1. Presented by:
Dr. Towhida Tasnim(IMO)
Dr. Mahir Muhtasima(Intern)
Dr. Sadia Hossain(Intern)
Dr.Nyeem Ahmed(Intern)
Dept. Of Paediatrics
TMC & RCH
2. Particulars of the patient
Name: Mohini
Age: 4 years.
Sex:Female
Religion: Islam
Source of History: Mother
Address: Parashlai,Mokamtola,Bogura.
Date of Admission:11/08/19 at 10.40 pm.
Date of Examination:11/08/19 at 11.45pm
Ward: Paediatric Ward
Bed no:15
3. Presenting complaints
Fever for 16 days
Swelling of both eyelids for 9 days
Cough for same duration
Unconsciousness for 1 day
4. History of present illness:
According to the statement of the patient’s mother the baby was
reasonably well 16 days back. At first, she developed fever which
was low to moderate initially then it became high grade Which
was more marked in evening to night and it was not associated
with chills and rigors or convultion.Fever was subsided by taking
paracetamol .Then she developed pain and swelling in the left
eyelid which was sudden in onset, severe in nature and non
radiating. It was relived by taking paracetamol for short time and
there was no aggravating factor. After few days she developed
same type of pain and swelling in right eye. The pain was
associated with low grade fever and highest recorded
temperature was 102⁰F..she was also suffering from cough for 16
days which was non productive and more marked at night. She
became unconsciouss one day back.
5. Continue….
Her bowel & bladder habit was normal previously but,
after being unconscious it was alterred.There was No
H/O sore throat, any abnormal movement, dyspnea,
chest pain, palpitation, convultion, photosensitivity,
abdominal pain, loose stool, any nail changes,
haematuria, bleeding from gums & any other mucosal
area. For above those complaints she got admitted in
this hospital for better management.
6. H/o of past illness:
She at first was admitted in SZMCH 16 days back with
complain of fever but then for some family problem
she was discharged with DORB and then she was
taken to local kobiraj but as she was not improving
and swelling of eyelid started so she consulted in
Mission hospital .she has no other significant H/O any
past illness or surgical intervention.
7. Birth history
Mode of delivery: Normal vaginal delivery.
Place of delivery: Home. There is no complication after
delivery.
Antenatal : Mothers pregnancy was uneventful. But She
didn’t take any visit during this period. TT dose was not
completed.
Natal: The child was delivered by NVD at home at about 38
weeks of gestation . There was no H/O prolong labour or
obstructed labour.
Postnatal : The child cried immediately after birth.
8. Feeding history
• Prelacteal feeding: No H/O giving prelacteal feed.
• Exclusive Breast feeding:- completed.
• Now she is on family diet
10. Drug history
There was H/O taking syp. FLUCLOX for her illness
while admitted in SZMCH. She also took some
kobiraji medications but can not mention what it
was. patient condition progressively worsen day by
day.
18. Examination of nervous system:
Cerebral function:
Orientation: Not oriented.
Consciousness: conscious.
Intelligence: Below normal
Memory: Cannot talk more than 2 words scentence
Speech: Twor words
Examination of cranial nerves:
Patient can’t perform properly due to small age
19. Cerebellar function test:
Posture: Supine
Nystagmus: Absent
Incoordination of limb: Absent
Dysarthria: Present
Head noding: Absent
• Motor function test:
Bulk of the muscle: reduced
Tone of the muscle: Reduced (hypotonia)
Power of the muscle: Reduced
Co ordination movement: Un co-ordinated
20. Reflexes:All superficial & deep reflexes was normal,
planter flexon bilaterally.
Gait: Unable to walk
Sensory function: Pain, touch, temperature, vibration,
position sense : Intact
Signs of meningeal irritation:
Neck rigidity: Absent
Kernig’s sign: : Negative
Brudzinski’s sign: Negative
21. Locomotor System:
1. Examination of lower limbs : (knee joints & ankle
joints)
INSPECTION:
- Colour : Normal
-Swelling : Absent
-Any deformities: Absent
-Muscle wasting: Present
PALPATION:
-Temperature: Normal
-Tenderness: Absent
MOVEMENT:
- Movement: Joint stiffness absent & movement normal
30. Respiratory system
Inspection:
Shape of the chest: Normal
Movement of the chest: normal
Respiratory rate: 38br/min
Chest indrawing: absent
Scar mark: absent
Any visible pulsation : absent
31. Palpation:
Position of trachea: Centrally placed
Position of apex beat: Lt 5th ICS just medial to mid
clavicular line
Chest expansion: symmetrical on both side
Vocal fremitus: normal.
32. • Percussion:
-Percussion note: Resonant all 0ver the lung field.
• Auscultation:
-Breath sound: vesicular.
-Added sound: absent
33. Salient features
Mohini, 4 years, 1st issue of her non consanguineous
parents, fully immunized, belongs to low socioeconomic
background, hailing from Mokamtola, Bogura was
admitted in this hospital on 11/08/19 with the complaints of
fever for 16 days which was marked evening and night, was
not associated with chills and rigors or convultion.it was
subsided by taking paracetamol for some time. She also had
pain and swelling in upper eyelids for 9 days which was
sudden, severe non radiating with no aggravating factor
and relieved by taking paracetamol for short time. She also
had cough which was non productive and it more marked
at night.
34. She had No H/O of chest pain, palpitations, sore throat,
convultion, skin lesion, any abnormal movement etc. no
other member of her family suffered for same type of
illness. She was admitted in SZMCH 16 days back with
fever for 1 day and discharged with DORB. She took some
kobiraji medication then. She was also consulted in
Mission hospital for swelling and pain in eyelids 9 days
back. She had no other H/O of any medical or surgical
interventions. she is well immunized and there is no H/O
same type of illness in her family. Her birth history,socio
economic history or feeding history revels no other
abnormality.
35. Cont.
On examination patient was severely anemic, pulse:
118b/min, BP: 90/50mm ofHg, Tem: 102⁰F, RR: 38br/min,
She was not oriented unconscious unable to walk and
talk with GCS -7/15. All reflexes were exaggarated planter
was extensor in both limbs. Sensory functions was intact.
Sign of meningeal irrition such as neck rigidity, kernigs
sign, brudzinsks sign were present. Other systemic
examination reveals nothing abnormality.
56. Treatment:
Supportive treatment:
Bed rest.
Diet: Initially normal then NG feeding with liquid.
Inf. 10% Libott’s junior.
Inj. Flucloxacilin
Inj. Neotack
Inj. Avil
Nebulization with sulprex solution
Syp. Napa
Supp. Napa
Cap. Retinol forte
Candex oral suspenssion
Blood transfusion- 2 unit
Eusithal eye drop
57. Specific treatment:
Inj. Ceftriaxon
Inj. Meropenum
Inj. Dexamethason
Treatment of co-morbidities:
Occupational therapy.
Developmental therapy.
Then patient was referred to DMCH/ DSH for better
managment
58. 1st day of F/U 2nd day of F/U 3rd day of F/U
Subjective
complaints:
Fever, pain& swelling of
both eyelids, cough:
present
Fever (reduced)
outward protrution of
eye ball
Fever free 14 hours
Decreased outward
protrution of eye ball
On
examination
App: ill-looking
Temp: 99⁰F
H/R: 120b/min
R/R: 32br/min
B/P: 90/50 mm of Hg
Heart: S1 & S2 audible.
Lungs: Clear
P/O: oral thrush
Abdomen: soft& non
tender.
Urine: 3-4 times.
Stool: 1 time.
App: ill-looking
Temp: 99⁰F
H/R: 110 b/min
R/R: 30 br/min
B/P: 80/50mm of Hg
Heart: S1 & S2 audible
Lungs: Clear
P/O: 0ral thrush
Abdomen: Soft & non
tender.
Urine: 3-5 times.
Stool: 2 times.
Eye-proptosis of right
eye ball
App: well
Temp: 98⁰F
H/R: 115b/min
R/R: 30br/min
B/P: 80/50mm of Hg
Heart: S1 & S2
audible
Lungs: Clear
P/O:normal
Abdomen: soft
Urine: 3 times.
Stool: 2 times.
Eye-protrution
decreased
Assessment Not improving Improving Improving
Plan: Candex oral suspension Inj.ROXADEX
Inj.MEROPENUM
Continue treatment
59. 4th day of F/U 5th day of F/U
Subjective
complaints:
Fever - present Fever - Present
On
examination
App: ill looking
Temp: 102
H/R: 120b/min
R/R: 28br/min
Heart: S1 & S2 audible
Lungs: Clear
P/O:normal
Abdomen: soft
Urine: 2 times.
Stool: 1 times
Eye-protrution absent
App: well
Temp: 100
H/R: 120b/min
R/R: 28br/min
Heart: S1 & S2 audible
Lungs: Clear
P/O:normal
Abdomen: soft
Urine: 5-6 times.
Stool: 2 times
Assessment Improved Improved
Plan: Continue treatment Reffered to DMCH or
DSH
60. During follow up of the patient, Patient condition was
relatively better than the admission but improvement
was not up to the mark. Then after initial diagnosis,
patient was referred to the higher centre
(DMCH/DSH) for better management.
