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Extern conference

Extern conference. 4 OCT 2007. History . A 4-month-old boy Chief complaint: high-grade fever 1 day Present illness: 3 d PTA he had low grade fever with no other symptoms. 1 d PTA he had high grade fever with chill without URI symptoms, N/V, or diarrhea.

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Extern conference

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  1. Extern conference 4 OCT 2007

  2. History • A 4-month-old boy • Chief complaint: high-grade fever 1 day • Present illness: • 3 d PTA he had low grade fever with no other symptoms. • 1 d PTA he had high grade fever with chill without URI symptoms, N/V, or diarrhea. • He exhibited lethargy and food refusal. The bulging of his anterior fontanelle was observed. He had no seizure.

  3. History • Present illness: • He took only acetaminophen every 4 hours but his symptoms did not relieved. • On the day of admission, he sought for a doctor and was diagnosed as brain edema. He was suggested to go to a hospital. • He had no history of trauma. Nobody in his family had symptoms like him.

  4. History • Pertinent underlying disease: none • Significant medical history: none (healthy) • Significant neonatal history: none • Developmental history: normal • Smile, hold head up,crawl, localize sounds, glare • Dietary history: absolute breast feeding

  5. History • Immunization: BCG, 1OPV, 1DPT, 2HBV • Current medication: none • Significant family history: • Father - HBV carrier • Mother - Euthyroid goiter

  6. Physical examination T 38.5oC, RR 50/min, HR 180/min, BP91/62mmHg BW 8.1 kg , Ht 50 cm GA: look sick, drowsiness, not pale, no jaundice, no edema, dry lips, slightly sunken eye ball, anterior fontanelle-bulging, 2x3 cm HEENT: pharynx-not injected, normal TM both ears

  7. Physical examination RS: normal breath sound, no adventitious sound CVS: normal S1&S2, no murmur Abd: soft, not tender, liver and spleen-not palpable Genitalia: WNL

  8. Physical examination • CNS: • pupil 3 mm BRTL, no facial palsy • motor power grade IV+ all • DTR 3+ all • Stiff neck : positive • Brudzinski’s sign : positive • Kernig sign : positive

  9. Brudzinski sign

  10. Problem list • Fever for 3 days • Drowsiness for 1 day • Bulging ant.fontanelle and presence of meningeal signs • Mild dehydration

  11. Differential diagnosis • Meningitis • Sepsis

  12. Approach to Acute Febrile Illness

  13. Definitionof fever • temperature -Rectal >38ºc -Oral >37.6 -Axillary >37.3 • Acute fever - fever with source - fever without source

  14. History taking • Fever : character, pattern, duration • Associate organ/systemic symptom - RS : cough, rhinorrhea, dyspnea - GI : nausea, vomiting, diarrhea, - GU : abnormal urine - NS : alteration of consciousness, seizure, severe headache

  15. History taking • Behavior activity e.g. drowsy, food/milk intolerance • Sick contact • Previous treatment, past medication • Underlying disease, recent immunization

  16. Physical Examination • Vital signs : • GA : irritability, sign of dehydration, pale, jaundice • HEENT : TM, nasal discharge, tonsils & pharynx • Skin rash , sign of soft tissue infection • CVS : new onset of murmur, embolic phenomenon

  17. Physical Examination • RS : breath sound, adventitious sound, percussion • Abdomen : BS, hepatosplenomegaly • NS : level of consciousness, fontanelle, motor system, meningeal irritation sign • Bone and joint system

  18. Investigation • CBC ,UA • Indication for LP in children with fever - alteration of consciousness - age<18 months with first episode of febrile seizure or complex febrile seizure - age<3 months with sepsis - suspected meningitis

  19. Meningitiswith sepsis

  20. Clinical presentation • Depend on the patient’s age - newborn: nonspecific - infancy: fever, vomiting, irritability, convulsion, tense& bulging fontanelle - children: fever, chills, vomiting, severe headache • Meningococcemia: purpura fulminans

  21. purpura fulminans

  22. Clinical presentation • Meningeal irritation sign - significantly less frequent in neonates - Brudzinski sign, stiff neck, Kernig sign

  23. Kernig’s signSevere stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

  24. Brudzinski’s signSevere neck stiffness causes a patient's hips and knees to flex when the neck is flexed.

  25. Treatment • Dexamethasone in Hib meningitis with in min after first dose of ATB can reduce risk for hearing and neurologic complication - 0.15 mg/kg q 6hr for 4 days or 0.4 mg/kg q 12 hr for 2 days

  26. gram negative diplococci within a neutrophil, typical for Neisseria meningitidis

  27. GBS

  28. S.pneumoniae

  29. H.Infuenzae type B

  30. E.coli

  31. Salmonella sp.

  32. Diagnosis • definite diagnosis: CSF examination and C/S • CSF gram stain • Rapid antigen testing: GBS, E.coli K1, S.pneumoniae, Hib, N.meningitidis • Hemoculture

  33. Investigation :admission D1 • Blood for H/C , CBC , BUN , Cr , Electrolyte , BS • LP and CSF analysis, CSF culture, gram stain • UA ,MUC

  34. Lab : Admission day1 • CBC : Hct 35.4, WBC 21160, N72.7, L 15.3,M11.9, Plt 371,000, MCV79.2 • BUN7, Cr0.3 , Na133, K 4.3, Cl 97, HCO3 16,AG20, BS 137 • U/A : pH 6.0 ,sp.gr1.015, WBC0-4, Glu3+, Protein -, Ketone - • CSF : Glu 56, TP 100, RBC 10,000, WBC 1,960 (correct WBC : 1,946) • CSF G/S : no bacteria was seen, few PMN

  35. Lab : Admission Day2 • Bacterial Ag profile: Hib, N. Meningitidis A, B/Ecoli, C, Y/W, Strep. Agalactiae, Strep. Pneumo : All Negative

  36. CSF profile

  37. CSF profile Nelson Textbook of Pediatrics 16th ed.

  38. Diagnosis Bacterial meningitis

  39. Treatment1 • 1.Empirical antibiotics • Cefotaxime (300mg/kg/day) 300mg iv q 6hr • Gentamicin (5mg/kg/day) 15mg iv q 8hr • 2.supportive treatments • Paracetamol(120mg/5ml)4ml oral prn for fever q4-6 hr • IV fluid

  40. Treatment2 • 3.monitoring • Record v/s q 4hr • Record neuro sign q4hr • HC,BW OD • Record I/O

  41. Lab : Admission Day2 • H/C : gram –ve rod • MUC : no growth • Bacterial Ag profile: Hib, N. MeningitidisA, B/Ecoli, C, Y/W, Strep. Agalactiae, Strep. Pneumo : All Negative

  42. Treatment3 • Ciprofloxacin <40 MKD> sig 110 mg iv q 8 hr

  43. Treatment • Add ciprofloxacin in Salmonella meningitis to prevent relapse • Change ATB to PGS in mennigococcal meningitis if sensitive

  44. Lab : Admission Day3 • CSF culture : Salmonella groupD • H/C :Salmonella groupD • Drug sensitivity : Cefotaxime, Ciprofloxacin

  45. Repeated LP • For diagnosis : in questionable caserepeated LP in 24 hrs • For evaluate response of treatment(48-72hrs after treatment) - cases with poor response - resistant organism - neonatal meningitis -those received steroid

  46. Complication • Seizure • Subdural effusion 20-30%,subdural empyema 1% • SIADH • Hearing loss (require hearing evaluation at the end of treatment) • Hydrocephalus • brain abscess

  47. Progress note

  48. Progress note

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