Case PresentationCase Presentation

Dr. Amr A. JamalDr. Amr A. JamalResident, Family Medicine ProgramResident, Family Medicine Program

Chief ComplaiantChief Complaiant

Identifying Data: Patient's name, age, sex; significant medical conditions,

informant (parent).Chief Compliant (CC): Reason that the child is seeking

medical care andduration of the symptom.

Chief ComplaintChief Complaint

5 y and 3/12 old boy, with no 5 y and 3/12 old boy, with no significant chronic problemsignificant chronic problem

Informant: Mother (reliable)Informant: Mother (reliable) Presented with:Presented with:

FeverFever 2/52 ago2/52 ago for 3/7for 3/7 bilateral calf painbilateral calf pain 10/710/7 Abdominal painAbdominal pain

1/71/7 VomitingVomiting 1/71/7 HeadacheHeadache 1/71/7

The feverThe fever

Preceded by:Preceded by: Runny noseRunny nose Non productive coughNon productive cough

3939 o o C ( C (@ @ home) home) Treated with OTC antipyretic & Treated with OTC antipyretic &

antitusiveantitusive Resolved completely after 3 daysResolved completely after 3 days

No sore throatNo sore throat No ear painNo ear pain No dysuriaNo dysuria No night sweatsNo night sweats No skin rashNo skin rash

The Calf PainThe Calf Pain

2/7 after being afbrile2/7 after being afbrile Bilateral, below the kneeBilateral, below the knee On / OffOn / Off Moderate in severityModerate in severity

Not awaking him from sleepNot awaking him from sleep Does not prevent him from Does not prevent him from

walkingwalking Aggravating by sitting or Aggravating by sitting or

walking for longtimewalking for longtime Relived by analgesic gel Relived by analgesic gel

massagemassage

Similar attacks in the last 2 Similar attacks in the last 2 yearsyears

Last complain 3/12 agoLast complain 3/12 ago No HNo Hxx of Trauma of Trauma No RednessNo Redness No SwillingNo Swilling No Skin rashNo Skin rash

He was taken to PHCHe was taken to PHC Was given Amoxicillin PO Was given Amoxicillin PO

TID for 1/52TID for 1/52 Stopped by the mother Stopped by the mother

because the Abx was because the Abx was perscribed without examing perscribed without examing the patientthe patient

Abdominal PainAbdominal Pain

Started in the early morning Started in the early morning in the day of admissionin the day of admission

Central Central Moderate in severityModerate in severity

The VomitingThe Vomiting

The main reason for coming to The main reason for coming to ERER

X 8 times X 8 times ( 2 since admission)( 2 since admission)

ProjctileProjctile Yellowish fluid with mucusYellowish fluid with mucus

11stst episode contains semi episode contains semi digested fooddigested food

Variable in amountVariable in amount No diarrheaNo diarrhea

Last bowl motion was normal in Last bowl motion was normal in color and consistencycolor and consistency

PMHPMHxx

Bronchial Asthma in early Bronchial Asthma in early childhoodchildhood Last attack at age of 2 yLast attack at age of 2 y

Rt. Inguinal HerniotomyRt. Inguinal Herniotomy 3y ago, in KKUH, no complication3y ago, in KKUH, no complication

Adenoid hypertrophy & frequent Adenoid hypertrophy & frequent tonsilitistonsilitis For 1 y, booked for surgery in KKUHFor 1 y, booked for surgery in KKUH

Otitis MediaOtitis Media Hx of fever 4/12 ago, diagnosed in a Hx of fever 4/12 ago, diagnosed in a

private clinic, Rx with Abx for 1/52private clinic, Rx with Abx for 1/52 Frequent dental clinic visitsFrequent dental clinic visits

Because of dental cariesBecause of dental caries Last intervention was 2/12 agoLast intervention was 2/12 ago

AntinatalAntinatal

FirstbornFirstborn Uncomplicated pregnancyUncomplicated pregnancy FT NSVD in KKUHFT NSVD in KKUH Apgar Score: 8 / 9Apgar Score: 8 / 9 BW: 2.900 KgBW: 2.900 Kg Discharged with his mothe Discharged with his mothe

in the 2in the 2ndnd day day

Development Development

Nutrient:Nutrient: On family dietOn family diet Used to be anorecticUsed to be anorectic

DevelopmentDevelopment No delayNo delay

Immunization:Immunization: Up to date Up to date Did not receive H. influenzae Did not receive H. influenzae

vaccinevaccine Received varicella vaccine 1 y agoReceived varicella vaccine 1 y ago

Allergy: Allergy: No known allergy for drug or foodNo known allergy for drug or food

Family HFamily Hxx

Maternal Grandmother was Maternal Grandmother was diagnosed TB 5/12 ago. diagnosed TB 5/12 ago. Treated for 2/12Treated for 2/12

32 y 30 y

18/125y 3/12

BA

Physical Physical ExaminationExamination

Observation

Sleep, mild dehydratedSleep, mild dehydrated No dysmorphic featureNo dysmorphic feature Vital Signs:Vital Signs:

P P 125125 RR RR 3535 TT 36.736.7 BP BP 109/50109/50

Growth parameters: Height Height 109 cm109 cm at 25at 25thth

centilecentile Weight Weight 16 kg16 kg at 5at 5thth centile centile HC HC 52 cm52 cm

Skin, HEENTSkin, HEENT

Skin:Skin: Not cyanosed, jaundiced or Not cyanosed, jaundiced or

palepale Normal skin turgorNormal skin turgor Normal capillary refillNormal capillary refill

Lymph Nodes:Lymph Nodes: No palpable lymph nodesNo palpable lymph nodes

Head:Head: Normal size & shapeNormal size & shape

Eyes:Eyes: PERRLAPERRLA

Ears:Ears: Normal shiny tympanic membranesNormal shiny tympanic membranes

Nose:Nose: Normal shape & patencyNormal shape & patency No discharge or bleedingNo discharge or bleeding

Mouth:Mouth: Pink, mildly dehydrated mucous membranesPink, mildly dehydrated mucous membranes

Throat:Throat: Congested hypertrophied non-follicular tonsilsCongested hypertrophied non-follicular tonsils

Resp. & CVSResp. & CVS

Thorax:Thorax: Normal symmetric shapeNormal symmetric shape No intercostal or substernal retractionsNo intercostal or substernal retractions

Lungs:Lungs: Normal vesicular breathingNormal vesicular breathing Good breath sound intensityGood breath sound intensity No added soundsNo added sounds

Heart:Heart: SS11 + S + S22 + 0 + 0

Abdomen:Abdomen: Scar of Rt. Inguinal herniotomyScar of Rt. Inguinal herniotomy Soft, lax, no palpable masses Soft, lax, no palpable masses

organomegalyorganomegaly No rebound tendernessNo rebound tenderness +ve bowel sounds+ve bowel sounds

Neuro. Neuro.

ConsciousConscious Cranial nervesCranial nerves

Obviously intactObviously intact Motor: Motor:

(after wake up)(after wake up) PowerPower 4/54/5 ToneTone normalnormal No muscle tendernessNo muscle tenderness

Reflexes:Reflexes: Normal ( Grade 3 / 4)Normal ( Grade 3 / 4)

Meningial signs: Meningial signs: No Nuchal rigidity There is Brudzinski's sign There is Kernig's sign

Urine DipstickUrine Dipstick

Specific GravitySpecific Gravity 1.0201.020 NitrateNitrate Negative Negative

pHpH 66 ProteinProtein TraceTrace GlucoseGlucose NegativeNegative KetoneKetone ++ ++ (was (was

+4 in ER)+4 in ER) BloodBlood NegativeNegative BiliBili negativenegative

In SummaryIn Summary

In SummaryIn Summary

Provisional Provisional DiagnosisDiagnosis

Viral illnessViral illness

Provisional DiagnosisProvisional Diagnosis

MeningitisMeningitis Viral illnessViral illness

URI with meningismURI with meningism MyositisMyositis

InvestigationsInvestigations

DiagnosisDiagnosis

differential diagnosis of differential diagnosis of Aseptic meningitisAseptic meningitis

VIRUSESVIRUSES Enteroviruses Enteroviruses Arboviruses Arboviruses Herpes viruses (HSV-2> HSV-6 > Herpes viruses (HSV-2> HSV-6 >

HSV-1, varicella zoster virus, HSV-1, varicella zoster virus, cytomegalovirus, Epstein-Barr cytomegalovirus, Epstein-Barr virus) virus)

Mumps Mumps Lymphocytic choriomeningitis virus Lymphocytic choriomeningitis virus HIV-1HIV-1 Other viruses (influenza, Other viruses (influenza,

parainfluenza, measles, rotavirus, parainfluenza, measles, rotavirus, coronavirus, parvovirus)coronavirus, parvovirus)

Bacteria Bacteria Spirochetes Spirochetes

B. burgdorferiB. burgdorferi (Lyme disease) (Lyme disease) T. pallidumT. pallidum (Syphilis) (Syphilis) LeptospiraLeptospira species (Leptospirosis) species (Leptospirosis) BorreliaBorrelia species (Relapsing Fever) species (Relapsing Fever)

Partially treated bacterial Partially treated bacterial meningitis meningitis

BartonellaBartonella species species BrucellaBrucella species species M. tuberculosisM. tuberculosis Chlamydia pneumoniaeChlamydia pneumoniae

Rickettsiae/EhrlichiaeRickettsiae/Ehrlichiae Mycoplasma Mycoplasma Parasites Parasites

Primary amoebic Primary amoebic meningoencephalitis meningoencephalitis

Toxoplasma gondiiToxoplasma gondii Noninfectious Noninfectious

Autoimmune disease Autoimmune disease Behcet disease Behcet disease Drug induced Drug induced Malignancy Malignancy Mucocutaneous LN syndrome Mucocutaneous LN syndrome

(Kawasaki disease) (Kawasaki disease)

management planmanagement plan

Admitted to the Ward Admitted to the Ward (Private since no free isolation room)(Private since no free isolation room)

Treatment:Treatment: Ceftriaxone 800 mg IV Q 12 hrCeftriaxone 800 mg IV Q 12 hr

100 mg/kg/day , 1100 mg/kg/day , 1stst dose was given in dose was given in ERER

Acetaminophen 240 mg PO Q 4-6 Acetaminophen 240 mg PO Q 4-6 PRNPRN

IVF (DIVF (D5%5% + ¼ NS + 10 mmol KACL/L) + ¼ NS + 10 mmol KACL/L) at rate 50 ml / hr (maintenance)at rate 50 ml / hr (maintenance)

Further Investigations:Further Investigations: Blood Culture if temperature spikesBlood Culture if temperature spikes NPA for virologyNPA for virology