Case History

Name: Hasan Kh. Al-Mahallawi Std. No: 120140746

Personal data:
 Nada I. Zorob, a 8-year old female patient (DOB: 23/3/2011), lives in Rafah.
She presented to the ER of EGH on Tuesday 23/4/2019, and admitted to the
medical pediatric department.
 The history was taken by me Hasan Kh. Al-Mahallawi, a 5 th year medical
student, on Wednesday 24/4/2019 at 10:30 am, from the patient’s mother who
was reliable & informative.

Chief Complaint:
 Feverish sensation for 3 days.

History of present illness:

The patient was doing relatively well until 3 days before presenting to the
pediatric ER complaining of fever which was gradual in onset and continuous in
course. Temperature was measured sublingually by the patient’s mother and it was
38.5oC before coming to the hospital. The fever is partially relieved by
antipyretics. There was associated projectile vomiting for 3 days. It was yellow in
color with no relation of food, no blood or bilious material. The patient denies any
recent head trauma or contact with ill persons. She also denies having limb
weakness or paresthesia, seizures, altered mental status, abnormal behavior,
cough, runny nose, ear pain, chest pain, SOB, abdominal pain, diarrhea, dysuria,
urgency, rash or joint pain. There was no previous similar attacks.

Review of systems:
  CVS: no cyanosis, no ankle swelling.
 Hematological: no petechiae, no bruises.
 Endocrine: no polyuria, polydipsia.

Past History:
The patient is not known to have any other chronic illnesses. She didn’t undergo any
surgery. She’s not on any regular medications, and she doesn’t have any allergies to
foods or drugs. She didn’t receive any blood transfusions, and there was no previous
admissions, or similar attacks.

Perinatal History:
 Prenatal: uneventful. No history of radiation, trauma or infections.
 Natal: vaginal delivery, full term, birth weight: 3Kg.
 Postnatal: no RD, cyanosis or jaundice, no NICU admission.

Nutritional History:
The patient shares family food.

Developmental History:
The patient is well developed and performing well in school. Her developmental age
is going with her chronological age. She weighs about 29 Kgs, and is 140 cm in
height, being bloew 25th percentile for her weight, and below 90th for her height.

Immunization History:
The patient’s immunizations are up to date. Her last vaccines at the age of 6 years
were: DT, bOPV vaccines.

Family History:
No history of kidney diseases running in the family. No known history of hereditary
diseases in the family. The parents are not consanguineous.

Social history:
The patient lives with her nuclear family, in a house whose condition is good (well
ventilated and exposed to sunlight). Their socioeconomical status is moderate, and
they have a medical insurance. There is no history of travel and no animal contact.

O/E:

General condition:
The patient is alert, conscious and oriented. She seems well-nourished, thriving well,
weighing 29 Kg (25th percentile in growth chart) and having a height of about 140cm
(below 90th in growth chart). She is having a pink IV cath, connected to IV set that
contains a saline bag and a pump.

Vitals: BP: 120/70, Temp: 38oC, HR: 80 bpm, RR: 20 breaths/min.

Head and Neck (including Eye, ENT):

No dysmorphism, no conjunctival pallor, no jaundice, no central cyanosis, no
lymphadenopathy, no sore throat.

Meningeal irritation signs:

 Neck rigidity: positive.
 Kernig’s sign: positive.
 Brodzinski’s sign: not obvious.

Chest:
 Chest is symmetrical and moving with respiration.
 Type of breathing is thoraco-abdominal pattern.
  Vesicular breathing.
 Normal air entry.
 No crepitations or wheezes.

Heart:
Normal S1, S2. No added sounds. No murmurs.

Skin: no rashes.

Hands:
No nail changes such as koilonychia or leukonychia, no palmar erythema, no
peripheral cyanosis.

Lower limbs: No edema.

CNS: Normal DTRs.

Abdomen:
 Inspection: the abdomen looks symmetrical, moving with respiration, mildly
distended. The umbilicus is normally inverted, centralized, with no signs of
inflammation of discharge. There are no scars, pigmentations, prominent
veins, visible peristalsis or pulsations. No visible masses.
 Active inspection: no divarication of recti muscles and no hernias.
 Palpation: no tenderness or masses, no organomegaly, liver span is about
10cm, kidneys are not ballotable.
 Percussion: tympanic in all areas.
 Auscultations: no exaggerated bowel sounds, no bruits.

Summary:
A previously healthy 8-year old female patient, presented with a few-day history of
fever and vomiting, with positive meningeal signs. She was admitted as a case of
meningitis.

Differential Diagnosis:
 Bacterial meningitis.
 Viral meningitis.
 Encephalitis.
 Brain SOL.

Management:
 Requested investigations:

CBC, LP.

Results:

- CBC: WBCs: 18K, Hg: 11.9, PLT: 426K.

- LP:
o Gross appearance: turbid, no blood.
o Chemistry: glucose: 50 mg/dL, protein: 35 mg/dL.
o Cells and differential: WBCs: 2500, PMN: 40%, LC: 60%.
o CSF culture: negative.

 Plan:
- Admission.
- PDS 500 cc Q6hr.
- Ceftriaxone, 1g IV.
- Vancomycin 270 mg IV Q6hr.
- Decort 3mg IV, Q6hr.