WELL COME TO THE

CLINICAL
MEETING

Presentar:
DR.K M ENAYET
RESIDENT,Year-2
PAEDIATRIC CARDIOLOGY
DR. MEHBUBA AFROZ
RESIDENT,Year-2
GENERAL PAEDIATRICS
Particulars of the patient:

 Name : Al-Islam
 Age : 09 years
 Sex : Male
 Address : Cumilla
 DOA : 01.10.19
 DOE : 01.10.19
Chief Complaints

 Fever for 20 days

 Cough for 20 days
H/O Present illness

 According to statement of informant father his child was

reasonably well 20 days back. Then he developed fever
which was high grade continued in nature, associated with
chills and rigor. Highest recorded temperature was 104ºF,
subsided by taking anti pyretic. He also developed cough
for same duration, which was productive in nature.
CONT’D
 Sputum was moderate in amount , whitish in colour, foul smelling and
increasing in the morning, not mixed with blood.

 On query father also gives h/o anorexia & wt loss over the last 20 days

 There is no history of respiratory distress, haemoptysis, headache,

convulsion , alteration of bowel habit.
Cont..

 1 yr back He was diagnosed as a case of pulmonary TB on

clinical basis and treated with anti TB drug with adequate dose
and duration and was improved.
 With these above complaints he was treated with registered
physician by conventional antibiotics.

 As his condition was not improved so he was admitted to

BSMMU for further evaluation.
Birth history:
Antenatal :
Mother was on irregular antenatal checkup.

Natal :
Delivered at term at home by NVD with average birth
weight .

Postnatal: Uneventful.
Developmental history:

 Ageappropriate and now reads in class three with

average school performance .
H/O past illness

 1 yr back He was diagnosed as a case of pulmonary TB on

clinical basis and treated with anti TB drug with adequate
dose and duration and was improved.
Feeding history:

 Now on family diet.

Immunization history:

 Immunized as per EPI schedule.

Travelling history:

 No history of travelling to Malaria or Kala-azar endemic

area.
Family history:

 1st issues of non consanguineous parents.

 Other family members are in good health.

Socio-economic history:

 Belongs to lower socioeconomic back ground.

 Lives in over crowded tin shed house, uses
sanitary latrine, drinks tube well water.
Treatment history:

 Conventional antibiotics with adequate dose and duration.

General examination:
 Appearance: ill looking.
 Pallor : moderately pale
 Clubbing
 Jaundice
 Cyanosis
 Edema absent
 Dehydration
 Koilonychia
 Leukonychia
BCG
 mark: present

Lymph
 node:

palpable at both ant post rt & left cervical chain (max 2.5 1.5 cm),

Rt axillary (apical and ant group) measuring about 2 1.5 cm, both rt & lt

Inguinal lymphnode which is firm in consistency, non tender , matted ,

not fixed to the overlying structure.

 Bony tenderness : absent
 Signs of meningeal irritation: absent
 Back and spine: normal
 Ear,nose and throat: normal
Vital sign:

 Heart rate : 90 beats/min, regular

 Respiratory rate : 20 breaths/min
 Temperature : 102º F
 Blood pressure :100/60 mm Hg
(both systolic and diastolic lies
50th to 90th centile)
Anthropometry
Height : 124cm
(Lies on 3rd centile)
Weight : 17kg
(Lies bellow 3rd centile ) WAZ (-4.5)
BMI :11 kg/m2
(lies bellow 3rd centile)
Systemic examination:
Respiratory system:
Inspection
Shape of the chest : normal
R/R : 20 breaths/min
Scar mark : absent

Palpation
Trachea : centrally placed
Apex beat : left 5th ICS, medial to mid-clavicular line
Chest expansibility : Reduced on rt side
Vocal fremitus : Increased in RT upper & mid zone
 Percussion note : Dull on rt upper and mid zone.
 Auscultation
 Breath sound : Bronchial on rt upper and mid zone
 Vocal resonance : Increased on rt upper and mid
zone
 No added sound
Alimentary system:

Oral cavity: healthy

Abdomen proper:
Inspection :
 Size and shape of abdomen-normal
 Umbilicus centrally placed & inverted
 Engorged vein or visible peristalsis – absent
 Palpation
 Abdomen is soft. Non tender.
 No organomegaly
 Fluid thrill : Absent
 Percussion note : tympanic
 Shifting dullness: Absent

Auscultation:
Bowel sound : present
Genitourinary system:
Inspection :
Abdomen is normal in size and shape.
Umbilicus centrally placed and inverted.
External genitalia normal.

Palpation :
Kidneys not ballotable
Bladder not palpable
Renal angle tenderness absent

Auscultation :
Renal bruits absent
Cardiovascular system:

Inspection
No visible pulsation

Palpation

Apex beat : left 5th ICS, medial to the mid
clavicular line.
P2 : Not palpable
Lt. parasternal heave : absent
Auscultation:
S1 & S2 are audible in all cardiac areas

No added sound

Locomotor system
 Look : no swelling or deformity

 Feel : Temp is not raised ,joints are non tender

 Move : No restriction of joint movement

Nervous system:
Higher psychic function : Normal
Cranial nerves – Intact, as per I could examine
Sensory system- Intact
Motor system
Muscle bulk and tone : Normal
Muscle power : Normal
Reflexes : Normal
Planter : Bilateral flexor
Gait : normal
Salient feature:

Al-Islam 09 years old boy 1st issue of non consanguineous parents,

immunized, hailing from cumilla got admitted with the complaints
of high grade, continued fever, associated with chills and rigors for
20 days. He also complained of cough which was productive in
nature for same duration. Sputum was initially moderate in
amount then gradually increasing in amount, whitish in colour,
foul smelling and increasing in the morning, not mixed with blood.
Cont’d

Also there is h/o anorexia & wt loss over the last 20 days.
1 yr back He was diagnosed as a case of pulmonary TB on
clinical basis and treated with anti TB drug with adequate
dose and duration and was improved. There is no history
of respiratory distress, haemoptysis, headache,
convulsion ,unconsciousness, alteretion of bowel habit.
Cont’d

With the above complaints he was treated with conventional

antibiotics with adequate dose and duration, but did not improved.

On examination, he was ill looking, severely wasted, febrile,

moderately pale ,anicteric, Clubbing absent ,BCG mark absent.

Generalized Lymphadenopathy present which was firm, non tender,

matted,not fixed with overlying skin or underlying structure.
 Vitalsare within normal limit except temperature 102º
F, Anthropometrically severely wasted.
 On respiratory system examination reveals RR 20 br/min
with features of consolidation over rt upper and mid
zone .
 Others system examination reveals nothing abnormality.
Provisional Diagnosis
 Lung Abscess

 Differential Diagnosis:
Consolidation due to
Pneumonia
Tuberculosis
Lung Abscess
Points in favor Points against

High grade continued Fever with chills &

rigor for 20 days
 cough with productive foul smelling
sputum for same duration
On exam :
Temp 102F
Features of consolidation over rt upper
& mid zone
Lymphadenopathy present
INVESTIGATIONS
 Complete blood count

Hb% 7.7 gm/dl

ESR 120 mm in 1st hour

TC 4500/cmm

DC N 31% L 56% M 13%

RBC 381000/cmm

Platelate 400000/cmm
 Urine R/M/E & C/S

Appearance clear

Sp Gravity 1.010
pH 7.0
Protein Nil
Pus cell 0-2 /HPF
Ep cell 0-2 /HPF
RBC Nil
C/S No growth
Sputum for AFB Not found
Sputm for multiplex PCR MTB not Detected
SGPT 12 U/L
TIBC 176 ug/dl
Iron 5ug/dl
S. Ferritin 977.3ng/ml
 Treatment

 Diet : normal
 Inj ceftriaxon (100mg/kg/day)
 Inj. Amikacin (7.5mg/kg/dose)
 Tab. Rimstar 4FDC
R :12.8 mg/kg I : 10mg/kg E :23.6 mg/kg P: 34.3
mg/kg
 Tab. Pyridoxin
 Tab. Montelukast
 Tab. Paracetamol
 Follow up on D2 (02.10.19)
Subjective Objective Assesment Plan
Fever Ill looking, Static
Cough T- 103º F Sputum for
Pulse 110/min multiplex PCR.
RR 22/min
BP 100/60 mmHg
(SBP & DBP lies
between 50th to 90th
centile )
Lungs:
Bronchial B/S with
dull percussion note
and vocal fremitus
and vocal resonance
increased over rt
upper & mid zone,
 Follow up on D3 (03.10.19)
Subjective objective assesment plan

Fever Ill looking, static Add Inj

Cough T- 102 F Clindamicine
Pulse 108/min
RR 24/min
BP 100/60 mmHg
(SBP & DBP lies
between 50th to 90th
centile )

Lungs:
Bronchial B/S with
dull percussion note
and vocal fremitus
and vocal resonance
increased over rt
upper & mid zone
 Follow up on D6 (06.10.19)
subjective Objective Assesment Plan

Fever Ill looking, Static Add Rimstar 4FDC

cough T- 102 F Blood transfusion
Pulse 110/min
RR 24/min Do S.Iron
BP 90/60 mmHg S. Ferritin
(SBP & DBP lies TIBC
between 50th to 90th
centile )
Lungs: Bronchial B/S
with dull percussion
note and vocal S.Iron: 5ug/dl
fremitus and vocal TIBC: 176ug/dl
resonance S. Ferritin:
increased over rt 977.3ng/ml
upper & mid zone
Follow up on D10 (10.10.19)
Subjective objective assesment plan

Cough persist Afebrile Improved Continue

Fever subsided Temp: 98.5ºF treatment
Pulse 98 b/min
R/R 22/min
Lungs: Bronchial B/S
with dull percussion
note and vocal
fremitus and vocal
resonance increased
over rt upper & mid
zone
 Follow up on D15 (15.10.19)
Subjective Objective Assessment Plan
No new complaints Well alert Static Do SGPT &
Temp 98F S.Creatinine
P 88 b/min
R/R 20/min

Lungs: Bronchial
B/S with dull
percussion note SGPT: 19U/L
and vocal fremitus S. Creatinine:
and vocal 0.65mg/dl
resonance
increased over rt
upper & mid zone
 Final Diagnosis

 Lung abscess due to pulmonary tuberculosis

THANK
YOU