Contents

Case Summary............................................................................................................................2
History Of Presenting Illness..................................................................................................2
Past Medical...........................................................................................................................3
Surgical History.......................................................................................................................3
Paediatric History...................................................................................................................4
Antenatal............................................................................................................................4
Birth....................................................................................................................................4
Postnatal.............................................................................................................................4
Feeding History...................................................................................................................4
Development History..........................................................................................................4
Family history.........................................................................................................................5
Social history...........................................................................................................................5
Immunization History.............................................................................................................6
Drug history............................................................................................................................6
Allergy history.........................................................................................................................6
Summary.................................................................................................................................6
Physical Examination..................................................................................................................7
General Examination..............................................................................................................7
Anthropometric Measurement..........................................................................................7
Vital Signs............................................................................................................................7
Specific Examination...............................................................................................................8
Neurological Examination...................................................................................................8
Respiratory Examination.....................................................................................................8
Cardiovascular Examination...............................................................................................8
Abdominal Examination......................................................................................................9
Investigations...........................................................................................................................10
Haematological Test.............................................................................................................10
Imaging.................................................................................................................................12
Lumbar Puncture..................................................................................................................14
EEG........................................................................................................................................14
Urine Test.............................................................................................................................14
PROBLEM LIST.......................................................................................................................15
 Case
Patient’s name : Muhammad Aidil Mahadi
RN : B396397
Age : 14 years old
Race : Malay
Gender : Male
Address : Pejabat Kesihatan Daerah Besut, 22300 Besut
Terengganu
Religion : Islam
Diagnosis : Post Tuberculous Meningitis
Person Giving History : Historian: Mother
Age: 45
Occupation: Nurse
Summary

History Of Presenting Illness

Aidil Mahadi, 14-year-old Malay boy diagnosed as Post-Tuberculous Meningitis complicated

with Hydrocephalus, Epilepsy and Spastic Quadriplegic. Further questioning revealed that
this diagnosis was confirmed when he was admitted in Hospital Raja Perempuan Zainab in
2008. He was diagnosed as Meningitis after had multiple previous admissions.
Patient’s 1st hospital admission, when he was 4 months old, he was treated as
bronchiolitis. He had persistent wheeze after discharge associated with intermittent cough.
Patient was started on MDI Ventolin and the symptoms were partially relieved. However, he
still had wheezing on MDI.
On 2009, patient was well and active until March that year. He started to have
continuous high grade fever associated with intermittent cough. Highest temperature
recorded was 38’C. The fever was partially relieved by paracetamol and worsened at night
with night sweats. He cannot sleep well and had tepid sponging. Positive sick contact with
father who had Pulmonary Tuberculosis. Patient was brought to Hospital Jerteh on
22/3/2009 at 2nd week of illness and was admitted. He was treated as Bronchopneumonia
with IV Zinacef for 6 days and Syrup EEA for 1 week. The fever was persisted in ward even
after 1 week of admission. However, his mother then took AOR discharge after child looks
improving. Mother claimed at home, patient was still active when temperature settle and no
history of fitting.
4/4/2009, a week after AOR discharge from Hospital Jerteh, patient was referred to
Hospital Jerteh to HRPZ(II) after mother noticed patient’s condition was deteriorating. He
was noted to have continuous high grade fever with intermittent cough, projectile vomiting,
lethargy and decrease level of consciousness. At HRPZ(II), patient was noted as lethargic
with neck stiffness and bulging of anterior Fontanelle. He was treated as clinical meningitis
and Lumbar puncture was done. He then developed episodes of Left focal fit (tonic
movement of left UL and LL) and went into Status Epilepticus which was aborted after given
IV Phenytoin 20mg/kg and IV Phenobarbitone. Patient was intubated for cerebral
resuscitation and then was referred to HUSM for ventilation and further management.
At HUSM, patient was admitted in 2 Delima, ventilated and sedated. He was treated
as Acute Hydrocephalus-suspected TB Meningitis. Anti TB and, IV Rocephine, IV Amikacin
and IV Dexamethasone were continued in ward. Then, Right EVD insertion was done by
neurosurgical team. Noted high pressure clear CSF with whitish sediment. On 8/4/09, it was
noted there was increase of TWC with 2 spikes of temperature. CXR was repeated, no new
pneumonic changes. IV Imipenem 170 mg qid was added. IV Dexamethasone was restarted
back as previously was off after completed 3 days.
Since, 12/4/09 patient was noted to have regular seizure activities. IV
Phenobarbitone 30 mg OD was continued. Mantoux reading is 12mm (positive). Mantoux
test was done (12mm). Patient was extubated and continued Anti TB, anti-epileptic and IV
Rocephine. IV Amikacin was completed for 5 days and IV Imipenem for 7 days. CSF for TB
PCR was done and the result was negative. Right parieto occipital VP shunt was inserted by
neurological. He was also diagnosed with Spastic Triplegic Cerebral Palsy. Patient was bed
and wheelchair bound since then. On 19/4/09 patient was transferred to ward 6s and was
treated accordingly. Patient remained afebrile. After seizure was controlled by medication,
patient was discharged.
Patient still had seizure at least 3 times every day lasted for 3 minutes until 2021. On
January 2022, seizure was well controlled after started Lamictal and almost 2 weeks free of
seizure. Patient is compliant to medication. Currently, patient has no fever and upper
respiratory tract infection.
Patient is brought by mother to HUSM for monthly follow up with Paediatrians due
to his condition, OKU card holder and wheel chair bound. Patient also goes to HUSM for
physiotherapy and occupational therapy. Parent was satisfied with HUSM’s treatment and
service.
Past Medical and Surgical History

1. Treated as Acute Bronchiolitis when patient was 4 months old

2. Treated as Bronchopneumonia in Hospital Jerteh on 22/3/09
3. Meningitis and Status Epilepticus were diagnosed in HRPZ(II) on 4/4/09. Had
Lumbar Puncture and intubated for cerebral resuscitation.
4. Referred to HUSM for further management and ventilation. Patient had VP Shunt
Insertion,
Paediatric History

Antenatal
Uneventful

Birth
Patient was born full term via Emergency Lower Segment Caesarian Section (EMLSCS) due to
severe Oligohydramnios at HRPZ (II). His birth weight is 2.6kg. He was discharged after 3
days.

Postnatal
No breathing problem, pallor, cyanosis, injuries, or convulsions upon labour. Patient had
Neonatal Jaundice on day 2 to day 5 of life. Patient was breastfed and was not treated by
phototherapy. Cord falls off after 1 week of life

Development History

Patient used to able to walk.

Mouthing
Babbling
Bang 2 cubes together.
Mother claimed patient is 6 months development delay.

Current
Fine and Gross Motor : Can roll over
Speech: Bubbling
Social : Respond to his name
Bedbound
Family history

Mechanic, h/o PTB Nurse at KK Kuala Besut

48 45

16 10

Father and Grandfather : Hypertension

Grandfather : Heart Disease
Mother : Allergic Rhinitis
Aunty : Asthma
No family history of epilepsy and Cerebral Palsy

Social history

 No pets at home
 No carpet at home
 Taken care by grandparents when parents working
Immunization History

Up to age

Drug history

IV Rocephine 550mg OD
IV Amikacin 100mg OD
Anti TB :

 Syrup Isoniazide 40mg OD

 Syrup Rifampicin 70mg OD
 Syrup Pyrazinamide 179mg OD
 Syrup Pyridoxine
 IV Dexamethasone 3mg TDS

Allergy history

Allergic to seafood

Summary

Aidil, 14 year-old boy with Post Tuberculosis Meningitis complicated with Spastic
Triplegic and Epilepsy.
Physical Examination

General Examination
 ADL fully dependant
 Wheel chair bound

Anthropometric Measurement

Height :
Weight:

Vital Signs
Specific Examination

Neurological Examination

Positive Clonus Test indicates a type of neurological condition that creates involuntary
muscle contractions. Babinski test’s positive also suggests neurological condition (stroke,
Meningitis, Spinal Cord injury etc…)

UPPER LIMBS Right Left

TONE Normal Normal
POWER 4/5 3/5
REFLEXES ++ ++

LOWER LIMBS Right Left

TONE Normal Hypertonic
POWER - 3/5
REFLEXES +++ ++++
CLONUS Positive Positive
BABINSKI Positive Positive

Respiratory Examination

The chest expansion was equal bilaterally. Tactile fremitus could not be assessed as patient
could not follow order. Otherwise, the trachea was centrally located and no tracheal tug
noted.
Percussion was resonant on all lung zones bilaterally. vocal resonance could not be assessed
as patient could not follow order
Breath sound were heard normally. Otherwise, no wheezing or stridor being appreciated.

Cardiovascular Examination

S1 and S2 heart sounds were heard with no additional heart sounds. No murmurs were
appreciated. Apex beat is normal
Abdominal Examination

The abdomen was not distended, and it moved symmetrically with respiration. The
umbilicus was centrally located and inverted. On superficial palpation, the abdomen was
soft and non-tender on all regions. no palpable mass was noted
Investigations

Haematological Test

1. Full Blood Count

BLOOD 2/6/2011 Unit Normal

CELL s range
WBC 13.5 H ×10^3/mm^3 3.50 – 11.0
RBC 4.60 ×10^6/ mm^3 3.80 – 5.80
Hb 11.3 g/dl 11.0 – 16.5
MCV 74 fl 76.0 – 96.0
MCH 54 Pg 26.5 – 33.5
MCHC 33.3 g/dl 31.5 – 35.0
HCT 34.0 L % 35.0 – 50.0
PLT 267 ×10^3/mm^3 158 – 410
Imaging

1. Chest X-Ray

2. Brain CT-Scan

 01.06.09 25.05.2009
a) Urgent NCCT brain performed on 01.06.09. Comparison made with previous scan on
25.05.2009.
 The previously seen right frontal subdural collection slightly reduced in size with
maximum thickness of 0.8cm
 No significant changes with pre-existing communicating hydrocephalus
 Similar appearance of right occipital subdural haemorrhage
 Hypodense area seen in left posterior parietal region could represent infarction
 Right EVD seen transversing the right temporo-parietal region with its tip abutting
the medial wall of right lateral ventricle.
  Left EVD seen transversing the left anterior parietal region with its tip within the
body of left lateral ventricle.
 Two Burr holes defect seen at EVD sites. The rest of the skull vault is unremarkable.
Impression:

1. Resolving right frontal subdural collection with communicating hydrocephalus. No

significant changes with previous CT.
2. Blocked right EVD.

10.5.2009 12.05.2009

b) Urgent NCCT brain performed on 12.05.2009. Comparison with previous CT imaging

done on 10.5.2009.

Impression:

Worsening right subdural collection with air fluid level and mass effect on the right
cerebrum.
Persistence communicating hydrocephalus.

Conclusion:
Features suggestive of hydrocephalus with cerebral oedema, most likely secondary to
meningitis. TB meningitis is a possible.
Lumbar Puncture

Procedure to rule out meningitis and encephalitis. Hence to know the exact reason of the
seizure.
1. CSF result (4/4/09)
Clear, colourless
Glucose: 04 (RBS: 6.7)
Protein: 2.6
Globulin: negative
AFB: negative
CSF Gram Stain: few Pus, organism not seen

EEG

Interpretation : Almost continuous bursts of synchronous asynchronous generalized

epilepsy discharges

Urine Test
1. Urine FEME C&S
To exclude any sign of urinary tract infection

Blood Culture

No growth
PROBLEM LIST

1.
2.
3.
LEARNING CONTRACT

Learning Objectives Resources and Evidence Criteria

Strategies

2) To educate patient’s a. Visit physiotherapy Video presentation on Assessment of booklet

family member on centre in HUSM and exercises that can be and video by
benefits of therapies ask medical specialist done to help patient supervisor.
available for child with for advice. and a booklet for
global developmental patient’s family
delay and exercises b. Reference from member.
that can help improves various sources such
the child ability. as medical books,
journal, brochure and
internet.
3) To educate patient’s a. Discussion with A booklet about Assessment of the
family member on medical doctors and epilepsy prepared for content of the booklet
managing the attitude specialist. the patient’s family. by supervisor.
for epilepsy

b. Reference from
various sources such
as medical books,
journal, brochure and
internet.
3) To educate patient’s b. Discussion with Video presentation on Assessment of booklet
family member on medical doctors and exercises that can be and video by
preventing specialist. done to help patient supervisor.
Tuberculosis and other and a booklet for
types of Infection patient’s family
b. Reference from
member.
various sources such
as medical books,
journal, brochure and
internet.