Pediatric Case Sheet Proforma for 6-Year-Old with Febrile Seizures
Patient Demographics
- Name: _______________
- Age: 6 years
- Sex: _______________
- Date of Presentation: _______________
- Time of Presentation: _______________
- Medical Record Number: _______________
Chief Complaint
- Seizure with fever
History of Present Illness
Seizure Characteristics
- Time of seizure onset: _______________
- Duration of seizure: <15 minutes ☐ / >15 minutes ☐ 1, 2
- Type: Generalized tonic-clonic ☐ / Focal ☐ 2, 3
- Number of seizures in 24 hours: Single ☐ / Multiple ☐ 1, 2
- Level of consciousness during seizure: Altered ☐ / Maintained ☐ 2
- Postictal state: Present ☐ / Absent ☐ Duration: _______________
- Any focal neurological signs: Yes ☐ / No ☐ Details: _______________ 3
Classification
- Simple febrile seizure (generalized, <15 min, single in 24h) ☐ 1, 2
- Complex febrile seizure (focal, >15 min, or multiple in 24h) ☐ 1, 2
Fever History
- Temperature at presentation: _______________°F/°C
- Duration of fever before seizure: _______________
- Fever onset relative to seizure: Before ☐ / During ☐ / After ☐ 4, 5
- Maximum temperature recorded: _______________
- Source of fever identified: Yes ☐ / No ☐ Details: _______________ 6
Associated Symptoms
- Meningeal signs: Neck stiffness ☐ / Photophobia ☐ / Bulging fontanelle ☐ 3
- Septic signs: Petechiae ☐ / Hypotension ☐ / Poor perfusion ☐ 3
- Behavioral changes: Lethargy ☐ / Irritability ☐ / Confusion ☐ 3
- Respiratory symptoms: Cough ☐ / Rhinorrhea ☐ / Difficulty breathing ☐
- Gastrointestinal symptoms: Vomiting ☐ / Diarrhea ☐ / Abdominal pain ☐
- Urinary symptoms: Dysuria ☐ / Frequency ☐
Past Medical History
Previous Seizure History
- History of febrile seizures: Yes ☐ / No ☐ 1, 5
- History of afebrile seizures: Yes ☐ / No ☐ 2
- Diagnosis of epilepsy: Yes ☐ / No ☐ 1
Developmental and Neurological History
- Developmental milestones: Normal ☐ / Delayed ☐ 3
- Baseline neurological status: Normal ☐ / Abnormal ☐ Details: _______________ 3
- Previous neuroimaging: Yes ☐ / No ☐ Results: _______________ 3
- Previous EEG: Yes ☐ / No ☐ Results: _______________
Other Medical Conditions
- Chronic illnesses: _______________
- Current medications: _______________
- Allergies: _______________
- Immunization status: Up to date ☐ / Not up to date ☐ 6
Family History
- Family history of febrile seizures: Yes ☐ / No ☐ 1, 6
- Family history of epilepsy/nonfebrile seizures: Yes ☐ / No ☐ 1, 3
- Family history of neurological disorders: Yes ☐ / No ☐ Details: _______________
Physical Examination
Vital Signs
- Temperature: _______________°F/°C
- Heart rate: _______________ bpm
- Respiratory rate: _______________ breaths/min
- Blood pressure: _______________ mmHg
- Oxygen saturation: _______________% on room air
- Weight: _______________ kg
General Appearance
- Alert and well-appearing: Yes ☐ / No ☐ 6
- Level of consciousness: Alert ☐ / Lethargic ☐ / Obtunded ☐
- Distress: None ☐ / Mild ☐ / Moderate ☐ / Severe ☐
Head, Eyes, Ears, Nose, Throat
- Fontanelle (if applicable): Flat ☐ / Bulging ☐ 3
- Tympanic membranes: Normal ☐ / Erythematous ☐ / Bulging ☐
- Pharynx: Normal ☐ / Erythematous ☐ / Exudate ☐
Neurological Examination
- Mental status: Normal ☐ / Altered ☐ 3
- Cranial nerves: Intact ☐ / Abnormal ☐ Details: _______________
- Motor examination: Normal tone ☐ / Hypotonia ☐ / Hypertonia ☐
- Reflexes: Normal ☐ / Hyperreflexia ☐ / Hyporeflexia ☐
- Focal neurological deficits: Present ☐ / Absent ☐ Details: _______________ 3, 6
- Meningeal signs: Neck stiffness ☐ / Kernig's sign ☐ / Brudzinski's sign ☐ 3
Cardiovascular Examination
- Heart sounds: Normal ☐ / Abnormal ☐
- Perfusion: Normal ☐ / Delayed capillary refill ☐ 3
Respiratory Examination
- Breath sounds: Clear ☐ / Crackles ☐ / Wheezing ☐
- Work of breathing: Normal ☐ / Increased ☐
Abdominal Examination
- Soft and non-tender: Yes ☐ / No ☐
- Organomegaly: Present ☐ / Absent ☐
Skin Examination
- Rash: Present ☐ / Absent ☐ Type: _______________
- Petechiae/purpura: Present ☐ / Absent ☐ 3
Immediate Management During Seizure (if applicable)
Safety Measures Implemented
- Positioned on side: Yes ☐ / No ☐ 1, 7
- Head protected: Yes ☐ / No ☐ 1
- Harmful objects removed: Yes ☐ / No ☐ 1
- Nothing placed in mouth: Confirmed ☐ 1, 2
- Patient not restrained: Confirmed ☐ 1, 2
Pharmacological Intervention (if seizure >5 minutes)
Diagnostic Evaluation
Indications for Lumbar Puncture
Lumbar puncture REQUIRED if: 3
- Meningeal signs present ☐
- Septic signs present ☐
- Behavioral disturbance present ☐
Lumbar puncture DISCUSSED based on clinical progression if: 3
- Focal febrile seizure without meningeal/septic signs ☐
- Repetitive febrile seizures without meningeal/septic signs ☐
Lumbar puncture NOT necessary if: 3, 6
- Simple febrile seizure ☐
- Well-appearing child ☐
- No meningeal signs ☐
Laboratory Tests (only as indicated to identify fever source)
- Complete blood count: Ordered ☐ / Not indicated ☐ 6
- Blood culture: Ordered ☐ / Not indicated ☐
- Urinalysis and culture: Ordered ☐ / Not indicated ☐
- Electrolytes: Ordered ☐ / Not indicated ☐
- Glucose: Ordered ☐ / Not indicated ☐
- Lumbar puncture: Performed ☐ / Not indicated ☐ 3, 6
Neuroimaging
- Routine neuroimaging for simple febrile seizure: NOT indicated ☐ 1
- MRI brain indicated if: 1, 7
- Febrile status epilepticus (>30 min) ☐
- Focal neurological findings ☐
- Abnormal neurological examination ☐
Electroencephalography (EEG)
- Routine EEG for simple febrile seizure: NOT indicated ☐ 6
- EEG indicated if: Concern for underlying seizure disorder ☐
Risk Assessment
Risk Factors for Recurrent Febrile Seizures
- Age <12 months at first seizure: Yes ☐ / No ☐ (50% recurrence risk) 1, 2
- Age >12 months at first seizure: Yes ☐ / No ☐ (30% recurrence risk) 1, 2
- Family history of febrile seizures: Yes ☐ / No ☐ 6, 5
- Previous febrile seizure: Yes ☐ / No ☐ 5
Risk Factors for Developing Epilepsy
- Multiple simple febrile seizures: Yes ☐ / No ☐ 1
- Age <12 months at first seizure: Yes ☐ / No ☐ 1
- Family history of epilepsy: Yes ☐ / No ☐ 1
- Combined risk factors: 2.4% risk by age 25 years 1, 2
- Simple febrile seizure alone: ~1% risk (same as general population) 1, 7
Indications for Rescue Medication (risk >20% for prolonged seizure)
Rescue medication (rectal/buccal diazepam) may be prescribed if: 3
- Age at febrile seizure <12 months ☐
- History of previous febrile status epilepticus ☐
- First febrile seizure was focal ☐
- Abnormal development/neurological exam/MRI ☐
- Family history of nonfebrile seizures ☐
Rescue medication prescribed: Yes ☐ / No ☐
Long-Term Management Plan
Anticonvulsant Prophylaxis
Neither continuous nor intermittent anticonvulsant therapy is recommended for simple febrile seizures 8, 1, 2
- Continuous prophylaxis (phenobarbital/valproic acid): NOT recommended ☐ 1, 2
- Intermittent prophylaxis (diazepam): NOT recommended ☐ 8, 1
Antipyretic Use
- Antipyretics for comfort: Acetaminophen ☐ / Ibuprofen ☐ 1, 2
- Note: Antipyretics do NOT prevent febrile seizures or reduce recurrence risk 1, 2, 6
Indications for Neurology Referral
Refer to pediatric neurology if: 3
- Prolonged febrile seizure before age 1 year ☐
- Prolonged AND focal febrile seizure ☐
- Repetitive (within 24h) focal febrile seizures ☐
- Multiple complex febrile seizures ☐
- Abnormal neurological examination with febrile seizure ☐
- Abnormal development with febrile seizure ☐
- First antiepileptic medication fails (if epilepsy diagnosed) ☐ 1
Neurology referral: Indicated ☐ / Not indicated ☐
Follow-Up Plan
- Early clinical re-evaluation (within 4 hours): Recommended for infants <12 months ☐ 3
- Follow-up with primary care physician: Scheduled ☐ Date: _______________ 3
- Neurology follow-up: Scheduled ☐ / Not indicated ☐ Date: _______________
Parent/Caregiver Education
Key Educational Points Discussed
- Benign nature of simple febrile seizures: Discussed ☐ 1, 6
- Excellent prognosis: No long-term effects on IQ, academic performance, or neurocognitive function ☐ 1, 7
- No structural brain damage from simple febrile seizures: Discussed ☐ 2
- Recurrence risk: Explained based on age and risk factors ☐ 1, 2
- Risk of epilepsy: ~1% (same as general population) ☐ 1, 7
Home Management Instructions
- What to do during a seizure: 1, 7
- Place child on side ☐
- Protect head from injury ☐
- Remove harmful objects ☐
- Do NOT restrain child ☐
- Do NOT place anything in mouth ☐
- Time the seizure ☐
When to Seek Emergency Care
Call emergency services if: 1, 2
- First-time seizure ☐
- Seizure lasts >5 minutes ☐
- Multiple seizures without return to baseline ☐
- Difficulty breathing or choking ☐
- Traumatic injury during seizure ☐
Rescue Medication Instructions (if prescribed)
- Medication name and dose: _______________
- When to administer: If seizure lasts >5 minutes 3
- How to administer: Demonstrated and understood ☐
- When to call emergency services after giving rescue medication: Discussed ☐
Fever Management
- Antipyretics for comfort: Acetaminophen/Ibuprofen dosing provided ☐ 1, 2
- Clarification: Antipyretics do NOT prevent seizures ☐ 1, 2
Disposition
- Discharged home: Yes ☐ / No ☐
- Admitted for observation: Yes ☐ / No ☐ Reason: _______________
- Transferred to higher level of care: Yes ☐ / No ☐ Reason: _______________
Physician Notes and Assessment
Clinical Impression
- Simple febrile seizure: Yes ☐ / No ☐ 1, 2
- Complex febrile seizure: Yes ☐ / No ☐ 1, 2
- Source of fever identified: Yes ☐ / No ☐ Details: _______________
Management Summary
Prognosis Discussion
- Excellent prognosis confirmed: Yes ☐ 1, 7, 6
- Parents reassured about benign nature: Yes ☐ 6, 9
- Written discharge instructions provided: Yes ☐
Physician Signature: _______________
Date: _______________
Time: _______________