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Meningitis

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Meningitis Powered By Docstoc
					Case Presentation

        Dr. Amr A. Jamal
     Resident, Family Medicine Program
Chief Complaiant

Identifying Data: Patient's name, age, sex; significant
    medical conditions,
informant (parent).
Chief Compliant (CC): Reason that the child is seeking
    medical care and
duration of the symptom.
Chief Complaint

   5 y and 3/12 old boy, with no
    significant chronic problem
   Informant: Mother (reliable)
   Presented with:
     Fever          2/52 ago   for 3/7
     bilateral calf pain       10/7
     Abdominal pain                      1/7
     Vomiting                  1/7
     Headache                  1/7
    The fever

   Preceded by:
        Runny nose
        Non productive cough
   39 o C (@ home)
   Treated with OTC antipyretic &
    antitusive
   Resolved completely after 3 days
        No sore throat
        No ear pain
        No dysuria
        No night sweats
        No skin rash
The Calf Pain

 2/7 was taken in the last
  He after being afbrile
 Similar attacksto PHC     2
 yearsgiven Amoxicillin PO TID
  Bilateral, below the knee
  Was
 for 1/52
 Last/ complain 3/12 ago
  On Off
    No Hx of Trauma
 Stopped by the mother
 Moderate in severity
     No Redness Abx was perscribed
     because the him from sleep
     Not awaking
      without examing the patient
     No Swilling
     Does not prevent him from
     No Skin rash
      walking
   Aggravating by sitting or walking
    for longtime
   Relived by analgesic gel
Abdominal Pain

   Started in the early morning in
    the day of admission
   Central
   Moderate in severity
The Vomiting

   The main reason for coming to
    ER
   X 8 times
       ( 2 since admission)
   Projctile
   Yellowish fluid with mucus
       1st episode contains semi digested
        food
   Variable in amount
   No diarrhea
       Last bowl motion was normal in
    PMHx
   Bronchial Asthma in early childhood
       Last attack at age of 2 y
   Rt. Inguinal Herniotomy
       3y ago, in KKUH, no complication
   Adenoid hypertrophy & frequent
    tonsilitis
       For 1 y, booked for surgery in KKUH
   Otitis Media
       Hx of fever 4/12 ago, diagnosed in a
        private clinic, Rx with Abx for 1/52
   Frequent dental clinic visits
       Because of dental caries
       Last intervention was 2/12 ago
Antinatal

   Firstborn
   Uncomplicated pregnancy
   FT NSVD in KKUH
   Apgar Score: 8 / 9
   BW: 2.900 Kg
   Discharged with his mothe in the
    2nd day
    Development

   Nutrient:
        On family diet
        Used to be anorectic
   Development
        No delay
   Immunization:
        Up to date
        Did not receive H. influenzae vaccine
        Received varicella vaccine 1 y ago
   Allergy:
        No known allergy for drug or food
Family Hx


          32 y         30 y

                              BA

         5y 3/12      18/12

   Maternal Grandmother was
    diagnosed TB 5/12 ago. Treated
    for 2/12
Physical Examination
    Observation

   Sleep, mild dehydrated
   No dysmorphic feature
   Vital Signs:
        P     125
        RR    35
        T           36.7
        BP    109/50
   Growth parameters:
        Height 109 cm             at 25th
         centile
        Weight 16 kg       at 5th centile
        HC      52 cm
 Skin, HEENT

  Ears:
  Skin:
      Not cyanosed, jaundiced
        Normal shiny tympanic          or pale
       membranes
      Normal skin turgor
    Nose:
      Normal capillary refill
      Normal shape
    Lymph Nodes: & patency
            No discharge or bleeding
      No palpable       lymph nodes
     Mouth:
   Head: mildly dehydrated mucous
       Pink,
    Normal size & shape
     membranes
  Throat:
  Eyes:
     
          Congested
         PERRLA hypertrophied non-follicular
             tonsils
    Resp. & CVS
   Thorax:
        Normal symmetric shape
        No intercostal or substernal retractions
   Lungs:
        Normal vesicular breathing
        Good breath sound intensity
        No added sounds
   Heart:
        S1 + S2 + 0
   Abdomen:
        Scar of Rt. Inguinal herniotomy
        Soft, lax, no palpable masses organomegaly
        No rebound tenderness
        +ve bowel sounds
    Neuro.
   Conscious
   Cranial nerves
        Obviously intact
   Motor:
             (after wake up)
        Power 4/5
        Tone    normal
        No muscle tenderness
   Reflexes:
        Normal ( Grade 3 / 4)
   Meningial signs:
        No Nuchal rigidity
        There is Brudzinski's sign
        There is Kernig's sign
Urine Dipstick

   Specific Gravity   1.020
   Nitrate            Negative
   pH                 6
   Protein            Trace
   Glucose                 Negative
   Ketone             ++ (was +4 in
    ER)
   Blood              Negative
   Bili               negative
In Summary
In Summary
Provisional Diagnosis
Viral illness
Provisional Diagnosis

   Meningitis
   Viral illness
       URI with meningism
   Myositis
Investigations
Diagnosis
 differential diagnosis of
 Aseptic meningitis
     Bacteria
  Rickettsiae/Ehrlichiae
 VIRUSES
   Mycoplasma
   Enteroviruses
         Spirochetes
   Parasites
   Arboviruses
        B. burgdorferi    (Lyme disease)
        Primary amoebic meningoencephalitis
     Herpes viruses (Syphilis) HSV-6 > HSV-
           T. pallidum (HSV-2>
        Toxoplasma gondii
      1, varicella zoster virus,
           Leptospira species (Leptospirosis)
      cytomegalovirus, Epstein-Barr virus)
     Noninfectious species (Relapsing Fever)
           Borrelia
     Mumps
        Autoimmune disease
       Partially treated bacterial
     Lymphocytic choriomeningitis virus
        Behcet disease
        meningitis
     HIV-1 induced
        Drug
       Bartonella species
     Other viruses (influenza, parainfluenza,
        Malignancy
        Brucella species
      measles, rotavirus, coronavirus,
       Mucocutaneous LN syndrome
       parvovirus)
        M. tuberculosis
       (Kawasaki disease)

         Chlamydia pneumoniae
management plan
   Admitted to the Ward
       (Private since no free isolation
        room)
   Treatment:
       Ceftriaxone 800 mg IV Q 12 hr
            100 mg/kg/day , 1st dose was given
             in ER
     Acetaminophen 240 mg PO Q 4-6
      PRN
     IVF (D5% + ¼ NS + 10 mmol
      KACL/L)
            at rate 50 ml / hr (maintenance)
   Further Investigations:

				
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posted:3/31/2013
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