds, compared to tonic-clonic seizures, which take much longer

Front 8

breath-holding spells

Back 8

• infants 6 months to 6 years of age
  
• autonomic nervous system
  
• infant angry or upset, period of crying, followed by breath holding in forced expiration
  
• child may lose consciousness and become cyanotic
  

Front 9

During the middle of dinner on your day off, you receive a call from one of your neighbors who remembers that you are a medical student. He is concerned about his 15-year-old daughter who had previously been in her usual state of health and has no significant past medical history. However, over the past 24 hours, his daughter suddenly spiked a fever of 103 F and has “not been herself,” acting very lethargic and dazed at times. He also notes that she has been breathing heavily, not been able to eat or drink, and has not urinated over the past 12 hours. He wants your advice about whether she should be taken to the ED. Although you are fairly certain that the best course of action would be to take her to the ED, you contemplate the differential diagnosis of her presentation. Given the limited history, which of the following is highest on your differential?

Back 9

Meningitis

Front 10

acute cystitis

Back 10

• infection
  
• lower urinary tract
  
• fevers
  
• dysuria
  
• less likely systemic features
  

Front 11

CNS tumour

Back 11

• longer presentation
• tachypnea
• lethargy
• more slow and gradual progression

Front 12

Meningitis

Back 12

• altered mental status change
• decreased po intake
• fever
• decreased urine output
• blood cultures and LP

Front 13

hypoglycemia

Back 13

• unlikely to be a source of fever
• does not affect urine output over significant period of time
• causes altered mental status

Front 14

You see a 6-year-old male in the ED who presents with a history of a 10-second episode of jerking movements of his extremities with unresponsiveness, observed by both of his parents. His parents claim he has had abdominal pain and small quantities of bloody diarrhea for two days. The child has no significant past medical history, has taken no medications recently, has no pets, and has not traveled outside of California in the past year. He attends kindergarten. Which organism is the most likely cause of the child’s symptoms?

Back 14

Shigella sonnei

Front 15

shigella

Back 15

• bloody diarrhea and WBCs in stool on Wright stain
  
• seizures (neurotoxin)
  

Front 16

Rotavirus

Back 16

• diagnosis using ELISA
  
• not associated with seizures
  

Front 17

C diff

Back 17

• diarrhea after antibiotic use
  
• diarrhea
  

Front 18

ETEC

Back 18

• noninvasive infection without WBCs in stool
  
• traveler's diarrhea
  
• water diarrhea
  
• no blood
  

Front 19

V cholerae

Back 19

• massive quantities of watery diarrhea
  
• severe dehydration
  
• no blood, usually
  
• endemic/epidemic form in developing countries
  
• not in US with no recent travel history
  

Front 20

A woman brings her 8-year-old son to the pediatrician after witnessing him stare blankly into the distance at dinner the previous week. He was unresponsive to her calling his name or any other stimuli, and it lasted for about 10 or 20 seconds. His teacher reports he does seem to daydream often in class but is able to keep up with schoolwork and excels in his studies. She doesn’t note him being disruptive or impulsive in class. His mother is concerned about these blank stares and unresponsive episodes. Which of the following is the most likely diagnosis?

Back 20

Absence seizure

Front 21

You are working overnight call in the ED when Charlie, a 3-year-old male infant, arrives after his parents witnessed an episode of convulsions at home. His parents report that Charlie was in his usual state of good health until three days ago when he developed fever, cough, and rhinorrhea. This evening they found him in bed with his eyes rolled upward, jerking all four of his extremities uncontrollably. He was unarousable from this state, which self-resolved after about two minutes. This has never happened before. Currently, Charlie is sleepy but arousable and complains of nausea. His vitals include T 103.2 F, P 112 bpm, BP 100/60 mmHg, RR 22 bpm, O2 sat 99% on room air. Aside from rhinorrhea and erythematous mucous membranes, the remainder of his physical exam is unremarkable. What is the next best step in management?

Back 21

Workup for source of fever