Case Presentation

BY:
Abhilash S (5061)
Abrar Hul Haq (5062)
Demographics
• Name: XYZ
• Age: 4 years
• Sex: Male
• Address: Mathikere, Bangalore.
• Date of admission: 06 October, 2020.
• Date of examination: 06 October, 2020.
• Informant is Mother and is Reliable.
Chief Complaints:
• Fever since 3 days.
• Vomiting since 1 day.
• 1 episode of convulsion 6 hours back.
History of Presenting Illness:
• The patient was apparently normal 3 days back after which he developed
fever which was sudden in onset, high grade type, continuous and was
associated with headache. It was not associated with chills and rigors.
• He also had 3 episodes of vomiting yesterday which was not preceded by
nausea, was projectile in nature, non-bilious and was mostly watery with
undigested food. It was not related to food intake.
• The mother also gives a history of an episode of convulsion 6 hours back
which lasted for 2 mins. It was associated with frothing of mouth and
involuntary micturition.
• The mother also gives a history of irritability and altered behavior of the
child and intolerance to bright light.
Negative History:
• No history of cough.
• No history of ear discharge.
• No history of sore throat.
• No history of abdominal pain, diarrhea.
• No history of jaundice.
• No history of rash.
• No history of gait abnormalities.
• No history of trauma.
Past History:
• No history of similar illness in the past.
• No history of convulsions.
• No history of tuberculosis.
• No history of prolonged hospitalizations or surgeries.
Birth History:
Antenatal History:
• 1st Trimester:
 Iron and folic acid supplementation was taken.
 No history of drug intake.
 No history of fever with rash.
2nd Trimester:
• Iron and Calcium supplements taken, 2 doses TT were given, Regular scans done, Findings were
normal.
• No history of raised BP.
• No history of Gestational Diabetes Mellitus.
• Fetal movements felt at 20 weeks.
3rd Trimester:
• No history of bleed pv.
Birth History:
Intranatal History:
• Vaginal, full term delivery, male child was 3kg at birth, Delivered at XYZ
hospital.
Postnatal History:
• No maternal complications.
• No history of NICU admission.
• No history of feeding problems and jaundice.
Immunization History:
• At Birth: BCG, Hep B birth dose, OPV-O given.
• 6th week:Pentavalent 1, OPV1, IPV1 given.
• 10th week: OPV2, Pentavalent 2 given.
• 14th week: OPV3, Pentavalent 3 given, IPV2 given.
• 9th month: MR 1 and Vitamin A-1 given.
• 20th month: MR 2, Vitamin A-2, DPT Booster, OPV Booster given.
Developmental History:
• Gross motor: Hops on foot; alternate feet going down stairs.
• Fine motor: copies cross; bridge with blocks.
• Social and adaptive milestones: plays co operatively in a group; goes
to toilet alone.
• Language milestones: sings song and tells poems and also tells stories.
Nutrition and Diet History:
• Up to 6 months - breast fed exclusively
• After 6 months - complementary feeding was started while continuing
breast feeding
• Currently - 3 - 4 meals per day and snacks such as banana and biscuits.
Meals mainly consist of mashed roti/rice/bread mixed with thick dal or
kichdi.
• Required Calorie:1350Kcal/day
• Net Calorie Intake: 1450Kcal/day
• Required Protein: 20g/day.
• Net Protein intake: 22g/day.
Personal History:
• Sleep: Disturbed.
• Bowel and Bladder movement: Regular and Normal
Family History:
• No history of Diabetes mellitus, Hypertension, Bronchial Asthma,
Tuberculosis.
• Pedigree chart:
Socioeconomic History:
• 3 membered family, Head of family studied till 10th grade.
• Occupation – Clerk.
• Income - 20000 per month.
• Socioeconomic status - Lower Middle class.
Summary:
• A 4 year old male child belonging to lower middle socioeconomic
class, adequately nourished and immunized upto date came with
complaints of fever since 3 days, vomiting since 1 day, one episode of
convulsion and also with photophobia and altered sensorium.
General Physical Examination:
• Child is drowsy & inactive, oriented to place and person, recognizes
parents. Examined in standing position
• Anthropometry: Weight = 16 kg, Height = 100 cm, Head
Circumference = 49 cm, Chest circumference = 56 cm, US:LS = 1.2:1,
MUAC :16.5cm.
• VITALS:
Temperature = 39.8°C
Pulse = 98 bpm.
RR = 26 cpm.
BP = 110/80mm of Hg.
General Physical Examination:
• Head to Toe Examination:
Head is normal in shape and size.
Eyes normal, no ptosis, squint, pallor, icterus, Pupils normal in size
and shape, bilaterally reactive to light.
ENT normal.
Neck stiffness present
Extremities normal, no pallor, icterus, peripheral cyanosis, or
clubbing.
Skin normal, no neurocutaneous markers.
CNS Examination:
• Glasgow Coma Scale: 14
• Mental Status: Child is drowsy, oriented to place and person
a. Memory – Immediate and short term memory – Unable to recall, long term
memory is normal.
b. Language – Follows Command, Fluent in speaking.
c. Handedness – Right handed.
• Cranial Nerve Examination: Normal
1 CN Smell
2 CN visual acuity, Field of vision, Color vision, Light reflex
3, 4, 6 CNs ocular movement, ptosis
5 CN - sensory part, Motor part - muscles of mastication, jaw jerk
CNS Examination:
7 CN muscles of facial expression, taste, stapedial reflex, tearing
8 CN Rinne's and Weber’s, Caloric test, Romberg’s, Tandem walking
9, 10 CNs pharyngeal and palatal reflex
11 CN SCM and Trapezius
12 CN Protrusion and movement of tongue
• Motor System Examination:
Inspection: Posture is normal, muscle bulk appears normal
Palpation:
Muscle bulk:
i. Arm = 16.5cm
ii. Forearm = 12cm
iii. Thigh = 25cm
iv. Calf = 20cm
CNS Examination:
Tone - Normal
Power - 4/5 in the following joints.
i. Shoulder
ii. Elbow
iii. Wrist
iv. Hip
v. Knee
vi. Ankle
Reflexes
 Superficial reflexes:
i. Corneal
ii. Abdominal
iii. Cremasteric
iv. Plantar
Show normal response
CNS Examination:
Deep reflexes:
i. Biceps
ii. Supinator
iii. Triceps
iv. Knee
v. Ankle
CNS Examination:
• Sensory System Examination: Normal
Touch
Temperature
Pain
Vibration
Proprioception
Tactile localization
Two point discrimination
Stereognosis
Graphesthesia not done
CNS Examination:
• Coordination
Not Done. (Done for children of age 6 and above).
• Gait: Normal
• Signs of Meningeal Irritation:
Neck stiffness – positive
Kernig’s sign – positive
Brudzinski sign – positive
CNS Examination:
• Examination for Increased ICT:
Fundoscopy
Head Circumference and MacEwan’s Sign (Done In Infants).
Summary:
• A 4 year old male child belonging to lower middle socioeconomic
class, adequately nourished and immunized upto date came with
complaints of fever since 3 days, vomiting since 1 day, one episode of
convulsion and also with photophobia and altered sensorium.
• On examination, child is drowsy, anthropometry is normal for age and
sex, temperature and BP are raised, with loss of immediate and recent
memory. Cranial nerves, motor system, sensory system and gait are
normal. Signs of meningeal irritation is present. Papilledema seen on
fundoscopy.
Diagnosis:
• Acute pyogenic meningitis

• Differential diagnosis:
i. Viral meningitis
ii. Encephalitis
iii. Brain Abscess
THANK YOU
Signs Of Meningeal Irritation: