Identifying Data:
Full Name: TR
Address: Forest Hill, NY
Date of Birth: April 22nd, 2012
Date & Time: September 1st, 2020
Location: Queens Hospital Center
Religion: Catholic
Source of Information: Mother- Reliable
Source of Referral: None
Mode of Transport: EMS.
Chief Complaint: “My daughter just had a seizure” x today.
HPI:
TR is an 8-year-old female patient with a PMHx of juvenile myoclonic epilepsy was brought in today by EMS due to seizing this morning. Patient’s mother woke up this morning at 5am and found out TR was seizing in her sleep. Mother states that the seizure lasted about 4-5 minutes and it stopped on its own. Mother denied change in skin color during seizure episode, foaming from mouth, urinary incontinence, jerky movement, or stiffness of the limbs. After this seizure episode, mother called the patient’s name and she then opened her eyes, did not talk to her and went back to sleep. Mother states patient is on Keppra and has not missed a dose. TR was in her normal baseline prior to this seizure episode and her last seizure episode was 6 months ago which was also during her sleep and lasted about the same time.
Within the first 3 hrs in ED as soon as patient tried to go to sleep she had another seizure episode. This time it lasted about 1 minute and 30 seconds with tonic-clonic activity and eyes rolled back but no change in skin color, foaming from the mouth or urinary incontinence. Second seizure was followed by postictal period of 5 minutes and 1 mg of Ativan given which helped patient eventually return to baseline again.
Next 4 hrs patient had a third seizure, this time lasting about 45 seconds to 1 minute which was very similar to the second seizure with tonic-clonic activity. This time 2 mg of Ativan was given and 500mg IV of Keppra. Patient denies loss of sensation, loss of strength, numbness or change in mental status.
Past Medical History:
Present illnesses – Juvenile myoclonic epilepsy x 3 years
Past medical illnesses – Juvenile myoclonic epilepsy x 3 years.
Hospitalizations: March of 2020, was hospitalized at QHC for seizures. Was discharged the same day. Neurologist switched from Dilantin to Keppra.
Immunizations- Up to date.
Past Surgical History:
None.
Medications:
Levetiracetam (Keppra)- 10mg/kg by mouth 2 times a day for seizures. Last dose was last night before sleep.
Allergies:
Denies drug, environmental or food allergies.
Family History:
No family history of cardiovascular diseases, cancer, strokes.
Father- 38 years old. Alive and well
Mother- 34 years old. Alive and well
Social History:
TR lives at home with her older sister and parents. She is in second grade and will soon start class online.
Habits- Likes to play with her friends at the park and eat ice-cream.
Travel- Has not recently traveled anywhere.
Diet- Likes to eat a lot of junk food and sweets, but mother forces her to eat healthy for the most part.
Exercise- Playing around with friends at the park.
Safety- TR uses all appropriate safety measures.
Review of Systems:
General: denies loss of appetite, fever, recent weight loss or gain, generalized weakness/fatigue, or night sweats.
Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution.
Head – Denies headaches, vertigo, or head trauma.
Eyes – Denies lacrimation, pruritis, visual disturbances, or photophobia. Last eye exam 2019 – does not know her visual acuity, normal pressure.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat– Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam 2020.
Neck– Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast – Denies lumps, nipple discharge, or pain.
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Denies chest pain, palpitations, edema/swelling of ankles/feet, syncope, known heart murmur.
Gastrointestinal system – Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
Genitourinary system –Denies urinary frequency or urgency, oliguria, polyuria, dysuria, incontinence.
Nervous – Patient has a history of seizures. Last seizure was 6 months ago. Mother reports 1 episode of seizure which occurred during sleep and lasted 5 minutes. Denies, sensory disturbances, ataxia, loss of strength, change in cognition / mental status.
Musculoskeletal system –Denies other muscle/joint pain, deformity or swelling, redness or arthritis.
Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Denies mood changes, depression. Denies sadness, OCD.
Physical exam:
General: Pt is alert and oriented x3, neatly dressed, and in slight distress due to the environment.
Vital Signs: BP: R L
Seated 110/60 108/56
Supine 100/55 104/60
R: 20/min unlabored P: 92, regular
T: 97.6 degrees F (oral) O2 Sat: 98% Room air
Height 4 feet and 2 inches Weight 70 lbs. BMI: 19.7 (normal)
Skin: warm to the touch & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.
Hair: Normal hair pattern.
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: Head is normocephalic, atraumatic. Non-tender on palpation.
Eyes – symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white;
conjunctiva & cornea clear.
Visual acuity (uncorrected – 20/20 OS, 20/20 OD, 20/20 OU).
Visual fields full OU. PERRLA, EOMs full with no nystagmus
Fundoscopy – Red reflex intact OU. Cup: Disk < 0.5 OU/no evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Ears: Symmetrical and normal size. No evidence of lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM’s pearly white / intact with light reflex in normal position AU. Auditory acuity hardly intact to whispered voice AU. Weber midline / Rinne, BC<AC AU.
Nose – Symmetrical / no obvious masses / lesions / deformities / trauma / discharge. Left nostril congestion due to mucus. Nasal mucosa pink & appears dehydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No evidence of foreign bodies.
Sinuses – Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Lips – Pink; no evidence of cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink. No masses: lesions noted. Non-tender to palpation. No evidence of leukoplakia.
Palate – Pink. Palate intact with no lesions; masses; scars. Non-tender to palpation; continuity intact.
Teeth –2 dental caries noted.
Gingivae – Pink. No evidence of hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.
Tongue – Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.
Oropharynx –no evidence of injection; exudate; masses; lesions; foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pinkish, no edema, lesions.
Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally.
Thyroid –Non-tender; no palpable masses; no bruits noted.
Thorax & Lungs:
Chest– symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP 2:1, non-tender to palpations.
Lungs– Clear to auscultation and percussion bilaterally. Chest expansions and diaphragmatic excursions symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart: No tenderness to palpation. JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.
Abdomen: No hernias noted. Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.
Peripheral Vascular:
The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.
|
|
Brachial
|
Ulnar
|
Radial
|
Femoral
|
Popliteal
|
D.P.
|
P.T.
|
| R
|
2+
|
2+
|
2 +
|
2+
|
2+ | 2 +
|
2 +
|
| L
|
2+
|
2+
|
2+
|
2+
|
2+ | 2+
|
2+
|
Upper & Lower Extremities:
No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Cranial nerves:
I . Olfactory: intact bilaterally
- Optic: OD OS
visual acuity 20/20 20/20 (uncorrected)
fundoscopic examination: (see eye exam)
III. Oculomotor, IV Trochlear, VI Abducens:
extraocular movements (intact), no nystagmus, ptosis.
direct and consensual pupillary light reflex intact bilaterally
accommodation restricted bilaterally
- Trigeminal: masseter/temporalis strength 5/5
corneal reflex intact OU.
VII. Facial: facial movements intact.
VIII. Acoustic: auditory acuity intact bilaterally to whispered voice, Weber: midline, Rinne: AC>BC
- Glossopharyngeal,
X Vagus: uvula midline, soft palate and pharynx rise symmetrically
- Spinal Accessory: sternocleidomastoid strength 5/5 bilaterally,
trapezius strength 5/5 bilaterally
XII. Hypoglossal: no tongue atrophy, deviation upon protrusion or fasciculations noted
Motor Systems no evidence of atrophy, fasciculations or abnormal movements
normal muscle bulk, contour and tone
Muscle Strength: Right Left
upper extremities 5/5 5/5
lower extremities 5/5 5/5
rapid alternating movements and point to point movements intact, no asterixis
gait normal, Romberg negative, slight pronator drift
Sensory Systems dull, thermal, and light touch sensation intact upper and lower extremities bilaterally, vibratory sensation intact over great toe bilaterally
proprioception, stereognosis, graphesthesia, two-point discrimination, point localization and extinction intact
Reflexes
Biceps Brach. Triceps Abd Knee Ankle Plantar Response
RT 2+ 2+ 2+ 2+ 2+ 2+ Down-going
LT 2+ 2+ 2+ 2+ 2+ 2+ Down-going
Assessment:
TR is an 8-year-old female patient with a PMH of juvenile myoclonic epilepsy was brought in today by EMS due to seizing this morning. Seizure lasted about 4-5 minutes and it stopped on its own. Mother denied change in skin color during seizure episode, foaming from mouth, urinary incontinence, jerky movement, or stiffness of the limbs. After 3 hours in the ED, patient experienced another episode of seizure as she was trying to fall sleep which lasted 1 minute and 30 seconds with tonic-clonic activity and postictal period of 5 minutes and 1 mg of Ativan was given. 4 hours after that, a third episode of seizure occurred which lasted about 45 seconds to 1 minute and this time 2 mg of Ativan was given and 500mg IV of Keppra. Physical exam was benign.
Differential Diagnosis:
1) Juvenile myoclonic epilepsy- They usually occur shortly after waking up and are associated with generalized tonic-clonic seizures which is also seen in our patient. JME are also associated with postictal period which is also seen with our patient as she seems confused after each episode.
2) Generalized (grand mal) seizures- which is pretty common to JME and presents with tonic-clonic episodes, followed by postictal confusion phase.
3) Focal (partial) seizures- These are also associated with jerky movement and our patient had a bit of a confusion state after seizures which can be interpreted as Todd’s paralysis.
Labs:
Increase levels of ALK PH0S (382) normal range (0-299)- most likely due to usage of Keppra.
Elevates potassium (5.4) normal range (3.5-5.1)
Elevated calcium (10.9) normal range (8.6-10.3)
Everything else- insignificant.
Plan:
1) Continue to monitor patient and her vital signs.
2) Her neurologist was contacted; Dr. P and the case was discussed with him. Neurologist recommended for the patient to be admitted to the closest hospital for video EEG and medication adjustment.
3) Cohens children’s hospital was contacted and they were able to admit patient. Mother agreed with transfer.
This entry is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.
