1) Febrile Convulsion

2) Febrile Convulsion With Speech Delay

3) Absence Seizure/Petit mal epilepsy
4) Provoked/Precipitated Fit
5) Tension headache
6) Child Having Increased Intracranial Pressure
7) Cerebral Palsy
8) Positional Plagiocephaly (Flat head)

1)
You are working as an HMO in a metropolitan ED. The nurse asked
you to see a 3-year-old boy who is in a cubicle with his mother. The
nurse hands you the triage sheet saying 3 year old presents with
ambulance after having seizure at home.
Task

History
o (watching cartoons on TV and suddenly started
shaking all over his body, lasted <1 minute, was
fine after that, did not wet himself, flu for the last
2 days with temperature 38C; husband with
history of seizures)
Physical examination
o (looks happy and interactive, vital signs normal
except T:38.2, chest and heart normal, soft,
nontender,
Diagnosis and Differential diagnosis
Management and prognosis
Counsel mother

Febrile Convulsion
Epilepsy
Trauma
Breath holding spell (anoxic or ..
Meningitis/Encephalitis
Meningococcemia
Hypoglycemia
Electrolyte imbalance: kidney failure, liver failure,
Drugs, Alcohol

DDx:

RCH Features:
Background to condition:
Convulsions, in a child between 6 months and 6 years of
age, in the setting of an acute febrile illness, without

previous afebrile seizures, significant prior neurological

abnormality, and no CNS infection.
occur in 3% of health children
are normally associated with simple viral infection
are benign
Simple febrile convulsions:
Simple febrile convulsions:
These are generalised, tonic-clonic seizures lasting less
than 15 minutes that do not recur within the same febrile
illness.
Complex febrile convulsions:
These have one or more of the following:
- focal features at onset or during the seizure- Duration
of more than 15 minutes- Recurrence within the same
febrile illness- Incomplete recovery within 1 hour.

Febrile status epilepticus

This is a febrile convulsion lasting for longer than 30
minutes.
Note:
o It is now recognised that some children can have
a presentation with convulsions and an acute
infectious illness (particularly gastroenteritis)
without documented fever. This is sometimes
referred to as "febrile convulsions". The
management and prognosis is the same as for
classical febrile convulsions.
6 and 5Fs
6 months to 6 years of age
Fever
Family history
Focal (NOT)
Frequent (NOT)

Hx:

What happened before the seizure? Fever? Sick? Rash?

Headache? Vomiting? Diarrhea? URTI? Sore throat?
Dysuria? LOC?
During seizure: duration? Focal or general? Bowel and
bladder control? Tongue bite?
After seizures: drowsy/slept all day
BINDS
FHx of seizures/epilepsy

General appearance and growth chart

Rash and neck stiffness
Vital signs and growth chart
ENT
Chest and heart
Abdomen
Neurologic examination

PEx:

Questions:

Will it happen again?

Does this mean he has epilepsy?
Will he be brain-damaged?
Does he need to see a specialist?
Dont you need to do some tests?

Management Advice
Place the child on his or her side, chest down, with head
turned to one side.
Never lie a fitting child or unconscious child on his or her
back
Do not force anything into the childs mouth
Undress child to their singlet and underpants to keep
them cool
Obtain medical help as soon as possible.
Ring or go to your local doctor or to your nearest hospital.
Even if the fit stops, have your child checked
Ring ambulance if seizure lasts >5 minutes

The only problem is that there is a 30% chance that it

might recur in the next 24 hours. I want you to be aware
of what to do if it happens again.
Whenever he falls sick, check temperature.
Do not let temperature beyond 38C
Give paracetamol
If he develops fits, put him in left lateral position to
prevent aspiration of stomach contents into the windpipe
Remove clothing and paracetamol per-rectal (20mg/kg)
The nurse outside will teach you how to do it
Once you recover from fits please come and see me.
Usually the fits last for less than 5 min
If they go beyond 10 min, and if they come again and
again, go to hospital with ambulance
(1 year old 50% ; 2 year old 30%)
Risk of epilepsy: 2-3%

Reading material.

2)

Dx and Mx

You are a GP and a 3 year-old-boy was brought into the clinic by his
mother. He had a fit lasting for 2 min around 1 hour ago. On
examination, everything is normal.

Task

Take relevant history

Explain the diagnosis and management to the mom

Hx:

What happened? How long ago? Who saw the fits?

Pattern of fits all over the body or only some parts of
the body
Generalized febrile convulsion
Focal other pathology probably infection
Did he bite his tongue or pass urine or stool during the
fits? Was it the first episode? Recent infection (sore
throat, ear infection, UTI)? Did he have a fever at that
time? Sore throat or upper respiratory tract infection?
Immunisation up to date
Family history of epilepsy or fits during fever
Pregnancy, delivery, Nutrition,
Childcare or KG? Any exposure to other sick children
Developmental problem speech problems? How is his
behavior otherwise? How is his interaction with you, your
husband and other kids?
Is he able to make sentences comprising 3 or more
words
How is his behavior and interaction with family and
friends
Do you think he responds well to your voice when he is
called
Any family history of speech disorder or special child in
the family
How is his appetite? Water work? Medication and
allergy?

The most likely diagnosis is febrile convulsion and it is

very common in this age group. Whenever the child
develops a high temperature, the brain senses some
involuntary signals in response to the high fever.
Please do not worry and this is not epilepsy. The only
problem is that there is a 30% chance that it might recur
in the next 24 hours. I want you to be aware of what to do
if it happens again.
Whenever he falls sick, check temperature.
Do not let temperature beyond 38C
Give paracetamol
If he develops fits, put him in left lateral position to
prevent aspiration of stomach contents into the windpipe
Remove clothing and give paracetamol per-rectal
(20mg/kg)
The nurse outside will teach you how to do it
Once you recover from fits please come and see me.
Usually the fits last for less than 5 min
If they go beyond 10 min, and if they come again and
again, go to hospital with ambulance
Regarding concern about speech problem, there are
many possibilities. I would like to refer him for hearing
test, to the pediatrician and speech pathologist.
Chance of recurrence after 1st seizure is 30% and after 2
seizures is 50%
Girls: 5 years old; boys: 6 years old
Meningitis: if child had repeated seizures, headache,
neck stiffness, if no other findings can be found
Workup done only if no cause/focus can be found and if
there is recurrence of febrile seizure

Tests

ABR (auditory brainstem response)

Otoacoustic emission testing

Causes of Speech delay

Hearing defects
Developmental disorder including Autism, Dyslexia (cant
read), Dyspraxia (unbalance orofacial muscle), ADHD
Physical and emotional factors (child abuse, neglect,
social deprivation)
Anatomical problems cleft palate, Cerebral palsy, MS,
muscular dystrophies
Anxiety and phobias
Speech delay is common and more common in boys. 10% of preschool kids suffer from some kind of speech problems. Failure to
communicate compared to other children is a sign.
Thorough assessment will be done by speech pathologist
including speech, language and motor skill assessment.
The therapy includes visual aids, toys, flash cards,
exercises to strengthen the oral muscle.
The prognosis is best if treatment is initiated before the
age of 3 years and it is important that the family and the
parents are involved.

3)

situation? School situation (His school performance has

been affected). How is the financial situation? How are
you getting along with him (She is his step mother.)? Is
he taking any medication? Any allergies? Past history of
epilepsy? Febrile convulsion? Family history of epilepsy?

A 9-year-old boy is in your GP clinic, brought by his step mother, with

complaint of staring blankly for a few seconds for the last 3months
Task

PEx:

Features

Hx:

Take history from the mother

(No Trauma, infection or loss of consciousness.
Resume to his daily activity. His school performance
is also affected. Pregnancy and Birth is fine.
Immunization is up to date. Diet ok. Water work and
bowel functions normal. Development is normal. No
Fhx.)

Ask for physical examination findings from the examiner

Discuss the diagnosis and further management plan to
the mother
Child stares blankly/Motion less for some time.
Episodes happen in 5-10 seconds.
Child can blink the eyes.
There can be smacking the lips. Chewing. Some
twitching of the muscle of eyes/face/fingers.
No loss of consciousness.
Lapse of consciousness.
4yrs to puberty.
Later on: either settle down or have epilepsy.
Need to exclude generalized seizure.
Anything happened before or during the activity? Any
shaking/ twitching/jerkey movement/tongue bite/loss of
urine or bowel. Did he have any injury, infection
(meningitis)? Does he have any headaches? Any
neurological deficits? Any weakness or numbness of the
limbs? Any problem with vision or hearing?
BINDS: Any problem during the birth? Any
trauma/resuscitation/medications? Growth charts.
Feeding and general health all is good. What is the home

Nothing is positive.
GA, Growth chart, V/S, Neurological deficits, rest of the
exam.
Hyperventilation can provoke the seizure episode. Ask
the examiner.
o

Mx:

(blow breath out several times and will provoke the

seizure)

Most likely the condition he has is Absence seizure the

cause is not found but can have a genetic predisposition.
This is caused by abnormal electrical discharges in nerve
cells of brain. I am going to refer you to the specialist. He
is going to do EEG (Electroencephalography: 3Hz wave
spike). This is a non-invasive procedure which involves
placing the electrodes and measuring the electrical
activity of the brain
Medications: Single drug for a long period of time (1year)
1st choice: Ethosuximide: S/E: related to the digestive
symptoms, stomach upset, nausea, diarrhea, anorexia.
Dizziness or drowsy/ headache/ vision: Myopia, problem
with gum. Pancytopenia/leukopenia. If you
find any infections, bleeding, problem with vision,
headache please come back to the hospital.
2nd choice: Sodium Valproate: S/E: liver function. Monitor
LFTs every 2months initially with the treatment.
Advice the mother: Be cautious if he is bathing/
swimming/ driving. Do not let him come close to the fire
or any other dangerous activity. Closely monitor the child.
If they have generalized fits: dont stop the fit, dont put
things in the childs mouth. Put the child on his side.
Immediately come back to the ED if it prolong more than
10mins. I will inform the teacher also.

4)

the first time he had a fit? Any family history of epilepsy?

Regarding his health, did he have recent flu-like illness?
Any recent change to his weight, or appetite? Any
problem with waterworks? Is he sleeping well? (sleep
deprivation, stimulus for epilepsy) Are you aware if he
might be using some drugs, alcohol, or if he smokes? Do
you think he is under a lot of stress at home, or in school?
How is his school performance? Any other concerns
regarding his growth and development?

A 16-year-old boy was brought to your GP clinic after having a fit at

school immediately following an injury at the playground. No relevant
past medical and surgical history. His family including sisters are well.
Complete examination after arrival was normal.
Task

Causes

Further history from mom

Give most appropriate investigation to examiner
Explain management in immediate future

Provoked seizures/Situational seizures/acute

symptomatic occurs within 7 days after acute brain
insult

Structural in nature
o

(head injury, stroke, infections such as encephalitis,

abscess, TB of brain, neurocysticercosis)

Metabolic/toxic
o

(kidney failure, liver failure, alcohol, drugs)

Hx:

Is the child hemodynamically stable or not?

Please tell me more about what happened? Exactly when
did it happen? were there any witnesses? Did he collide
with anything, something or someone? Do you think he
tripped and fell? Did he land on his head? Any trauma to
the head? Before the fit, was he conscious? Breathing on
his own? Was he confused? Any headache, N/V? Did
anyone describe the fit to you? Was it over the whole
body? Or just one side of the body
(focal/stroke/abscess)? Do you think the fit started in one
part of the body and later involved the whole body
(Jacksonian March)? During the fit, did he wet himself?
Or did he pass stools? Do you think he bit his
tongue/lips? After the fit, did he recover himself? Was he
confused? Was he communicating with anyone? Is this

Inx:

FBE, CRP (to R/O infection), LFTs, KFTs (r/o

liver/kidney- electrolyte imbalance), BSL to check
hypoglycemia (juvenile diabetes), urine dipstick
(infection), chest xray and plain xray of skull, drug
screening with moms consent. Later on, CT scan might
be needed.
Guideline: CT scan/MRI is done as first line investigation

Mx:

At the moment, all our examination is normal. It seems

like there is nothing structurally wrong with his brain that
might have caused this kind of seizure because there is
no family history and seizure was brought on by possible
trauma to the head. Im not concerned about epilepsy.
However, should he develop more fits, we will do an EEG
to rule out epilepsy. Most likely, this was a provoked fit
that is commonly seen after head injury. However, there
are certain metabolic as well as infectious causes of
seizures that we need to rule out, that is why I am
sending him to the hospital where he will be kept under
observation for a few hours in ED. They will do some
tests in the blood and urine as well as some imaging to
rule out any serious causes. There is a high chance that
he might develop fit within the next 7 days. He will be
observed by the specialist neurologist and if required,
they might give him some sedatives. However,
antiepileptic medications are usually not required in these
cases. If he loses consciousness or with repeated fits or if

the fits continue for more than 10 minutes, the specialist

might start you on IV phenytoin.
I will liaise with the ED consultant about your childs
condition and progress, please come back to me once he
is discharged from the hospital.

5)
PEx:
You are a GP and your next patient is a 7-year-old girl brought by her
father because of recurrent headaches

Task

4 headache cases: tension, posterior fossa tumor,

migraine, URTI (sinusitis)

History

Physical examination (normal)

Diagnosis and management

Migraine
Tumor
Meningitis
Tension
Vision problem
Sinusitis
Trauma
Diabetes mellitus

HPI: SOCRATES = where exactly is the pain? When did

it start? Is it going somewhere else? Is it throbbing,
pinching, squeezing? Aggravating factors: hunger, light,
movement (sinusitis), relieving factors, associated factors
(early-morning vomiting, fever, trauma)? Severity (1-10)?
Any lumps or bumps in the head? Any problems with
vision? URTI? Cough or colds?
HEADSSS? Are you a happy family? Do you spend
time with her? Do you have financial problems? Does she
go to school? Does she like her teachers? Has she ever
complained about any bullying? How is her school
performance?
BINDS is she eating well? Is there any concern about
the development? Do you have any other kids? Any
major difference you find with development of both?
FHx: tumors, migraine, DM, etc MA

(headache x 3 weeks all over the head)

DDx:

Hx

General: dehydration, pallor, jaundice, healthy

Vital signs and growth chart; BP is important!
ENT: FUNDOSCOPY is a must; sinusitis, tympanic
membrane,
Neck, rigidity, LAD,
Chest and Lungs & Heart
Abdomen
Neurological examination
Urine dipstick and BSL
Child Neuro:
ITPRC (inspection tone power reflexes
coordination)

Dx and Mx:
Your child most likely has a condition called tension
headache. It is important to realize that her headache is
real but it is not serious. The reason most likely is
because you dont have time for Mary and shes probably
missing that.
I would like to arrange a family meeting. I would like to
see your wife as well. For her pain, you can give her
panadol.
I would like to refer her to the counselor. They are experts
I would organize a social worker to liaise with the school
(for school issues).
Are you sure? Yes, from all the information you have
given, I believe it is a tension headache.
Can you refer me to a specialist? I am happy to refer you
to a specialist for a 2nd opinion. If he needs to have some
more investigations, she may request to do so.
Review. Reading material.
Red flags: Vomiting, Fever, Rash
MRI preferred in children than CT scan (less radiation
exposure)

6):

respiration. It is caused by increased pressure inside the

skull.These symptoms can be indicative of insufficient
blood flow to the brain (ischemia) as well as compression
of arterioles. In response to rising intracranial pressure
(ICP), respiratory rate increases. The increase in
ventilation is exhibited as an increase in rate rather than
depth of ventilation, so the Cushing reflex is often
associated with slow, irregular breathing.)

You are a GP and your next patient is a 10-year-old girl brought by

her mom due to headaches for the last 6 months.
Task

History
o

(6mos headache increasing in intensity; starts in

occipital area then becomes generalized; associated
early morning 6-8/10 in severity with vomiting;
affecting grades and skipping school, (+) FHx of
migraine)

Physical examination

Diagnosis and management

PEx:

ENT: exclude sinusitis (tenderness of sinuses); visual

acuity, PEARL (pupils equal and reactive to light), eye
movements to check for diplopia, nystagmus,
FUNDOSCOPY (swelling and blurring of optic disc),
visual fields,

NECK STIFFNESS,

(papilledema on funduscopy)

Hx:

Can you tell me more about it? Duration? Progressive?

Type of pain (dull/steady/severe)? Severity? When does
it usually happen? How frequently does she have the
headaches? Radiation (generalized)? Any particular
timing in the day? Aggravating factors: worse with
coughing, sneezing or straining? Does the headache
wake the child at night? Does she take any medications?
Associated symptoms: Nausea? Vomiting? Relieved by
vomiting? Drowsy? Loss of consciousness?
Weakness/numbness? Diplopia? Gait problems?
Problem with bright lights? Trigger factors (food,
hormones)? Relieved by sleep? Personality changes?
Sinusitis, URTI? Have you ever checked her BP? School
performance? Social stressors?
General health? FHx (migraine, vision, tumors)
General appearance
Vital signs: especially BP (140/90); PR: 70/minute
shows Cushings reflex (The Cushing reflex classically
presents as an increase in systolic and pulse pressure,
reduction of the heart rate (bradycardia), and irregular

Neurologic: Inspection, tone, power, reflexes, gait,

cerebellar signs, cranial nerves

Dx and Mx:
From history and PE findings, most likely your child has
increased pressure on the brain which can be due to a
nasty growth or brain tumor. I do not mean to scare you
but she needs to be evaluated further ASAP. I will call the
ambulance and send you to the hospital where she will
be seen by a pediatric neurologist.

To find the cause, she needs an MRI scan to see inside

the brain and locate the abnormality, and if confirmed,
she may need surgery and that will be decided by the
specialist and will be followed-up on a regular basis.

For migraine: Avoid triggering factors,

paracetamol/NSAIDS at maximum, rest, refer to pediatric
neurologist for prophylactic treatment

7)

Hx:

You are a GP and an 8-month-old baby is brought by his mother for

routine immunization which was delayed for 2 months because of his
grandmothers funeral. The child is arching his back and mother is
concerned about this.

Sorry for your loss. Do not worry, I can arrange for the
immunization.
Can you tell me more about his arching? Scissoring of his
legs or crossing of legs while you hold him? Weakness or
stiffness of his limbs?
BINDS: social smile (4mos)? Prone to supine (5mos)?
Roll over (5mos) Babble (6mos)? Dada/baba (8mos)?
Peek a boo (8mos)? Vision? Hearing? Waterwork?
Fever? Medical condition?
How about your pregnancy? Was it a planned
pregnancy? Did you have any infection (TORCH)? Was it
a term or preterm delivery? What about her delivery?
Birth weight? About labor? Was the baby resuscitated?
Complications? What about his previous growth charts?
Family history of any developmental disorder?

General appearance
Vital signs and growth charts
Neurologic examination: increased tone and reflexes

Most likely John has a movement and postural disorder

due to damage to an immature developing brain called
cerebral palsy. It is a group of non-progressing and
permanent disorder and in his case, it most likely
occurred due to the infection that you had in pregnancy or
because he was resuscitated in nursery after birth. To
further confirm or diagnose his condition I will refer him to
neurologist pediatrician for complete neurologic and
developmental examination so that we can come up with
a definitive diagnosis.
Is it serious? Yes, it is serious and I am sorry for that. You
are not alone and he will be taken cared of by a MDT:
Specialist pediatrician
GP
Physiotherapist: practical advice to parents and carers
about positioning, handling, and play

Task

History
o

(noted to be arching back and not able to sit

unsupported)

Physical examination
Diagnosis and management

Cerebral Palsy
Cannot be diagnosed until 2 years of age
Non-progressive but permanent disorder of movement
and posture due to a defect in the developing immature
brain
Etiology: may be related to events in prenatal, perinatal,
or postnatal periods; cause is unknown
Perinatal asphyxia (<10%) cases and postnatal illnesses
or injuries (10%)
Association: LBW (<1500g) and prematurity
Classification:
Type of motor disorder (spasticity most common),
dyskinesia,
Distribution (hemiplegia [30%], diplegia [25%],
quadriplegia [45%])
Severity
70% associated disorders: visual problems, hearing
impairment, communication disorders, epilepsy,
intellectual disability, specific learning disability or
perceptual disorders

PEx:

Mx:

Occupational therapist: developing childs UL and selfcare skills

Speech pathologist: severe eating and drinking difficulties
and communications and augmentative communication
systems
Orthotists/prosthetists
Dietitian
Psychologist
Social worker
Any complication or health problem in the future will be
dealt accordingly and I will give you the contacts of
support groups and CP clinic.
Review. Reading materials.

8)

DDx:

David, 9-months-old presents with his mom who is concerned about

his babys head. She thinks that his head is oddly shaped.

Task

Features

History (3months
Physical examination (Head Circumf. growing along 25
centile)
Differential diagnosis
Management
Asymmetry of skull with normal head circumference
flat head
Most common cause of an abnormal head shape
Congenital or acquired
Results from infant sleeping in one position
No impairment of cerebral development or intellect
Treatment: changing side to which the child usually faces
for sleeping then regularly changing sides and
encouraging time in prone position while awake
cranial remodeling helmet (best from 4-8 months)

Hx:

PEx:

HPI: since 3 months

BINDS especially delivery and development
FHx of abnormal head

General appearance
Vital signs and growth chart
Neck for congenital torticollis
Head for suture lines if rigid
Dysmorphic features
Developmental assessment
Neurological examination

Plagiocephaly or craniocynostosis (premature fusion of

one or more sutures of cranial vault and base, which act
as lines of growth)
Cranial XRay to see suture line whether patent or not
(equal, symmetrical, closed at the same time) often
unreliable in <3 months when low mineralization of skull
is difficult to see
Prompt referral to pediatric caraniofacial surgeon done
at 5-10 months

Mx:

Prevent further deformities

Keep baby in supine position but give tummy time with
mom observing
Reposition baby during sleep and feeding
Refer to craniofacial unit at RCH if failed conservative
treatment up to 6 months; might use cranial remolding
helmet
External cranioplasty