Age: 7.0
Sex: M
Vaccine: FLU3, FLU3
Symptoms: Blood magnesium increased, Blood phosphorus decreased, Blood potassium normal, Blood sodium normal, Blood urea normal
Clinical narrative: History was obtained from chart and parents. This is a 7yo male that presents today after a witnessed seizure. He was born at 24wks gestation with a twin. He was found to have IVH at birth that caused hydrocephalus. A Shunt was placed at 1-2months of age. He has had no difficulties with his shunt placement, but does have a history of developmental delay. Today the family brought the patient into a follow up appointment. He received a flu shot and as they were leaving started to act abnormal. He developed left gaze preference and the turned his head to the left. He became very tense and his arms flexed bilaterally. Family reports small convulsions in all extremities. This event lasted ~20 minutes total. He was brought to the ED and given Diastat. The episode resolved but the pt subsequently was intubated. No recent illness or fever. Family denies nausea, vomiting, diarrhea, or fever. No change in cognitive status. No family history of seizures. Possible seizure 2 years ago reported by his teacher. He suddenly leaned back and became tense/stiff for several seconds. Father brought him to the hospital at that time but was sent home as he had returned to normal. No fevers or other abnormalities noted at that time. Patient is a 7 year old with history of prematurity (24 weeks) hydrocephalus and VP shunt admitted to the PICU after seizure. He had a seizure with head deviation to left and generalized tonic-clonic activity lasting >20 minutes at Clinic after receiving a flu vaccine at his regular clinic visit. He initially needed oxygen support and bag-mask ventilation at the scene for apnea and was subsequently intubated. He received Diastat at the scene and was loaded with 20mg/kg of Keppra on arrival. He was stable in the PICU and was able to be extubated overnight on day of admission. He was transferred to the floor on 12/10 and continued to do well. He had no further seizure activity. A shunt series was performed and was normal. Head CT unchanged from previous MRI.  At time of discharge he was stable on room air, eating, drinking and behaving normally.   L A B O R A T O R Y   R E S U L T S   S U M M A R Y       Specimen: 12859792 - Collection: 12/09/2011 18:15  CHEMISTRY  Calcium               8.2      L      mg/dL        8.6 - 10.5            Phosphorus            3.9             mg/dL        3.0 - 6.0             Magnesium             1.9             mg/dL        1.6 - 2.3             ********************************************************************  Specimen: 12857749 - Collection: 12/09/2011 13:50  HEMATOLOGY  WBC                   12.19           x10(3) mcL   4.50 - 14.50          HGB                   13.9            gm/dL        11.5 - 15.5           HCT                   41.1            %            35.0 - 46.0           Platelet              185             x10(3) mcL   150 - 450             Abs Imm Gran          0.05     H      x10(3) mcL   0.00 - 0.04           Abs Neut              6.78            x10(3) mcL   1.80 - 7.50           Abs Lymph             4.59            x10(3) mcL   1.50 - 6.00           Abs Mono              0.54            x10(3) mcL   0.10 - 1.00           Abs Eos               0.18            x10(3) mcL   0.00 - 0.50           Abs Baso              0.05            x10(3) mcL   0.00 - 0.10           % Imm Gran            0.4             %                                  % Neutro              55.6            %                                  % Lymph               37.7            %                                  % Mono                4.4             %                                  % Eos                 1.5             %                                  % Baso                0.4             %                                  RBC                   4.92            x10(6) mcL   4.00 - 5.20           MCV                   83.5            fL           77.0 - 95.0           MCH                   28.3            pg           25.0 - 33.0           MCHC                  33.8            gm/dL        31.5 - 36.5           RDW                   12.4            %            11.5 - 14.5           MPV                   11.5            fL           8.2 - 12.4            CHEMISTRY   Sodium                139             mmol/L       135 - 145             Potassium             3.7             mmol/L       3.5 - 5.2             Chloride              103             mmol/L       99 - 112              Carbon Dioxide        25              mmol/L       20 - 30               Anion Gap             11              mmol/L       7 - 14                Calcium               8.8             mg/dL        8.6 - 10.5            Glucose               117      H      mg/dL        65 - 110              BUN                   12              mg/dL        5 - 20                Creatinine, New Calib 0.32            mg/dL        0.26 - 0.64           Creatinine, Old Calib 0.5             mg/dL        0.4 - 0.8             ********************************************************************  Specimen: 12857750 - Collection: 12/09/2011 14:40  URINALYSIS/FECES  Color Ur              YELLOW                                             Clarity Ur            CLOUDY                                             Specific Gravity  Ur  1.017                        1.005 - 1.035         pH Ur                 6.0                          4.6 - 8.0             Glucose Ur            NEGATIVE                     NEGATIVE -            Ketones Ur            NEGATIVE                     NEGATIVE -            Protein Ur            TRACE                        NEGATIVE -            Blood Ur              NEGATIVE                     NEGATIVE -            Bili Ur               NEGATIVE                     NEGATIVE -            Urobilinogen Ur       NORMAL          mg/dL        0.2 - 2.0             Nitrite Ur            NEGATIVE                     NEGATIVE -            Leukocytes Ur         NEGATIVE                     NEGATIVE -            ********************************************************************  Radiology:  Shunt series 12/9 Impression: Intact ventriculoperitoneal shunt tubing.  CT head 12/9 IMPRESSION: Right frontal ventriculostomy catheter in place with a stable appearance of the ventricles with regards to the comparison MRI examination 11/9/2009.  Discharge Physical Exam   Constitutional: Afebrile General: No acute distress. Appropriately interactive during exam. Head/Neck: Normocephalic, atraumatic Eyes: PEERL. Normal conjunctiva. No discharge or drainage ENT: Mucous membranes moist. No pharyngeal erythema. No nasal discharge Chest: Non-labored respirations. Lungs clear to auscultation bilaterally. CV: Regular rate and rhythm, no murmur. Cap refill < 2 seconds. Peripheral pulses intact and equal. Abdomen: Soft, non-tender, non-distended. Bowel sounds active. No organomegaly Lymph: No lymphadenopathy Extremities: Moves all extremities spontaneously and equally. No clubbing, cyanosis or edema Neuro: Global delay. Just awoke from sleep with poor cooperation with exam. Slurred speech but understandable to mother.  Skin: No visible rashes or lesions  Discharge Medications:  Current medications as of 12/11/2011 02:15   Ritalin 5 mg oral tablet  5 mg (1 tablet) by mouth once a day (in the morning)   Tylenol  425 mg by mouth every 4 hours as needed for Fever or Mild Pain   Keppra 100 mg/ml oral solution  140 mg by mouth 2 times a day Please take 140mg (1.4mL) two times a day for 1 week. At the end of the week, please increase to 280mg (2.8mL) two times a day.