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 check- up 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 4 th 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.

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 seconds. No medications and consult were done. 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 seconds. No medications and consult were done. The frequency of seizures increased which prompted consult (USTH CD to JRRMMC) On the 3 rd day of life On the 5 th day of life

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. 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 admission, The patient had no episodes of seizure until the 18 th HD. He was given Phenobarbital 25mg OD and Levetiracetam 65mg/pptab twice a day. On the 18 th HD

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. On the 45 th HD, 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 re- admitted, 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. Few hours prior to consultation, At the USTH CD ER At the USTH CD ER

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 6 th 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: (-) seizure disorder (+) HPN – maternal and paternal grandparents (+) CA of the bone – maternal grand uncle (+) paternal grandfather – kidney disease

Family Profile NameAgeRelationEducational Attainment OccupationHealth Rochelle Ann 25Mother2 year certificate course on Associate Tourism ReceptionistHealthy Victoriano30Father2 nd year collegeunemployedHealthy

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 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 4 th 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

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