Mum of 2 arrives into A&E with her 2 year old son who has had a ‘funny turn’ earlier this morning and is worried he might have injured himself. He has been feeling unwell the last few days.
Please take a focused history
Discuss the management plans with the parent
2 years old
Mum - Aisha Ali
HPC - About 4 hours ago you was changing little faisal when you noticed he was having funny turns. You was surprised as you think he had a seizure but you are unsure. When asked about how he looked, reveal his arms and legs went stiff and his legs began to shake. It lasted for about half a minute and was completely fine afterwards. No tongue biting, no incontinence, no vomiting. When asking about his history mention he has been feeling unwell lately with a runny nose and high temperatures. You’re finding it difficult to get him to sleep and notice his temperature usually runs high during the night and he is most irritable then. Last temperature reading was 39 and has been fluctuating from 38-40.
You have been managing with calpol, last dose was 4 hours ago. You have been giving him calpol regularly but was unable to keep his temperature under control. For the last two days he’s been having a runny nose and hasn’t been drinking and eating like he used to. You have put it down to the flu. But you are worried about his fever, despite treating him. No diarrhoea or constipation, you deny and vomiting. No rashes, he has normal wet nappies. Changing every three hours like usually. He has been off foods and is drinking less milk but you are keeping him hydrated with lots of fluids. No cough, no urinary symptoms such as pain or smelly urine.
PMHx - Nil
Spontaneous vaginal delivery at 39 weeks
Birth weight - 3.2kg
No prenatal or postnatal complications
Drug history - nil,
allergy to penicillins (rash)
Reached key developmental milestones.
FHx - dad has asthma, no fhx of epilepsy
Lives with mum and dad and younger sibling (4 year old sister)
I = it's the start of epilepsy. Your neighbours son has it and its frightening you
C = that he will have epilepsy and it will develop into learning difficulties
E = to have a brain scan
History of presenting complaint
Past Medical History