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 non-
consanguineous 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 : 76cm (50thpercentile)

Weight : 5.5 kg (25thpercentile)
Head circumference : 39 cm ( >25 th percentile)

Vital Signs

Pulse rate : 105 beats / min(strong, regular with good volume)

Respiratory rate : 32 breaths / min (normal)
Blood pressure : 104/70mm Hg (normal)
Temperature : 37º C (Not febrile)

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.