Case Study: Diagnosis & Treatment of Meningomyelocoele with Hydrocephalus & Meningitis in , Exercises of Medicine

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CASE PRESENTATION

Saturday 23

rd July, 2016 MODERATOR: DR HW IDRIS PRSENTERS: POSTING NUMBERS: 33,34,35,36 & 52

HISTORY AND EXAMINATION

IDRIS USMAN

PN: 033

BIODATA

• (^) Name: I.R
• (^) Age: 7/
• (^) Sex: Female
• (^) Religion: Islam
• (^) Address: Faskari Road T/wada kaduna
• (^) Tribe: Hausa
• (^) Informant: Mother.

PRESENTING COMPLAINT

she was 7days on admission

• (^) Lower back swelling at birth
• (^) Large head 3/
• (^) Fever 2/
• (^) Vomiting 14hrs
• (^) Convulsion 12hrs

• (^) Is a product of full term gestation, booked at 4/12 of gesataion & was regular on folic acid, no exposure to radiation,
• (^) pregnancy was said to be larger, Mother had high grade fever at 5/12 of gestation, no other sickness during pregnancy.
• (^) Neither smoke not ingest alcohol, not on any anti convulsant, labour was not prolonged and delivery was spontaneous.

• (^) Associated with lower limbs weakness, no fecal or urinary incontinence,
• (^) Mother noticed rapidly progressing increase in the size of the head from 3/12 of life.
• (^) Associated with excessive cry, poor sucking, poor sleep, inability to hold

• (^) patient started vomiting 14hrs prior anytime she was breast fed, non projectile, non billous, non bloody
• (^) had a total of 4 bouts estimated volume of about 30-40ml/bout,
• (^) no abdominal distention, diarrhoea, constipation, no hx of passage of blood in stool,

• (^) Patient started convulsion 2hrs after the onset of vomiting,
• (^) Described as generalized tonic clonic, upward rolling of the eyes, had a total of 3 episodes.

• (^) This is the 1st episode of convulsion in patient’s life, the last meal was 4hours prior to the onset of the 1st convulsion.
• 24 hrs dietary recall
• No hx of contact with someone with convulsion, no family hx of febrile convulsion or seizure disorder,

• (^) no hx of aversion to light, no proceeding catarrhal symptoms, no hx of eye or ear discharge, ear tugging,
• (^) No hx of bulging anterior fontanelle, No hx of loss of conciousness.
• (^) Patient neither lost sight nor hearing

• (^) Stayed for 21 days admission, on some medications and was discharged home on follow ups.
• (^) Following onset of fever, vomitting & convulsions, paracetamol syrup was given at home and was then rushed to this facility as the convulsion prgresses.

Past Medical history

• (^) This is the 3rd admission in patient’s life, all in this facility,
• Had blood transfusion durig the surgery,
• No hx of recurrent hand and foot swelling, no yellow discoloration eyes, or progressive whitening of the palms and soles

NUTRITION HISTORY

• (^) Put to breast 30min after delivery.
• (^) Predominantly breast fed.
• (^) Complimentary feeding @ 6TH/12 of life: pap, sugar
• Appetite has reduced since onset of current symptoms.

IMMUNIZATION HISTORY

• (^) Has not had any vaccine: had several visits, but was told no due to the back swelling.