CHAPTER I

INTRODUCTION

1.1 Issue Background

Neuromusculosceltal system is the ninth block in the third semester of the
Medical Education Competency Based Curriculum in the Faculty of Medicine,
Muhammadiyah Palembang. Tutorial is an implementation of Problem Based
Learning (PBL). The tutorial process is divided into 10 groups of 10 people
who are guided by a lecturer / tutor as a facilitator to solve existing cases.
From the Problem Based Learning (PBL) program, students are able to
learn actively and independently, also design learning processes effectively.
The tutorial process is divided into 2 sessions and 1 tutorial plenary
discussion. In session 1, students are asked to classify terms, to find
hypotheses. Then, in session 2, students were asked to be able to submit
arguments and make conclusions together. At the end of the week, a plenary
tutorial will be held where students are given the opportunity to express their
opinions in front of experts in their fields.

1.2 Purpose and Objectives

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system at the
Faculty of Medicine, Muhammadiyah University of Palembang.
2. Can solve the case given in the scenario with the method of analysis and
learning group discussion.
3. Achieving the objectives of the tutorial learning method.

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 CHAPTER II
DISCUSSION

2.1 Tutorial Data

Tutor : dr. Rista Silvana, Sp.Og
Moderator : Melenia Rhoma dona YS
Secretary of table : Maulidiyah Tasya Salsabilla
Secretary of board : Vena Putri Mulya Nuralgisca
Day and Date : Tuesday, October 22nd 2019
(13.00 – 14.45 pm)
Thursday, October 24th 2019
(13.00 – 14.45 pm)

Rule of Tutorial :
1. Mutual respect among fellow tutorial participants
2. It is forbidden to eat and drink during the tutorial
3. Using good and proper communication

2.2 Case Scenario

“ The Unexpectable Suizure”

Tini a 3 years old girl, was bought by his mother to the emergency
department of RSMP with a chief complain of seizure followed with fever
twice since 1 hours ago,with a duration of seizure ± 25 minutes, and second
seizure for about 5 minutes, tonic clonic both hands and legs, rolled up eyes,
during the seizure Tini was unconscious but before and after the seizure Tini
was conscious.
Since 1 days before admitted to the hospital, Tini was experiencing high
fever, cough, runny nose, and discomfort while swallowing. Three hours after
the fever, Tini was experiencing seizures for about about 5 minutes. Tini never
experience a seizure before. Tini mother’s have experienced febrile seizure

2
during his childhood. Tini was born spontaneously with a help of midwives,
aterm and cry spontaneously.

Physical Examination
General appearance: looks midly sick, consciousness: composmentis, BW: 14
KG, BH: 94 cm
Vital sign: Pulse 124x/m (feels and pressure normal), respiratory rate 32x/m.
Temp 390C.

Spesific Examination
Head: Eyes: Isokor pupil , light reflexes (+), Nose: rhinorea (-/-), faring:
hiperemic, tonsil: T3/T3, detritus (+), crypt not widened
Neck: theres no neck rigidity
Thorax: systemic, retraction (-)
Cor: normal heartsounds, murmur (-), gallop (-)
Pulmo: vesicular (+) normal, rhonki (-), wheezing (-)
Abdomen: normal bowel sound, hepar and lien were not palpable
Extremity: warm akral, joint stiffness (-)

Neurological status: Nn. Craniales: normal

Motoric function:
Superior extremities extremities Inferior
Right Left Kanan Kiri
Movement Large Large Luas Luas
Power 5 5 5 5
tonus Eutoni Eutoni Eutoni Eutoni
klonus - - - -
Physiological reflex Normal normal Normal Normal
reflex Pathology - - - -
Sensoric Function: normal
Meningeal reflexes: (-)

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2.3 Clarification of Terms
No. Term Meaning

1. Seizure Sudden attack or relapse of a disease

(Dorland, 2015).

2. Murmur Periodic short duration sound that comes from the

heart or blood vessels (Dorland, 2015).

3. Rhinorea Watery mucus secretion from the nose

(Dorland, 2015).

4. Tonic Clonic Convulsions with loss of consciousness and severe

muscle contractions (Dorland, 2015).

5. Fever The increase in body temperature above normal

(37 ° C) (Dorland, 2015).

6. Hiperemic Redness of the pharynx (Dorland, 2015).

7. Detritus Particular material produced or remaining after

wear or network disintegration (Dorland, 2015).

8. Cough Expulsion of air from the lungs suddenly with noise

(Dorland, 2015).

9. Isokor Equation pupil size on both pieces of eye

(Dorland, 2015).

10. Vesicular Normal breath sounds (on pulmonary)

(Dorland, 2015).

11. Composmentis Fully aware or mental health (Dorland, 2015).

12. Gallop Heart rhythm abnormalities (Dorland, 2015).

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 13. Eutoni Normal tone (Dorland, 2015).

14. Tonus Mild muscle contractions and continuous, that the

skeletal muscles help maintain posture and blood
returns to the heart (Dorland, 2015).

15. Sensoric Introduction implus of receptors to the central

nervous system, the brain and spinal cord
(Dorland, 2015).

16. Motoric Muscles or nerves that affect or produce movement

(Dorland, 2015).

2.4 Identification of Problem

1. Tini a 3 years old girl, was bought by his mother to the emergency
department of RSMP with a chief complain of seizure followed with fever
twice since 1 hours ago,with a duration of seizure ± 25 minutes, and
second seizure for about 5 minutes, tonic clonic both hands and legs,
rolled up eyes, during the seizure Tini was unconscious but before and
after the seizure Tini was conscious.
2. Since 1 days before admitted to the hospital, Tini was experiencing high
fever, cough, runny nose, and discomfort while swallowing. Three hours
after the fever, Tini was experiencing seizures for about about 5 minutes.
3. Tini never experience a seizure before.Tini mother’s have experienced
febrile seizure during his childhood. Tini was born spontaneously with a
help of midwives, aterm and cry spontaneously.
4. Physical Examination
General appearance: looks midly sick, consciousness: composmentis, BW:
14 KG, BH: 94 cm
Vital sign: Pulse 124x/m (feels and pressure normal), respiratory rate
32x/m. Temp 390C.

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 5. Spesific Examination
Head: Eyes: Isokor pupil , light reflexes (+), Nose: rhinorea (-/-), faring:
hiperemic, tonsil: T3/T3, detritus (+), crypt not widened
Neck: theres no neck rigidity
Thorax: systemic, retraction (-)
Cor: normal heartsounds, murmur (-), gallop (-)
Pulmo: vesicular (+) normal, rhonki (-), wheezing (-)
Abdomen: normal bowel sound, hepar and lien were not palpable
Extremity: warm akral, joint stiffness (-)
6. Neurological status: Nn. Craniales: normal
Motoric function:
Superior extremities extremities Inferior
Right Left Right Left
Movement Large Large Large Large
Power 5 5 5 5
Tonus Eutoni Eutoni Eutoni Eutoni
Klonus - - - -
Physiological reflex Normal normal Normal Normal
reflex Pathology - - - -
Sensoric Function: normal
Meningeal reflexes: (-)

2.5 Priority of problem

The priority problem is in the 1st identification, Tini a 3 years old girl, was
bought by his mother to the emergency department of RSMP with a chief
complain of seizure followed with fever twice since 1 hours ago,with a
duration of seizure ± 25 minutes, and second seizure for about 5 minutes, tonic
clonic both hands and legs, rolled up eyes, during the seizure Tini was
unconscious but before and after the seizure Tini was conscious.

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 The reason is in this identification there is a chief of complain that makes
Tini go to emergency department and this complain can endanger her life.

2.6 Analysis and Synthesis of Problem

1. Tini a 3 years old girl, was bought by his mother to the emergency
department of RSMP with a chief complain of seizure followed with fever
twice since 1 hours ago, with a duration of seizure ± 25 minutes, and
second seizure for about 5 minutes, tonic clonic both hands and legs,
rolled up eyes, during the seizure Tini was unconscious but before and
after the seizure Tini was conscious.
a. What the meaning of a chief complain of seizure followed with fever
twice since 1 hours ago?
Jawab: It is meaning is the possibility of Tini has a fever seizure that
is seizures accompanied by fever (temperature ≥ 100.4 ° F or 38 °c),
without infection nervous system, which occurs in infants and
children 6 to 60 months. Nelson and Ellenberg, using data from the
National Collaborative Perinatal Project and determined that fever
seizures are classified as simplex or complex. Simplex fever seizures
are defined as seizures that occur after a fever, which lasts for less
than 15 minutes and does not repeat within 24 hours. Complex fever
seizures are defined as focal seizures, lasting more than 15 minutes,
and or repeatedly within 24 hours. Seizure attacks on sufferers of
fever can occur one, two, three or more times during an episode of
Fever. So one episode of fever seizures can consist of one, two, three
or more seizures attacks (Priguna, 2014).
Fever seizures are the most common acute neurological disorder
occurring in infants and children due to the absence of central nervous
system infections. Fever seizures occur at the age of 3 months to 5
years and rarely occur for the first time at the age of < 6 months or > 3
years. Fever seizures can occur when the body temperature above
38oC and high temperatures can cause seizure attacks. Child's ACH

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 with fever seizures have different seizure thresholds where the child
with a low seizure threshold occurs when the body temperature is 38
degrees Celsius but in a child having a high seizure threshold occurs
at a temperature of 40 degrees Celsius can even More than that. Fever
can occur at any time and can occur at the time after seizures as well
as children with fever spasms have a higher temperature compared to
the control fever disease (Priguna, 2014).

b. What the meaning of seizure duration is ± 25 minutes?

Jawab: It is meaning Tini has a febrile seizure which is categorized in
a complex febrile seizure. Because these complex febrile seizures
occur more than 15 minutes and experience repeated seizures that is
more than 1 in 24 hours (Sihaloho, 2015).
In other word, Long-lasting seizures (more than 15 minutes) are
usually accompanied by an increase in oxygen and energy
requirements for skeletal muscle contraction that eventually occurs
hypoxemia, hypercapnia, lactic acidosis caused by anaerobic
metabolism, arterial hypotension accompanied by irregular heartbeat
and increased body temperature caused increased muscle activity
(Tebing, 2017).

c. What the meaning of seizure was tonic clonic both hands and legs,
also rolled up eyes?
Jawab: It is meaning that the seizure caused by the discharge of
electrical charge to the body, especially extremities (hands and legs)
so that the occurrence of rigid spasms (tonic) and clonic (slump), this
electrical charge also flows to the eye so that the eyes appear rolled up.

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 Syntesy:
According to Natsume (2017), generalized tonic-clonic seizures are
bilateral and symmetric generalized motor seizures, that occur in an
individual with loss of consciousness. The tonic-clonic seizure
consists of a tonic (bilateral increased tone, lasting seconds to minutes)
and then a clonic (bilateral sustained rhythmic jerking) phase,
typically in this order, however variations such as clonic-tonic-
clonic and myoclonic-tonic-clonic can also occur. A clonic seizures is
a seizure with bilateral, sustained rhythmic jerking and loss of
consciousness. It is distinguished from repetitive serial myoclonic
seizures by the rhythmicity of the jerking and that it occurs in the
setting of loss of consciousness. Repetitive serial myoclonic seizures
(for example in myoclonic status epilepticus) are associated with
irregular jerking, often with partially retained awareness.

d. How about anatomy fisiology in this case?

Jawab:
1. Anatomy Brain

Picture 1. Brain
Source: Scanlon, 2016
The brain is a very important organ because it is the computer center
of all organs, a part of the central nerve located in the cavity of the
skull (Kranium) which is enclosed by a strong membrane of the brain.

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Parts of the brain:
1. The hypothalamus is the front end of the diesenfalon located
below the hypothalamic sulcus and in front of the hypothalamic
interpundenkular nucleus is divided into various nuclei and core
regions. The functions to control and regulate the autonomic
nervous system also works with the pituitary to maintain fluid
balance, maintain body temperature regulation through increased
vasoconstriction or vasodilation and affect hormonal secretion
with the pituitary gland, also as a center of hunger and control
body weight, as a regulator sleep, blood pressure, aggressive and
sexual behavior and emotional response center.
2. The thalamus is on one side of the third ventricle and its primary
activity is as a center for connecting the sensation of odor that all
memory impulses, sensations and pain receive through this
section.
3. Spinothalamus tract (the fibers immediately cross the opposite
side and enter the spinulis medulla and ascend). This section is
responsible for sending pain impulses and temperature to the
thalamus and cerebral cortex.
4. The pituitary gland is considered a glandular mask because a
number of hormones and their functions are regulated by this
gland. The pituitary is a part of the brain that is three times more
likely to develop tumors in adults.
5. Thermostatic Hypothesis: propose that body temperature above
that point will inhibit appetite.
6. Afferent Mechanisms: four main hypotheses about afferent
mechanisms involved in regulating food input have been
proposed, and the four hypotheses have nothing to do with each
other.

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2. Anatomy Tonsil
Tonsils consist of lymphoid tissue that is coated by a respiratory
epithelium. The Waldeyer ring is a lymphoid network that forms a
circle in the pharynx consisting of palatine tonsils, pharyngeal tonsils
(adenoids), lingual tonsils, and tubal tonsils (Snell, 2011).

Palatine tonsils are a mass of lymphoid tissue located within the

tonsillar fossa at both corners of the oropharynx, and are bounded by
the anterior pillar (palatoglossus muscle) and posterior pillar
(palatopharyngeal muscle). The oval-shaped tonsils are 2-5 cm long,
each tonsil has 10-30 crypts that extend into the tonsillar tissue. The
tonsils do not always fill the entire tonsillar fossa, the empty area
above it is known as the supratonsillar fossa. Tonsils are located
laterally in the oropharynx. Limited by:

Lateral - superior pharyngeal constrictor muscle

Anterior - palatoglossal muscle
Posterior - palatopharyngeal muscle
Superior - palate mole
Inferior - lingual tonsils

The surface of the palatine tonsils is covered with flaky epithelium

which also coats the invagination or tonsillar kripti. Many
lymphfanodules lie beneath connective tissue and are spread along
crypts. Lymphonoduli are immersed in the stroma of reticular
connective tissue and diffuse lymphatic tissue. Lymphonodules are an
important part of the body's defense mechanism that is spread
throughout the body of the lymphatic vessels. Noduli often converge
and generally show the germinal center (Snell, 2011).

3. Anatomy Pharynx
According to Snell (2011), pharynx is located behind the rice cavity,
mouth, and laryx. The shape is like a funnel with a wide top located

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 below the cranium. The lower part is followed by esophagus ceramcal
vertebrae emam. The pharyngeal wall consists of 3 layers: mucosa,
fibrous, and muscular. Pharynx is divided into 3:
1. Nasopharynx: located under the nasal cavity, above the soft palate
2. Oropharynx: behind the cavum oris and extends from the soft palate
to the upper edge of the epiglottis.
3. Laryngopharynx: behind the aditus larynges and the posterior
surface of the larynx, extending from the upper edge of the
epiglottis to the lower edge of the cricoid cartilage.

e. What the meaning of febrile seizure?

Jawab: Febrile seizure neurological disorders are most common in
infants and children caused by no central nervous system infection.
Febrile seizures occur at the age of 3 months to 5 years Febrile
seizures can occur when body temperature is above 38oC
(Scoot, 2014).

f. What are the etiology in this case?

Jawab: Seizures can be caused by several causes, namely perinatal
conditions, infections, metabolic conditions, poisoning,
neurocutaneous syndromes, systemic diseases, diseases or other
causes such as trauma, tumors, fever, idiopathic
Synthesis:
Seizures can occur in the acute phase of CNS infection caused by
bacteria, viruses, or parasites (Price and Wilson, 2016).
1. Metabolic disorders, as disorders that underlie seizures, include
hyponatremia, hypernatremia, hypoglycemia, hyperosmolar states,
hypocalcemia, hypomagnesemia, hypoxia and uremia. Neurologic
symptoms of changes in serum sodium levels occur due to an
increase or decrease in neuronal intracellular fluid volume and are
associated with absolute levels of less than 125 mEq / L or more

12
 than 150 mEq / L but more importantly correlate with the speed of
these changes (Price and Wilson, 2016) .
2. Brain tumors are another cause of seizures obtained, especially in
patients aged between 35 and 55 years. Seizures can be a symptom
of certain brain tumors, especially meningiomas, glioblastomas,
and astrocytomas. Tumors that are located supratentorium and on
the cortex are most likely to cause seizures. The highest incidence
of tumors located along the central sulcus is accompanied by
involvement of the motor area (Price and Wilson, 2016).
3. Cerebrovascular insufficiency arteriosclerotic and cerebrum
infarction are the main causes of seizures in patients with vascular
disease, and this seems to increase with the increasing population.
Large infarctions and deep infarctions that extend into subcortical
structures are more likely to cause recurrent seizures (Price and
Wilson, 2016).
4. Various toxic materials and drugs can cause seizures. seizures are a
manifestation of the toxic effect. Drugs that have the potential to
cause seizures are aminophylline, antidiabetic drugs, lidocaine,
phenothiazines, fisostigimin, and tricyclic. Alcohol and cocaine
abuse can also cause seizures (Price and Wilson, 2016).

g. How about relationship between gender and age with the complain of
this case?
Answer: Children under the age of < 2 have a risk of 3,4 times greater
than a fever seizure compared to a child > 2 years old. Sufferers of
fever most occurred at the age of two first years (13-24 months) ie
39.8%. On the condition of fever increase in temperature of 10C will
result in basal10%-15% metabolism increase and oxygen demand will
increase by 20%. In a child aged 3 years of brain circulation reaches
65% of all tubu, compared to adults who are only 15%.

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 For gender, fever seizures have been more suffered by boys compared
to girls with a ratio of 1.2:1, a boy who suffers from a fever seizure of
55% and a daughter of 45% it is due to women gained cerebral
maturation that faster than men (CCDI, 2016).

h. What is the classification of febrile seizure? And in this case what

type of febrile seizure?
Answer: According to Rianawati (2017), there is two classification of
febrile seizure:

No Clicic Simple febrile Complex

seizures febrile seizures
1 Duration < 15 minute >15 minut
2 Seizure type general general/fokal
3 Over in sometime 1 time > 1 time
4 Defysit neurologis - ±
5 Family have been febrile ± ±
seizure before
6 Family never have been ± ±
febrile seizure before
7 Have an abnormal ± ±
neurologis before

1. Simple febrile seizures:

a. Febrile seizures that last briefly <15 minutes
b. Will stop by myself
c. Not repeated within 24 hours
d. Simple febrile seizures constitute 80% of all febrile seizures
e. About 80-90% of all seizure cases are classified as simple
febrile seizures.

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 2. Complex febrile seizures:
a. Seizures that last more than 15 minutes
b. One-sided focal or partial seizures, or generalized seizures
preceded by partial seizures
c. Repeated seizures (multiple) or more than 1 time in 24 hours

i. What is the classification of seizure? And in this case what type of

seizure?
Jawab: According to Berman (2010), there is two classification of
seizures, focal and generalized.
1. Partial seizures (focal, local)
a. Simple partial seizures
Consciousness is not disturbed, may include one or more of the
following:
1) Signs - motor signs, twitching of the face or one side of the sign
or autonomic symptoms: vomiting, sweating, flushing, dilated
pupils.
2) Symptoms of somatosensory or special sensory: listening to
music, feeling as if falling from the air, paresthesia.
3) psychological symptoms: dejavu, fear, panoramic vision.
4) Seizures body; seizures setipa same general movement.

b. complex partial
1) There is a disturbance of consciousness, although at first as
partial seizures simplex
2) Can include automatism or automatic movement: taste-
ngecapkan lips, chewing, menongkel movement repetitive
movements of the hands and the other hand.
3) Can be no automatism: gaze riveted

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2. Generalized Seizures
a. seizures absens
1) Impaired vigilance and responsiveness
2) Marked with eyes glued to that generally lasts less than 15
seconds
3) onset and rapid suffix, after the kempali alert and full
concentration

b. myoclonic seizures
1) Twitch - involuntary twitch muscles or group of muscles that
occurs suddenly.
2) Often seen in healthy people selaam sleep but when the
pathological form of the twitch-twitch sinkrondari shoulders,
neck, upper arms and legs.
3) generally takes less than 5 seconds and occur in clusters
4) Loss of consciousness only for a moment.

c. Tonic-clonic seizure
1) Beginning with loss of consciousness and as a tonic, general stiff
in muscles of the extremities, trunk, and face that lasted less
than 1 minute
2) Can be accompanied by loss of bowel and bladder control
3) When a tonic clonic seizures followed on ekstrenitas top and
bottom.

d. seizures atonik
1) Miss the sudden tone that can cause drooping eyelids, head
down, or fall to the ground.
2) Short and occur without warning.

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j. What the patofisiology of fibrile seizure?
Answer: Infection ektrakranial (tonsilofaringitis)  stimulation of
leukocytes (monocytes, lymphocytes, and neutrophils)  secretion of
endogenous pyrogens  (IL-1, IL-6, TNF-α, and IFN) 
endothelium stimulation of the hypothalamus  arachidonic acid
release  increased synthesis of PGD E2 (prostaglandin)  an
increase in the benchmark thermostat  the mechanism of the
increase in heat  temperature rises  fever  changes in the
balance of neuronal cell membranes  diffusion of potassium ions
and sodium ions through the membrane  loose electric charge 
loss of electrical charge extends to the entire cell or to the cell
membrane by means of neurotransmitters  Febrile Seizure.

Synthesis:
Extracranial infections such as acute otitis media, tonsillitis and
bronchitis can cause a toxic bacteria grow rapidly, resulting toxic that
can spread throughout the body via the haematogenous and limfogen.
In these circumstances the body undergoes systemic inflammation,
and the hypothalamus will respond by raising the body temperature
regulation as a sign the body is in danger systemically (Shinnar, 2009).
Cells are surrounded by a membrane composed of lipids and the inner
surface is the outer surface is ionic. Under normal circumstances the
cell membranes of neurons can be passed easily by potassium ions
and extremely difficult by the ion sodium and other electrolytes,
except for chloride ions. As a result, the concentration of potassium in
a higher neuronal cells and a low sodium concentration, while outside
the neuron cells are the opposite situation. Due to differences in the
type and concentration of ions inside and outside the cell, then there is
a potential difference of the cell membranes of neurons. To maintain
the necessary balance of this membrane potential energy and the
enzyme Na-K-ATPase found on the cell surface. Changes in body

17
 temperature rise effect on seizure threshold values and neural
excitability. Any increase in body temperature of 1 degree celsius will
increase 10-15% basal metabolism and oxygen requirements by 20%,
resulting in an increase in temperature will result in an increased need
for glucose and oxygen. At a high fever will lead to hypoxic tissues
including brain tissue. In hypoxic tissue anaerobic metabolism runs,
one molecule of glucose will only produce 2 ATP, so the state will
hipoksi energy shortages and disrupt the normal function of the pump
Na + into the cell increases and piles of extracellular glutamic acid.
Heaps of extracellular glutamic acid will result in increased
permeability of the cell membrane Na + ions into the cell. Na + ions
into the cell it easy on the state of fever. Changes in ion concentration
intracellular and extracellular Na + will result in changes in cell
membrane potential of neurons to cell membrane in a state of
depolarization. The fever can damage neurons that GABA-ergic
inhibition function disrupted and lead to seizures (Shinnar, 2009).

k. What the patofisiology of tonic clonic?

Answer: Infection ektrakranial (tonsilofaringitis)  stimulation of
leukocytes (monocytes, lymphocytes, and neutrophils)  secretion of
endogenous pyrogens  (IL-1, IL-6, TNF-α, and IFN) 
endothelium stimulation of the hypothalamus  arachidonic acid
release  increased synthesis of PGD E2 (prostaglandin)  an
increase in the benchmark thermostat  the mechanism of the
increase in heat  temperature rises  changes in the balance of
neuronal cell membranes  diffusion of potassium ions and sodium
ions through the membrane  loose electric charge  loss of
electrical charge extends to the entire cell or to the cell membrane by
means of neurotransmitters  removable cargo up to the extremity
litrik  hands and feet suffered stiff and kelonjotan  Tonic clonic
seizures (Tebing, 2017).

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l. What the classification of consciousness?
Answer: According to Guyton (2014), there is six classification of
consciousness:
1) Compos mentis (conscious), the normal consciousness, awake,
able to answer all the questions about his surroundings.
2) Apathy, that state of consciousness was reluctant to connect with
the surrounding, indifferent attitude.
3) Delirium, namely anxiety, disorientation (person, place, time),
rebelled, screaming, hallucinations, sometimes to fancy.
4) Somnolence (Obtundasi, Lethargy), which reduced alertness,
psychomotor responses are slow, easy to fall asleep, but the
consciousness can be recovered when stimulated (easily aroused)
but fell asleep again, able to give a verbal answer.
5) Stupor (soporocomatose), which is the state such as sound asleep,
but no response to pain.
6) Coma (comatose), which can not be woken up, no response to any
stimulation (no gag reflex response of the cornea and, perhaps
also no pupillary response to light).

m. What the risk factor of complex febrile seizure?

Answer: The risk of complex febrile seizures are usually marked with
a febrile seizure recurrence of febrile seizures occurring a second time
as many as half of these patients. This is based on the age at first
febrile seizure is the most important risk factor in this recurrence,
because the younger the age at first febrile seizure, the higher the risk
occurs and efficacy profile as a comparison (Gupta, 2016).
Genetic or hereditary factors, for example in older people with a
history of febrile seizures (in childhood), siblings with history of
febrile seizures and parents with a history of epilepsy without fever
determine the child can experience complex febrile seizures are also
marked by seizures fever (Handy, 2016).

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2. Since 1 days before admitted to the hospital, Tini was experiencing high
fever, cough, runny nose, and discomfort while swallowing. Three hours
after the fever, Tini was experiencing seizures for about about 5 minutes.
a. What the meaning of Tini was experiencing high fever, cough, runny
nose, and discomfort while swallowing?
Answer: Fever, cough, runny nose, and discomfort experienced while
swallowing Tini indicates infection of the respiratory tract (infection
ektracranial). Infections that occur can cause a fever or hyperthermia
which then triggers the onset of a seizure. So, seizures experienced by
Tini is a seizure caused by infection ektrakranial (tonsilofaringitis).

b. What the relationship between additional complain and chief

complain?
Answer: Respiratory tract infections  Tonsilofaringitis and body
trying to fight toxins using endogenous pyrogens  the release of
endogenous pyrogens stimulate the endothelial cells of the
hypothalamus  issued arachidonic acid  stimulate the release of
prostaglandins to affect the work of the hypothalamic thermostat 
consequently set point increase  Fever occurs  The temperature
rise is followed by a rise in basal metabolism and increased oxygen
requirement  then disruption of the cell membrane  disorders of
balance changes in the cell membrane of neurons  ion diffusion
occurs K + and Na +, loose electrical charges  off electric charge
extends to the entire cell or other cell membrane with the help of
neurotransmitters  Febrile convulsion.
So it can be said that the relationship between these complaints is
equally a result of an infection ektracranial (Shinnar, 2009).

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c. What the patofisiology of fever?
Answer: Infection ektrakranial (tonsilofaringitis)  stimulation of
leukocytes (monocytes, lymphocytes, and neutrophils)  secretion of
endogenous pyrogens  (IL-1, IL-6, TNF-α, and IFN) 
endothelium stimulation of the hypothalamus  arachidonic acid
release  increased synthesis of PGD E2 (prostaglandin)  an
increase in the benchmark thermostat  the mechanism of the
increase in heat  temperature rises  Fever (Sudoyo, 2014).

d. What the patofisiology of cough?

Answer: Infectious respiratory viral infections that spread through the
sparks caused when coughing or sneezing and direct contact or
exposure to droplets that contain viruses. After entering the virus into
the body the virus meets protection including physical, mechanical,
humoral, and immune cellular protection. Physical in mechanical
protection as follows, Fine hairs on the nose filter and catch pathogens,
most mucus layers in the upper respiratory tract, catching potential
invaders. The angle from the posterior contact of the nose to the
pharynx causes large particles to hit the back of the throat. Silia at the
bottom of respiration capture and transfer pathogens up to the cough
and cold pharynx (Prince and Wilson, 2016).

e. What the patofisiology of runny nose?

Jawab: Infection ektracranial  antigen into the respiratory tract 
arrested macrophages  activates the secretion of inflammatory
mediators  secretion of histamine  vasodilation, decrease
capillary pressure and permeability and mucus secretion by goblet
cells  antigen out with mucus expenditure (rhinorrhea)  runny
nose (Prince and Wilson, 2016).

21
 f. What the patofisiology of discomfort while swallowing?
Answer: Infeksi ektracranial  antigen masuk ke saluran pernapasan
 ditangkap makrofag  mengaktifkan sekresi mediator inflamasi
in the airways (pharynx and tonsils)  sekresi histamine, bradykinin,
serotonin and prostaglandin  nocireseptor spina cord thalamus
cerebral cortex perception of pain when swallowing (Prince and
Wilson, 2016).

g. What the meaning of Three hours after the fever, Tini was
experiencing seizures for about about 5 minutes?
Answer: It is meaning Tini has a febrile seizure which is categorized
in a complex febrile seizure. Because these complex febrile seizures
experience can repeated seizures that is more than 1 in 24 hours
(Sihaloho, 2015).

3. Tini never experience a seizure before. Tini mother’s have experienced

febrile seizure during his childhood. Tini was born spontaneously with a
help of midwives, aterm and cry spontaneously.
a. What the meaning of Tini never experience a seizure before?
Answer: Tini having seizures due to a virus infection or bacterin
(ektracranial infection) is tonsilofatingtis acute, not of the destruction
of the arrangement of the central nervous system (Jensen, 2012).

b. What the meaning of Tini mother’s have experienced febrile seizure

during his childhood?
Answer: Means there is a family history of febrile seizures and never
experienced this disease is a genetic disease or family disease,
allowing Tini experience febrile seizures because their mother's
family factors that have experienced febrile seizures.

22
 Synthesis:
Genetic or hereditary factors, for example in older people with a
history of febrile seizures (in childhood), siblings with history of
febrile seizures and parents with a history of epilepsy without fever.
This shows that children who have a history of seizures in a person's
family is the risk for febrile seizures 4.5 times greater than those
without a history and a history of seizures factors in the mother, father
and siblings showed a significant association for having empty cells
(Handy, 2016).

c. What the meaning of Tini was born spontaneously with a help of

midwives, aterm and cry spontaneously?
Answer: The meaning of seizures experienced by Tini is not because
there are relations during childbirth and pregnancy, childbirth and
pregnancy as normal.

4. Physical Examination
General appearance: looks midly sick, consciousness: composmentis, BW:
14 KG, BH: 94 cm. Vital sign: Pulse 124x/m (feels and pressure normal),
respiratory rate 32x/m. Temp 390C.
a. How is the physical examination interpretation?
Answer: According to Guyton (2014), this is the physical examination
interpretation:
Circumstances Interpretation
General appearance Looks midly sick Abnormal
consciousness Composmentis Normal
Body weight 14 Kg Normal
Body height 94 Cm Normal
Pulse 124x/m Normal
Respiratory Rate 32 x/m Normal
Temperature 390C Abormal

23
Synthesis:
1. The pulse: 124x / min Within normal limits
The rate (beats / min)
AGE
Break (get up) Rest (sleep)

Newborn 100-180 80-60

1 week - 3 100-220 80-200

months

3 months - 2 80-150 70-120

years

2 years - 10 70-140 60-90

years

> 10 years 70-110 50 - 90

2. Respiration rate: 32x per minute Within normal limits

Age Range Average Time To Sleep

neonates 30-60 35
1 month - 1 30-60 30
year
1 year - 2 25-50 25
years
3 years - 4 20-30 22
years
5 years - 9 15-30 18
years
> 10 years 15-30 15

24
 3. Temperature: 400 C (Febris) or abnormal
 Normal: 360 C - 37.50 C
 hypopirexia / hypopermia: <360 C
 Fever: 37.50 C - 380 C
 Febrile: 380 C - 400 C
 Hypertermia: > 400 C

b. How the abnormal mechanism of physical examination?

Answer: Infection ektrakranial (tonsilofaringitis)  stimulation of
leukocytes (monocytes, lymphocytes, and neutrophils)  secretion of
endogenous pyrogens  (IL-1, IL-6, TNF-α, and IFN) 
endothelium stimulation of the hypothalamus  arachidonic acid
release  increased synthesis of PGD E2 (prostaglandin)  an
increase in the benchmark thermostat  the mechanism of the
increase in heat  temperature rises  Fever (Sudoyo, 2014).

5. Spesific Examination
Head: Eyes: Isokor pupil , light reflexes (+), Nose: rhinorea (-/-), faring:
hiperemic, tonsil: T3/T3, detritus (+), crypt not widened
Neck: theres no neck rigidity
Thorax: systemic, retraction (-)
Cor: normal heartsounds, murmur (-), gallop (-)
Pulmo: vesicular (+) normal, rhonki (-), wheezing (-)
Abdomen: normal bowel sound, hepar and lien were not palpable
Extremity: warm akral, joint stiffness (-)
a. How is the specific examination interpretation?
Answer:

Keadaan Interpretasi
Head Eyes : pupil isokor Normal
light reflexes (+) Normal

25
 Nose: rhinorea (-/-) Normal
faring: hiperemic Faringitis
Tonsil: T3/T3 Tonsilitis
detritus (+) Abnormal
crypt not widened Normal
Neck Theres no neck rigidity Normal
Thorax systemic, retraction (-) Normal

Cor Normal heartsounds Normal

Murmur (-) Normal
Gallop (-) Normal
Pulmo vesicular (+) Normal
Rhonki (-) Normal

wheezing (-) Normal

Abdomen Normal bowel sound Normal

hepar and lien were not Normal
palpable
Extremitas Warm akral (-) Normal

Joint stiffness (-) Normal

b. How the abnormal mechanism of specific examination?

Answer: Infection ektracranial  antigen into the respiratory tract 
arrested macrophages  activates the secretion of inflammatory
mediators in the airways (pharynx and tonsils)  secretion of
histamine, bradykinin, serotonin and prostaglandins  redness,
swelling and peumpukan antigen in the tonsils and pharynx 
Tonsilofaringitis and detritus (Prince and Wilson, 2016).

26
 Picture 2. Tonsilitis
Source: Snell, 2011

6. Neurological status:
Nn. Craniales: normal
Motoric function:
Superior extremities extremities Inferior
Right Left Right Left
Movement Large Large Large Large
Power 5 5 5 5
tonus Eutoni Eutoni Eutoni Eutoni
klonus - - - -
Physiological reflex Normal normal Normal Normal
reflex Pathology - - - -
Sensoric Function: normal
Meningeal reflexes: (-)

a. How is the neurological status interpretation?

Answer: From the results The interpretation of neurological status is
normal, did not reveal any abnormalities. This indicates seizures
experienced by Tini was not caused by a neurological disorder or
other words to help get rid of the diagnosis of epilepsy (Gerard, 2012).

27
7. How to diagnose the case?
Answer: According to Gonzalez (2012), there is how to diagnose the case:
1. Anamnesis, it takes some of the information that can support the
diagnosis toward febrile seizures, such as:
a) Determining the presence of seizures, certain types of seizures,
awareness, long seizures, temperature before and during seizures,
frequency of seizures after the interval, causes fever outside of the
central nervous system.
b) Some things that can increase the risk of febrile seizures, such as
genetics, suffering from certain diseases are accompanied by high
fever, seizures first with a temperature below 39 ° C.
c) Some of the factors that influence the occurrence of recurrent
febrile seizures are age <15 months when the first febrile
convulsions, a family history of febrile convulsions, seizures soon
after a fever or when the temperature is relatively normal, history
of fever frequently, first febrile seizures febrile convulsion comlpex
2. Clinical picture, which can be found in patients with febrile seizures
are:
a) The body temperature reaches 39 ° C
b) The child often loses consciousness when seizures.
c) Children often terlemar head up, eyes bulging, legs and arms began
to stiffen, Baian child's body be shaken. Symptoms depend on the
type of convulsive seizures
d) Pale skin and may be blue
e) The attack took place for several minutes after the child was
conscious
3. Physical examination and laboratory
In simple febrile seizures, may not find a physical disorder neurology
and laboratory. In the complex febrile seizures, neurological physical
abnormality is found in the form of hemiplegi. On EEG examination
found abnormal waves in the form of sharp waves. Slowing of EEG

28
 activity have less prognostic value, although patients with complex
febrile seizures more often show abnormal EEG; EEG also can not be
used to predict the occurrence of epilepsy in the future. Do also check
darag, ion electrolytes (sodium and potassium) and blood sugar
(Gonzalez, 2012).

8. What is the Differential Diagnosis in the case?

Answer:

Febrile convulsion
simplex Complex meningitis encephaliti Epilepsy
s
Convulsions + + + + +

Frequency not Recurrin recur recur not

of seizures Repeat g (> 2x) Repeat
in 24 hours

Duration of <15 > 15 > 1 hour > 1 hour > 15

seizures minutes minutes minutes

Fever + + + + -

Awareness compost compost ↓ ↓ ↓

mentis mentis

Family + + - - +
history

Stiff neck - - + + -

29
9. How is the Supporting examination the case?
Answer: Supporting examination aims to remove serious diagnosis or at
least laboratory data that support clinical suspicion Supporting
examination in children with fever seizures is as follows:
1. Laboratory Examination
Laboratory examination in children with fever seizures aimed at
evaluating the source of infection caused by fever or other conditions
e.g. gastroenteritis Dehydration accompanied by fever and laboratory
examination, among others, complete blood screening, serum
electrolytes (especially in children with dehydration, blood sugar levels,
serum calcium, phosphorus, magnesium, Urea, Nitrogen Bloof (BUN)
and urinalisis levels. Other tests that may be helpful are anticonvulsant
levels in the blood in the child who get treatment for seizure disorders
as well as checking blood sugar levels when there is a prolonged
decline in consciousness after seizures (Rianawati, 2017).
2. Lumbar Puncture
Lumbar uncture in children of simple fever that is aged < 18 months is
strongly advised to do observation and further examination such as
lumbar puncture because it is an examination of cerebrospinal fluid
conducted to enforce or Eliminating the possibility of meningitis as
well as in children who have complex fever seizures (because more
related to meningitis) can be conducted lumbar puncture examination
and performed in children aged 12 months due to clinical signs and
symptoms Possible meningitis at this age at a minimum can even be the
absence of symptoms. In infants and children with fever seizures that
have received antibiotic therapy, lumbar puncture is an important
indication because the previous antibiotic treatment can cover the salary
of meningitis (Rianawati, 2017).
3. Electroencephalographic Examination
Electroencephalographic Examination is the most frequently performed
investigation is the electroencephalography (EEG) examination.

30
 Routine EEG examination should be recorded when conscious at rest, at
bedtime, with photic stimulation and hyperventilation. This EEG
examination is an important laboratory examination to help diagnose
epilepsy for the following reasons. This examination is diagnostic tool
to evaluate patients with obvious or dubious seizures. EEG examination
results will help in making a diagnosis, clarifying the correct type of
seizure and recognizing epilepsy syndrome (Rianawati, 2017).
4. Radiological Examination
Radiological examination like CT scan (Computed Tomography Scan)
of the head and MRI (Magnetic Resonance Imaging) of the head is to
see whether or not there are structural abnormalities in the brain. Head
CT scan is performed if there is a contra indication on MRI, however
this head MRI examination is the brain imaging procedure of choice for
epilepsy with high sensitivity and is more specific than CT scan.
Because it can detect small lesions in the brain, hippocampal sclerosis,
cortical dysgenesis, tumors and cavernous hemangiomas, as well as
refractory epilepsy which is very possible surgical treatment. MRI
examination of the head usually includes: T1 and T2 weighted "with a
minimum of two slices namely axial slices, coronal slices and saggital
slices (Rianawati, 2017).

10. What is the working diagnosis of the case?

Answer: Complex febrile seizure et causa tonsilofaringitis.

11. How is the Treatment of the case?

Answer: ccording to Greenwood (2009), there is a treatment of this case:
1. At the time of seizures:
a. Diazepam rectal: 5 mg to bw to < 10 kg 10 mg to bw > 10 kg or
0.5 – 0.75 mg/kgbw
b. Diazepam iv: 0.2 – 0.5 mg/kg bw

31
2. Still seizures
Phenytoin iv 20 mg/kg bw, slowly
3. After the seizure stops
Treatment is a treatment given if there is one or more symptoms. Given
continuously within a certain time (1 year)
a. Valproic acid: 10-40 mg/kg bw divided by 2-3 doses
b. Phenobarbital: 3-5 mg/kg bw/day divided by 2 doses
4. Intermittent treatment is a treatment that is given when the child has a
fever, to prevent the occurrence of fever seizures
5. Antipyretic
a. Paracetamol or acetaminophen 10-15 mg/kg bw/ times administered
4 times
b. Ibuprofen 10 mg/kgBB/time administered 3 times

Synthesis:
Diazepam rectal (0.5 mg / kg) or BB <10 kg rectal diazepam 5 mg, BB>
10k rectal diazepam 10 mg, or lorazepam (0.1 mg / kg) should be given if
interavena access can not be obtained easily. If intravenous access has
been obtained diazepam better than rectally administered intravenously. IV
administered dose of 0.3-0.5 mg / kg / times with maksimu administration
of 20 mg. If the seizure has not stopped diazepam rectal / IV can be
administered two times at intervals of 5 minutes. Intravenous lorazepam,
diazepam equivalent efficacy to intravenously with minimal side effects
(including respiratory depression) in the treatment of acute seizures
(Greenwood, 2009).

If by twice administration of diazepam rectal / intravenous there are

seizures can be given phenytoin IV with an initial dose of 20 mg / kg,
diluted in NaCl 0.9% by diluting 10 mg of phenytoin in 1 ml of 0.9% NaCl,
with the speed of administration of 1 mg / kg / min , a maximum of 50 mg
/ min, the maximum initial dose is 1000 mg. If there is still a seizure denan
phenytoin, phenobarbital IV can be administered with an initial dose of 20

32
 mg / kg, without dilution to speed administration of 20 mg / min. If
seizures stop with phenytoin then continue with the provision of
maintenance 12 hours later with a dose of 5-7 mg / kg / day in 2 doses. If
seizures stop by fenoborbital, then continue with the provision of
maintenance 12 hours later with a dose of 4-6 mg / kg / day in 2 doses
(Greenwood, 2009).

For prophylaxis to prevent recurrence of seizures later

 Diazepam intermittent prophylaxis with oral / rectal dosage of 0.3 mg /
kg / once every 8 hours, given only during episodes of fever, especially
within 24 hours after the onset of fever.
 Continuous prophylaxis with phenobarbital dose of 4-6 mg / kg / day
divided into 2 doses or valproic acid at a dose of 15-40 mg / kg / day
divided 2-3 doses. Prophylaxis is given only in certain cases such as
febrile seizures with status epilepticus, there is a real neurological
deficits such as cerebral palsy. Prophylaxis given for 1 year

12. What are the complications in the case?

Answer: According to Christoper (2013), in patients who have seizures
febrile seizures usually occur hemiparesis old. Paralysis in accordance
with focal seizures that occur. There is flaccid paralysis first, but after two
weeks raised spasticity. Prolonged febrile seizures can cause anatomical
abnormalities in the brain, causing epilepsy. There are several
complications that may occur in febrile seizures:
a. aspiration pneumonia
b. asphyxia
c. mental retardation

33
 13. What is the prognosis for the case?
Answer:
Quo ad Vitam : Dubia Ad Bonam
Quo ad Sanationam : Dubia Ad Bonam
Quo ad Functionam : Dubia Ad Bonam

Synthesis:
One third of children who present with one febrile seizure will present
with a second episode during a future febrile disease. Risk factors for the
recurrence of febril seizure are a positive family history of febrile seizure,
a first febrile seizure before 18 months of age, the occurrence of a first
febrile seizure less than one hour after the start of a fever, and febrile
seizure at a body temperature of less than 38 °C . Febrile seizures will
recur in 4% of children with no risk factors but in 75% of the children
with previously described risk factors (Lainon, 2018).

14. What is Medical Doctor Competences of this case?

Answer: Medical Doctor competences of this case is medical doctor
competences number 4. Diagnosing, perform independently and complete
management of graduate doctors were able to make the clinical diagnosis
and management of the disease do independently and thoroughly.
4A. Competency achieved upon graduation doctor

15. How is the islamic point of view of this case?

Answer:

‫ي أَني َرب‬
َ ‫سـن‬ َ ‫الراحمينَ أ َ ْر َحم َوأ َ ْن‬
َّ ‫ت الض ُُّّر َم‬ َّ
The meaning: “Allah, indeed I have been inflicted with disease and you
are a merciful God among all merciful” (Q.S. Al-Anbiya: 83)

2.7 Conclusion
Tini three years old girl, had a febrile seizure type of tonic clonic et causa
infection ektracranial (tonsilofaringitis acute).

34
2.8 Conceptual Framework

Family risk Acute

factor Tonsilofaringitis

Secrete of exogenous and endogenous phirogen

Syntesis Prostagladin

Increase of body temperature

Fever

Increase of basal Increase of oxygen

metabolism (10-15%) demand (20%)

Hypoxia

Changes in neurotransmitter exsitation and inhibition

Unplug electricity

Febrile Seizure

35
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