CLINICAL CASE PRESENTATION
Presented by
Dr.Md.Sazzad Haider Shahin
Dr.Arifin Nahar
Particulars of the patient
Name : Master Nahin
Age : 4 years
Sex : Male
Religion : Islam
Address : Joysen , Pirgasa ,
Rangpur
Father’s name : Md.Azad Hossain
Date of admission : 19-o1-1o
Date of examination : 24-01-10
Informant : Mother .
The presenting complaints:
H/O Fever for 20 days
Weakness of both Right upper and lower limbs
for 3 days .
The history of present illness
• According to the statements of the
mother the child was resonably all right
20 days back .Then he developed fever
which was low grade and intermittent
in nature and not associated with chills
and rigor and subside by taking
paracetamol . Mother also complaints
child developed weakness of both upper
and lower limbs on rt. Side for last 3
days associated with difficulty in speech
.There is no history of
Headache ,Vomiting , Convulsion ,Visual
disturbance ,Chiken pox , otitis media ,
Joint pain or swelling ,Trauma to the
head ,contact with TB patient, cough
, respiratory distress, feeding
problem in infancy and any
discolouration lips and mouth during
playing . With this complaints they
treated locally by M.B.B.S Doctor
but the condition of patient not
improved . So they admit their child
in RPMCH for proper management .
History of past illness:
• No significant past
illness.
Treatment History
Child was treated by
Syp . Napa
Syp. Orcef
Syp.Allervil
Birth History
Uneventful antenatal history &
Mother was regular antenatal
checked up & immunized.
Delivered in Hospital at term
normally.
Immunization history:
Immunized as per EPI
schedule .
Development History
Normaly according to age
Family History
He is 2nd issuse of his
non
consanguineous parents.
Family history HTN absent
Socio-economical
History
He came from a low socioeconomic
family
House : Kacha
Latrine : Use slab latrine
Water supply : Use tube wel water for
Cooking , drinking and
washing purposes .
General physical examination
Appearance : Ill loking
Anaemia : Absent
Jaundice : Absent
Cyanosis : Absent
Kolonychia : Absent
Clubbing : Absent
Dehydration : Absent
Oedema : absent
Lymph node : Not palpable
Temperature : 98oF
ENT : NAD
• Pulse : 98/m
• BP : 90/60 mm of Hg
• Skin survey : BCG mark present in left upper
arm .
• Height : 103 cm (100.98% of NCHS
growth median).
• Z-Score - +o.25%
• Weight :15 kg. (93.75%of NCHS growth
median).
• Z-Score --- -0.66 .
• Fundoscopy –Normal .
Systemic examination
EXAMINATION OF NERVOUS SYSTEM :
HIGHER PSYCHIC FUNCTION :
Orientation of time and place – lost
State of conciousness –Alert
Memory – Lost
SPEECH –
Dysarthia
EXAMINATION OF CRANIAL NERVE –
Intact .
MOTOR FUNCTION –
Bulk of the muscle Normal on both upper and
lower limbs
Tone of muscle
Power of muscle -
LIMBS RIGHT LEFT
UPPER 1/6 Normal
LOWER 1/6 Normal
REFLEXES ---
UPPER LIMBS -
Reflexes Rt. Side Lt. Side
Biceps Exaggerated Normal
Triceps Exaggerated Normal
Supinator Exaggerated Normal
LOWER LIMBS -
Reflex Rt. Side Lt . Side
Knee Exaggerated Normal
Ankle Exaggerated Normal
Planter Extensor Normal
CLONUS-
Ankle –Absent
Knee- Absent .
Gait - pt.is unable to walk .
SENSORY FUNCTION- I NTACT
SIGN OF MENINGEAL IRRITATION :
Neck rigidity –Absent .
Kerning’s sign-Absent .
B.Cardiovascular system
Pulse-98/min , regular ,n0 radio femoral delay
BP -90/60 mm of Hg
Precordium -
inspection –Normal
Novisible pulsation in apical area ,no scar mark
Palpation : apex beat in Lt. 5th intercostals
space –just medial to the mid clavicular line.
Auscultation : 1st and 2nd ht sound normally
audible
No added sound
Haemopoietic system:
Anemia : absent
Jaundice : absent.
Koilonychia : absent.
Gum and oral cavity: normal
Bony tenderness: absent
Liver : not palpable
Spleen : not palpable
Sign of meningial irritation : absent.
Alimentary system
Lip/gum/oral cavity/tongue- Healthy
Abdomen:
Inspection-
Shape - Normal
Flank - Normal
Umbilicus - central and inverted.
No visible - Peristalsis, scar mark, dilated
vein
Alimentary system
Palpation-
Abdomen - non tender, soft & local temp.
normal
Liver - Not palpable
Spleen - Not palpable
Kidney - Not ballotable
Fluid thrill - Absent
Purcussion-
Upper border of dullness-at Rt. 5th ICS
along MCL
Tympanic all over the area
Auscultation-
Bowel sound-present
Respiratory system
Inspection-
Shape & size-normal
Movement of chest- B/L symmetrical
RR- 36/ bpm
No- chest indrawing/ICR,SCR
No visible apical impulse/engorged vein-present
Palpation-
Trachea-centrally placed
A. beat-in 5th ICS just medial to the MCL
Chest expansibility-normal
Vocal fremetus-normal
Purcussion-
Ressonant in all over the areas
Auscultation-
B/S-vesicular in all areas
No added sound was present
OTHER SYSTEM EXAMINATION REVEALS
NORMAL FINDING.
Salient features
Master Nahin ,4 years old immunized boy,
2nd issue of a non consanguinous parents
hailing from Pirgasa ,Rangpur admitted in
to RpMCH with the complaints of fever
for 20 days which was low grade and
intermittent in nature and not associated
with chills and rigor and subside by taking
paracetamol . Mother also complaints
child developed weakness of both upper
and lower limbs on rt. Side for last 3 days
associated with difficulty in speech.
There is no history of
Headache ,Vomiting ,Convulsion ,Visual
disturbance ,Chiken pox , otitis media , Joint pain
or swelling ,Trauma to the head ,contact with TB
patient, cough , respiratory distress, feeding
problem in infancy and any discolouration lips
and mouth during playing.Family history of HTN
is absent . Examination reveals patient is ill
looked . jaundice, cyanosis absent. Height- 103
cm(100.98% of NCHS growth median). Z –Score
+0.25 .Weight 15 kg (93.75%of NCHS growth
median). Z-score - 0.66 . , Temp – 98 o F .Pulse
98/m, BP 90/60 mm of Hg , ENT and Fundoscopy
examination reveals normal .
Examination of Nervous system reveals pt. is
alert , Loss of Orientation, Time ,Place and
Memory ,Dysarthia present , examination of
both upper and lower limbs Bulk and Tone of
muscle normal on both side ,Deep reflexes
are exaggerated on Rt.Side , Planter
response extensor on rt. Side . On left side
reflexes are normal . Other systemic
examination reavels normal .
PROVISIONAL DIAGNOSIS :
Acute stroke syndrome
Points in favour Points against
Hemiparesis on Rt.Sided limbs . No h/o
H/O Fever . vomiting
A phasia No h/o
Loss of orientation and memory . headache.
Deep reflexes are exaggerated on No h/o
rt. Side . convulsion .
Planter response extensor on
rt.side .
Differential diagnosis
Intracranial space occupying lession
Points in favour Points against
Hemiparesis on Rt.Sided limbs . No h/o vomiting
H/O Fever . No h/o headache.
A phasia No h/o convulsion .
Loss of orientation and memory . Vision normal
Deep reflexes are exaggerated on
rt. Side .
Planter response extensor on
rt.side .
Meningoencephalitis :
Points in favour Points against
Hemiparesis on Rt.Sided Pattern of fever
limbs . No h/o headache.
H/O Fever . No h/o convulsion
A phasia No h/o vomiting
Loss of orientation and Signs of meningeal
memory . irritation absent
Deep reflexes are
exaggerated on rt. Side .
Planter response extensor
on rt.side .
Investigations
CBC –
Hb 60%
WBC – 20,800 /cmm
Neut – 80 %
Lymph – 16 %
Eosin - 02%
Mono - 02%
Baso - 00%
Esr - 90 mm in 1st hour
PBF - Neutrophilic leucocytosis
Platelet count :2,50000 / cmm
Urine R/E : albumin trace
pus cell 3-8 /HPF
Widal test-
TO-1/160
TH-1/160
AH-1/40
BH-1/40
MP-Not found.
Prothrombin time-
Test-12.6 sec.
Control -12 sec.
INR-1.05
APTT-
Test-40.1 sec.
Control -34.0 sec.
Lipid profile –
S.Cholesterol – 113 mg/dl. (109-189 mg/dl)
S.Triglyceride -98 mg/dl. (30-86mg/dl)
S.HDL -34 mg/dl (55-65mg/dl)
S.LDL -59mg/dl.( <150 mg/dl)
R.B.S-82mg/dl .
S.Creatinine -0.6mgdl.
SGPT -59U/L.
X-RAY Chest P/A View- Normal.
Echocardiogram –Normal study .
No Intracardiac mass, no thrombosis or
vegetation
CT Scan of brain- Brain oedema .
Plan of Investigations:
MRI of Brain .
Magnetic resonance of angiography .
Treatment given -
Antibiotics .
Inj.Dexamethason .
Syp .Acyclovir .
Syp.Paracetamol .
Physiotherapy .
CONFIRM DIAGNOSIS :
