Examkin

Question

Difficulty: MediumPediatric Neurologic Disorders

A 13-month-old boy is brought to the emergency department by his parents after a witnessed generalized shaking episode that lasted for approximately 2 minutes. The parents report that he lost consciousness, his arms and legs stiffened, and then jerked rhythmically. Afterwards, he was very drowsy but returned to his normal baseline within 30 minutes. He has had nasal congestion, a mild cough, and a subjective fever for the past 24 hours. The patient was born at term, and his developmental history is notable for sitting independently, pulling to a stand, cruising along furniture, and using a neat pincer grasp. He can say "mama" and "dada" purposefully. He has received all age-appropriate vaccinations. In the emergency department, his temperature is 39.5∘C39.5^\circ\text{C} (103.1∘F103.1^\circ\text{F}), pulse is 145/min, and respirations are 36/min. Physical examination shows a well-appearing, interactive infant who is playing with a stethoscope. The anterior fontanelle is flat and soft, and the neck is supple without resistance to passive flexion. Tympanic membranes are clear. Lung auscultation reveals mild, diffuse wheezing and upper airway noise with no retractions. Neurologic examination shows normal muscle tone, symmetric reflexes, and no focal deficits. Which of the following is the most appropriate next step in the management of this patient?

  1. Discharge home with supportive care and reassuranceAnswer
  2. B
    Perform a lumbar puncture to evaluate for central nervous system infection
  3. C
    Administer broad-spectrum intravenous antibiotics
  4. D
    Administer nebulized albuterol for airway reactivity
  5. E
    Refer to physical therapy for delayed motor milestones

Answer

The most appropriate next step is to discharge the patient home with supportive care and reassurance.
The correct approach is to discharge the patient home with supportive care and reassurance. This patient has experienced a classic simple febrile seizure, which is defined as a generalized seizure lasting less than 15 minutes that does not recur within a 24-hour period in a child between 6 months and 5 years of age. Given that he is fully immunized, has returned to his neurologic baseline, and exhibits a clear viral source for his fever (bronchiolitis/URI symptoms), further diagnostic workup (e.g., lumbar puncture, EEG, neuroimaging) or pharmacotherapy is not indicated. These seizures are benign, do not cause brain damage, and have an excellent long-term prognosis.

Step-by-Step Solution

1
Identify the nature of the neurologic event.
The patient had a generalized seizure lasting less than 15 minutes that has not recurred in 24 hours, occurring in the setting of a fever.
These characteristics define a simple febrile seizure, which has an excellent prognosis and distinct management pathway.
2
Evaluate the patient for secondary causes or "red flag" symptoms.
The patient is fully immunized, well-appearing, interactive, has a flat fontanelle, and lacks meningeal signs. An identifiable viral source (bronchiolitis/URI) is present.
Ruling out central nervous system infections (like bacterial meningitis) is essential to avoid missing a life-threatening condition.
3
Determine the appropriate management plan based on the findings.
Supportive care, antipyretics for comfort, and parental reassurance are indicated. The patient can be safely discharged.
Simple febrile seizures do not require neuroimaging, EEG, lumbar puncture (in immunized children >12 months), or prophylactic antiepileptic medications.

Key Concept

Diagnosis and management of simple febrile seizures
Estimated Time:1m 30s
Rate this question

Topics

Pediatric Neurologic Disorders

More questions from this topic