Case Write Up ( Peadiatrics) Sangari.docx

CASE WRITE UP 1 PAEDIATRIC POSTING SANGARI A/P SARKUNA SINGAM 1001439079 Year 4, Group 1 29.8.2015

HISTORY TAKING Patient's Information Name : Mohammad shairel lufti bin kairul azri Age : 3 month old Gender: Male Ethnicity/ Religion : Malay, Islam Address: Merchang Date of admission : 9/8/2015 ( 6 days ago) Date of clerking : 15/8/2015 ( 3 pm) History taken from : Mother Chief Complaint 1. Fever and cough for 1 day 2. Jerky movements of all his extremities for 5 minutes on the day of admission History of presenting illness Patient was apparently well until 6 days ago after feeding the child, the mother noticed that the child was feverish which was sudden on onset with runny nose and cough. After a while, the child became less active and appeared drowsy. The mother then decided to bring the child to the outpatient clinic and on their way there, the child's body suddenly went stiff and unresponsive with his jaw clenched, there was uprolling of the eyeballs and bluish discoloration around his lips. This was followed by jerky movements of all his limbs. Thankfully, by then they have already reached the clinic and the boy was given medications which managed to abort the seizure. After that, the child appeared to be tired and went into deep sleep and his temperature was 39◦c for which the doctor gave fever medications and referred him to HSNZ.This is apparently the child's first seizure episode and it lasted for 5 minutes. There was no trauma noted during the seizure. Upon arrival at HSNZ, several investigations were done which included chest x-ray, blood and urine test. The doctor also suggested a lumbar puncture to be done on the child but was refused by the mother and the child was again given medications for his fever which was still

persisting and he was admitted in the ward. He was started on antibiotics the second day. Otherwise, there were no unusual cry, no respiratory distress, no apnea, no petechia or purpuric lesions or birth marks, no vomiting, no change in bowel habit or feeding difficulties. The child however has history of ill contact with his uncle who had fever, cough with coryzal symptoms. The child also did not have any trauma ,history of otitis media or given any medications prior to the fitting episode. There is also no family history of febrile convulsion or epilepsy in the family. As for his progress for this admission, his fever has gradually reduced on 3rd day onwards although there is still some cough. Otherwise, there has been no recurrence of seizure and the child has become active again and is feeding well. Systemic Review General : Has fever, no rashes, no feeding difficulties Cardiovascular system : One episode of cyanosis, no shortness of breath, no sweating Respiratory system : Has cough, No breathing difficulties or noisy breathing Gastrointestinal system : No vomiting, change in bowel habit or weight loss Urinary system: 10 wet nappies per day, No change in urine colour or passing of foul smelling urine Nervous system: Had one episode of fits and loss of consciousness, no abnormal movements Musculoskeletal system : No limb or joint swelling Past medical history Antenatal period was uneventful and all the scans done were normal. He was delivered at full term via spontaneous vertex delivery with no instrumental assistance but require active resuscitation as he had some breathing problem and was admitted in neonatal intensive care for 10 days and was discharged well. Later, he had prolonged neonatal jaudice for more than 2 weeks and was given phototherapy for 2 days and his jaudice gradually reduced after that. His weight was 2.7 kg at birth. This is the child's second hospitalization. He has no known medical illness and has never undergone an operation before. Drug/ Allergy history The child was not given any medications prior to admission except for the ones given at the outpatient clinic for his fever and fits. He has no known drug or food allergy.

Nutritional history Shairel is still being exclusively breastfed and there were no feeding difficulties during this course of illness. Development history The child still has slight head lag, is able to grasp object placed in his hand, turns to sound, smiles and laughs responsively. Immunization history The child has just had his second dose of DtaP, IPV and Hib vaccines. Family history

Both the father and mother are well and this is their first child. Her parents had a nonconsanguineous marriage. No one in the family has had similar problems. There are no known medical illnesses in the family such as tuberculosis, diabetes mellitus, asthma, or any other familial diseases. No neonatal or childhood deaths. Social History His father is a 30 year old man who works as a carpenter and his mother is a 26 year old housewife who takes care of the child. Both their income is enough to sustain the family and they live in a house equipped with all the basic amenities with clean water. The mother in law has been helping the mother to take care of the child during their stay at the hospital. There is no problem in transportation to the hospital.

PHYSICAL EXAMINATION General Inspection Shairel appeared well and active while lying on his mother's lap. There were no sign of respiratory distress, dysmorphic features or other visible abnormalities. He appears to be well-nourised and well hydrated. Growth and development is compatible with his age. Anthropometric Measurement Height Weight

: :

76cm (50thpercentile) 5.5 kg (25thpercentile)

Head circumference

:

39 cm ( >25 th percentile)

: : : :

105 beats / min(strong, regular with good volume) 32 breaths / min (normal) 104/70mm Hg (normal) 37º C (Not febrile)

Vital Signs Pulse rate Respiratory rate Blood pressure Temperature General Observation Hands

: Pink, warm, no signs of clubbing, cyanosis and pallor. Capillary refill time < 2seconds.

Arms

: No rashes

Head

: Anterior fontanelle does not appear to be bulging and posterior fontanelle has closed.

Eyes

: No pallor, no jaundice, no sunken eyes, and no periorbitaledema.

Mouth

: Lips and tongue are moist, no angular stomatitis, no central cyanosis and oral hygiene is good. Tonsils was not inflamed.

Neck

: No cervical lymph nodes enlargement.

Lower limbs : No pitting oedema or any visible dermatological lesions.

Central Nervous System (Motor) Examination Inspection

: No abnormal posture, muscle wasting, fasciculation or abnormal movements.

Tone

: Upper limbs and lower limbs are normal.

Reflex

: Reflexes were brisk on both extremities.

Plantar response were downgoing. Power and coordination could not be assessed on this patient.

Abdominal Examination Inspection : Moved with respiration, not distended, no scars, no visible mass, dilated veins, visible pulsation, or visible peristalsis seen Umbilicus was inverted and centrally located. Palpation

: Soft and non-tender. No organomegaly.Kidneys were not ballotable

Percussion

: Abdomen was resonant, no signs of ascites.

Auscultation : Normal bowel sounds were heard.

Respiratory System Examination Inspection

: No chest deformity, scars, rashes, visible pulsations and dilated veins. Chest moved symmetrically on respiration. Thoraco-abdominal type of respiration. No signs of laboured breathing such as alar nasi flaring, accessory muscle usage, expiratory grunting, chest wall recession and difficulty in speaking.

Palpation

: No deviation of trachea from midline. Apex beat is felt at 4thintercoastal space at midclavicular line.

Percussion

: Resonant on both sides of the chest.

Auscultation : Normal vesicular breath sounds was no added sounds.

Cardiovascular System Examination Inspection

: No deformities, scar or visible pulsation

Palpation

: Apex beat was felt at the left 4th intercostal space midclavicular line No heaves and thrill

Auscultation : First (S1) and second (S2) heart sounds were heard and no murmurs

Summary Shairel, a 3 month old boy presented with fever and cough for one day and one episode of seizure lasting for 5 minutes. On physical examination, his tone were normal on all limbs however his reflexes were brisk on both extremities with downgoing plantar response on the lower extremities. Provisional Diagnosis : Shairel, a 3 month old child is presenting symptoms suggestive of meningitis. Points for : 1) Age < 3months, lethargy and drowsy, high fever( 39 ◦c) , one episode of seizure, reflexes of all fours limbs were brisk. Points against : 2) No unusual cry, no poor feeding, no vomiting, no respiratory distress, no petechial or purpuric lesions, no bulging fontanelle Differential diagnosis 1) Febrile convulsion Points for : High fever, cough with coryzal symptoms, generalized tonic-clonic seizure not more than 15 minutes Points against : Age < 3months, no family history of seizure

2) Encephalitis Points for : High fever, one episode of fits, lethargy and drowsy Points against : No vomiting, no feeding problem, no rashes, no lymphadenopathy, no conjuntivitis

Plan 1) Admit the child 2) Do some investigations: a) Full blood count - to detect any infection b) Blood glucose ( to rule out hypoglycemic cause)

c) Blood urea and serum electrolyte - To detect fluid or electrolyte imbalance d) Blood culture ( To detect any bacteremia) e) CRP/ ESR ( To detect any elevated acute phase protein) f) Urinalysis and urine culture - To rule out urinary tract infection. g) Chest X-ray - To rule out any respiratory tract infection. h) Coagulation screening : To detect any bleeding disorders. i) Lumbar puncture for CSF examination and culture - To detect and confirm meningitis. 3. Monitor him on the following parameters : - vital signs 4 hourly - Input/output chart - Fit chart - Daily head circumference - Daily central nervous assessment

4. Treatment 1) To control fever : Advice his mother to not put excessive clothing on the child and give anti-pyretics ( syrup/rectal paracetamol) 2) Intravenous fluid replacement : if there's any sign of fluid and electrolyte disturbance. 3) If there is another seizure lasting more than 5 minutes : Give anticonvulsant ( Rectal diazapam) 3) Antibiotics for suspected meningitis ( Example : Ceftriaxone/ cefotaxime + ampicilin/vancomycin) 4) Steroid ( dexamethasone) : To reduce complication of meningitis especially deafness.

5. Disharge( after 24 hours of cessation of therapy without complication) and follow up -To assess development at home and school performance, head circumference, occurrence of fits/ behaviour changes, vison, hearing, speech up till 4 years old (to ensure that the child has a normal development)

Discussion Meningitis : inflammation of leptomeninges. Aseptic meningitis : refers to viral meningitis ( similar picture seen in lyme diseases, tuberculosis, syphilis) Causative agents Viral : Cytomegalovirus, coxsackievirus, herpes simplex virus, epstein barr virus, adenovirus Bacterial Age group

Organism

Neonatal- 3 months

Group B Streptococcus E.coli and other coliforms Listeria monocytogenes

1 month - 6 years

Neisseria meningitidis (meningococcal) * Streptococcus pneumoniae Haemophilus influenza

> 6 years

Neisseria meningitidis Streptococcus pneumoniae

Complications Subdural effusion, local vasculitis ,local cerebral infarction, SIADH,hydrocephalus, cerebral abscess, hearing loss, learning difficulties, cerebral palsy Investigation To confirm diagnosis : •

CSF full examination and culture by performing lumbar puncture Contraindication to Lumbar puncture :

•

Hemodynamically /cardiorespiratory unstable

•

Abnormal `doll eye`s reflex` or unequal pupils, focal neurological signs

•

Immediately after a recent seizures

•

Signs of ↑ICP (papilliedema, coma etc)

•

Coagulopathy

•

Thrombocytopenia

•

Local infection on site of puncture

Investigation to support diagnosis : •

Rapid antigen test for meningitis organism (blood, CSF, urine)

•

PCR of blood and CSF for possible organism

•

Blood culture, throat swab, urine culture, stool culture for bacteria/ virus To exclude diferential diagnosis:

•

Blood glucose (rule out hypoglycemia if LOC, seizures)

•

Urea, electrolyte and creatinine, liver function test (electrolyte imbalance which causes seizures) To detect Complications :

•

CT/ MRI brain scan (Altered consciousness, late seizures, neurological abnormalities, enlarging head circumference, subdural effusion/ empyema) Definitive Treatment (antibiotics) •

< 1 month: Penicillin + Cefotaxime for 21 days duration (Grp B Strep/ E.coli)

•

1 – 3 month: Penicillin + Cefotaxime for 10 - 21 days duration (Grp B Strep/ E.coli/H.infl/Strep Pneumoniae)

•

> 3 months: Penicillin + Cefotaxime /Ceftriaxone for 7 -14 days variable (H.infl/Strep Pneumoniae/ N. meningitides) Steriods

•

To prevent hearing impairment

•

Best effect on first or before antibiotic dose

•

Dexamethasone 0.15mg/kg 6hrly for 4 days

Reflective Writing Through this case, I have learned that one of the major component in figuring out the diagnosis is the age of the child. Previously, I have mistakenly thought that febrile convulsion is possible from the age of 3 months but now I know that if a child who is less than 6 months presents with seizure, it very important consider meningitis unless proven otherwise. I have also learn a bit more on how to take a focused history and important questions that I should as in case of a child with seizure. As the child in this case is only 3 months, I have become more aware of the subtle signs that could indicate an infant is not feeling well and some of the main indicators are feeding habit, sleeping pattern, unusual cry, irritability and lethargic. I have also learned on how to manage a child who have features suggestive of meningitis without a confirmatory test which was lumbar puncture in this case and that was to give antibiotics against possible causative organism in his age category so as to not risk the possibility of meningitis which could cause many detrimental effects such as mental retardation, deafness, hydrocephalus and cerebral palsy.

References 1.Lissauer, T., & Clayden, G. (2012). Infection and Immunity. Illustrated Textbook of Paediatrics (4th ed., pp. 243-247). Edinburgh: Elsevier. 2. Hj Muhammad Ismail, H., & Hoong Phak, N. (2012). Neurology. Paediatric Protocols for Malaysian Hospitals (3rd ed., pp 215-218). Kementerian Kesihatan Malaysia. 3. Marcdante. K, & Kliegman. R (2014). Infectious Diseases. Nelson Essentials of Paediatrics (7th ed., pp. 342-346). Philadelphia: Elsevier.