APPROACH TO THE CASE OF MENINGITIS

APPROACH TO THE CASE OF MENINGITIS

NAME, AGE, SEX, AND ADDRESS OF THE CHILD WITH 

CONSANGUINITY OF MARRIAGE OF THE PARENTS.

CHIEF COMPLAINTS

1.H/0-Abnormal higher mental functions- lethargy, altered sensorium, convulsions

cranial nerve Palsies- deviation of angle of mouth,drooling of saliva,squinting, diplopia

Focal neurological defecit: monoplegia,diplegia

Involved Movements:tremors,chorea, hemiballismus

2.h/s/o-raised ICT I.E VOMITING,HEADACHE,BLURRING OF VISION

3.h/s/o-meningeal inflammation ie:neck pain,photophobia,restriction of neck movements

4. h/s/o-bowel,bladder complaints

H/O ETIOLOGY:

H/O Head injury(may ppt. TBM)

h/o otorhrea(pyogenic meningitis)

h/o any t/t outside in form of i/m or i/v(partially t/t meningitis)

h/o vaccination/drugs(acute disseminated encepahalitis)

h/o rash,fever,alt sensorium,convulsion(viral encephalitis)

h/o contact with TB

h/o diarrhoea,fever,chronic cough(HIV)

h/o immunization

H/O COMPLICATIONS

h/o bedsores,contractures,bladder bowel complications, decorticate / decerebrate positioning, procedure h/o

FAMILY H/O

NUTRIONAL H/O

BIRTH H/O

DEVELOPMENTAL H/O

SOCIOECONOMIC H/O

EXAMINATION:

·        Decubitus

·        Vitals:

·        Anthropometry with interpretation

·        Pallor,cyanosis,ictrus,clubbing,LN,edema

·      Stigmata of tb: phlycten, scrufuloderma, sinuses, erythma nodosum

·        Anterior fontanelle(upto 18 mnths)

·        Size of head

·        Crackpot sign

·        Bcg scar +nt/nt

·        Neurocutanous markers

·        Dysmorphic facies

·        +nce/-nce of i/v line/ryle tube

·        Bed sores,contractures

·        Sign of malnutrion/vitamin def.

·        +nce/-nce of patency of VP shunt

INVESTIGATIONS

·       Csf(after fundus examination)

·       Cect

·       Montoux,chest x-ray,gastric lavage for afb

·       Cbc with lymphocytosis,esr,hiv,

·       LFT(prior to t/t for monitoring)

·       KFT

·       Electrolyte-to rule out SIADH

DIAGNOSIS

_________yrs. Old m/f child with chronic meningoencephalitis with/without hemi/monoparesis with/without cranial n. Involve. With/withoutsigns of raised ict.

Probable etiology:__________

FAQ:

·        D/D

·       STAGES OF COMA

·     STAGES OF TBM ND PROGNOSIS OF EACH STAGE

·       SIGN OF MENINGEAL IRRITN

·       SIGN OF RAISED ICT

·       TYPES OF HERNIATION

·       MNGT. OF TBM AND COMPLICATIONS

·       TYPES OF SHUNT AND COMPLICATIONS

to support the approach,example of a cns case:

 abhay 4yr. old male child resident of farukhabad district,1st born child of non-consanginous hindu marrraige.
child presented to our hospital with the following chief complaints:
       
                 1 episode of convulsion 20 days back with h/o unconciousness for 3 hrs
                  decorticate positioning 20 days back

     h/o present illness:
h/o has been given by mother of the child and seems to be reliable.according to the mother of the child he was apparenty asymptomatic 20 days back when one evening while getting up from sleep child complaint of headache to he mother and within minutes developed generalised convulsion all over the bodywith upward rolling of the eyeballs followed by 2 episode of vomiting which seem to b projectile.the episode was followed by unconciousness and increased tone of body for 3 hrs.

         the parents took the child to pvt. hospital where tratment in form of injectables was given where child gained conciousness but was altered,with eye opening and irritable crying and decorticate positioning with focal seizure on right side of body.treatment was given for 3 days after which they brought the child to this hospital and here he presented with right sided convulsions with deviation  of mouth toward left and drooling of saliva from right side.this episode occured three timed on the same day of admission despite given 2 loading doses of anticonvulsants after which they subsided but there was persistance of high grade fever.
        
           child gained concoiusness after 4-5 days of treatment in form of antibiotics,mannitol and  steroids and anticonvulsants...but on recovery complained of decreased vision,decreased power of right upper and lower limb and irritability.

 there has been h/o purulent ear discharge alternating with each ear for past 1-1/2 yrs.which subsides with treatment and reappears.
there is h/o fever with rash,most probly measles 1 yr. back.
no h/o contact with t.b,diarrhoea,chronic cough,drooping of eyelids,breathlessness,cyanosis and bleedind tendencies





 past history:
child has been having generalised convulsions followed by period of unconciousness for arnd 1 hr.from 4 mnth of age.at the interval of 4-6 mnth till this episode occured.no proper treatment or investigations were done for these episodes. these episodes were never preceded by fever,but mother noticed rise in temperature after the convulsions.

birth history

child was 1st born normal vaginal delivery,mother had h/o leaking p/v 1 hr before delivery and child cried 30 min after birth suggestive of birth asphyxia.
child had an episode of uprolling of eyeballs with tightening of body at day 2 life and subsided after 4-5 min...no treatment ws given

developmental milestone
child had normal dev. milestone app. for his age before illness.
at present:
gross motor:pedals tricycle,cannot hop
vision and fine motor:cannot copy as his vision is affected
hearing and lang:can tell short stories but cannot count
social:can dress and undress himself.



feeding h/o
  child was not breast fed till 7 days of life till then honey and cow milk was given ,after then breast feeding till 1 year of age...then complementary feed in form of cow milk and home made food.

nutrition history
before illness child was taking 900 kilocalories defecient in 500 kilocalories and 9 grams protien deficient in 5 gram...currently child is taking 1400 kilocalories and 10 gram protien per day.

 immunization history
no immunization since birth according to mother,except oral polio vaccine.

social history
4 members in family,per caipta income rs.1200 so according to modified b.j prasad classification ,fall in lower social class.

EXAMINATION
 gen condition: child sitting comfortably on mother's lap
vitals:
   temp:98.6 F
 pulse:136/min,regular,normorhythmic,normovolumic,no radio radial or radio femoral delay
resp. rate-38/min abd. thoracic
no pallor,icterus,cyanosis,clubbing or palpable lymph nodes
bp=90/70 mm hg in rt arm sitting position

ANTHROPOMETRY
wt=14 kg as expected 16.3kg according to who growth chart
ht=90 cm as expected 103cm acc. who growth chart
hc=48cm as expected 50 cm acc. who growth chart
wt /ht>90%
acc. to mclaren's classification-child is stunted

CNS EXAMINATION
child is concious,alert,oriented to person and self. but irritable
memory:immediate memory intact,recent could not be tested
nodding movement of head present
speech and language-able to tell name and comprehend but fluency is not there.
cranial nerve examination 
olfactory:could not be tested
optic:light reflex normal(direct and consensual)
accomodation reflex +nt
  vision -only hand movement 
occulomotor:rt sided medial rectus palsy
trochlear:rt.-unable to move rt eyebal in abduction and downward movement
  left:-normal
trigeminal:-intact 
abducent:normal
facial:weakness in frowning
          loss of nasolabial fold of right side
          drooling of saliva frm right
           slight deviation on left side
vestibulocochlear,glossopharyngeal,spinal accesory,vagus,hypogossal normal.

CVS:apex at 4th ics jst medial to mcl
         s1 s2 nrml
RESP. SYS:B/L A/E EQUAL
PER ABD EXAM:soft. no organomegaly

probable diagnosis
4 year old male with history of birth asphyxia and convulsion with rt sided hemiparesis with rt sided 7th nerve involvment,cause most probably seems vascular in origin