Pediatric CVA Malaria Case Dr Rakesh.pptx

case presentation of stroke with malaria in pediatric medicine

1. CASE PRESENTATION Dr Rakesh Kumar PG Trainee (Pediatrics Unit-II) Children hospital Larkana By

2. CASE SCENARIO 07 years old male child namely Zubair ahmed S /O Abdullah R/O Larkana admitted in Peads Unit-II via Emergency Department (CLF Larkana), on 08 -12-2023 with C/O: Fever - 05 days Rt sided weakness - 02 days

3. HISTORY OF PRESENTING ILLNESS : According to patient’s mother as historian , patient was alright 5 days back then he developed Fever which was sudden in onset, undocumented, intermittent, no specific time of occurrence , no any aggravating factor, associated with Rigors/chills, not associated with Night sweats, any ear discharge, sore throat, burning micturition, or abdominal pain.

4. Rt sided weakness; Acute onset, lasting for 1 day, involving Rt Arm then progressed to Rt leg & difficulty in speaking. Severity of weakness ( Subtle, struggling with holding cup) No visual disturbance, diplopia, behavioural changes. No hx of fits, ALOC, No bowel or bl adder control loss.

5. HOPI CONT : For the complaints of fever they went to a doctor who treated as Malaria & prescribed medications in form of i /v injections, & antipyretic syrup also investigations were done in the form of blood test (CBC and MP). Patient took medicines for 2 days but condition was not improving, then he developed further signs as Rt side weakness, malaise. Then they took pateint to CLF larkana where Rx was started in the form of I/V antibiotics. NG Tube passed.

6. SYSTEMIC REVIEW: GENERAL : No hx of loss of Appetite / weight loss, sleep was normal. CNS : Rt side weakness. Difficulty in speaking. No ALOC (Altered level of consciousness) , Trauma, Headache, fits, body ache. No history of nasal regurgitation, diplopia, vertigo or vomiting. There is history of drooling of water from right side of mouth. CVS : No hx of SOB, Palpitations chest pain or cyanosis. RESP : No hx of cough , no chest pain . GI T : No hx of abdominal pain, diarrhea/Constipation. GENITOURINARY : No hx of polyuria, hematuria , Pyuria, dysuria, pain in flanks. LOCOMOTOR : No Bone/joint pain, no swelling SKIN : No hx of rashes.

7. PAST HISTORY : PAST MEDICAL HX: PAST SURGICAL : Unremarkable ALLERGIC HISTORY : BLOOD TRANSFUSION: Not transfused in past.

8. BIRTH HISTORY : Birth History insignificant

9. FEEDING HISTORY Current weight :21 kg Required calories :1525kcal calories taking: 1311kcal Deficient = 214 kcal 2 rot i med: size 32 0kca l 1 plate rice : 200 kcal 2 cup tea: 60kcal 5 slice biscuit 175kca l daal 1 plate :200kcal Sabzi 1plate 150kcal Milk with sugar 206 kcal Total = 1311 kcal

10. IMMUNIZATION HISTORY: Vaccinated according to parents( record not available) DEVELOPMENTAL HISTORY: (Normal) Achieved all developmental milestones up to age

11. FAMILY HISTORY 4 st product of consanguineous marriage. Total 3 sibling, healthy & alive, He lives with his parents , both parents are alive and healthy. This patient Sis: healthy & alive 24 yrs Bro: healthy & alive 20 yrs Bro: healthy & alive 22 yrs

12. SOCIO ECONOMIC: Father is shopkeeper by occupation Lower middle socioeconomic status . Total 6 family members , living in 2 roomed kacha house. All expenses on disease afforded by his father. Tap water is source of water Poor hygiene, improper waste disposal. No domestic animal at home.

13. HISTORY SUMMARY: 7 yrs old, Developmentally normal m ale child came with c/o Fever for 5 days & right sided weakness for 1 day. Fever was sudden i n onset, undocumented , having No specific time of occurrence , @ with rigors & chills , Rt Side Weakness: Acute onset, lasting for 1 day, involving Rt Arm then progressed to Rt leg along with difficulty in speaking For fever they went to a Doctor in Larkana where CBC MP done, diagnosed as Malaria & treated accordingly. Then condition worsened & progressed as Rt Arm, & Rt leg weaknesses, along with speaking difficulty. After all this they rushed to CLF on same day as disease progressed, then admitted to ward.

14. DIFFERENTIAL DIAGNOSIS:

15. EXAMINATION

16. EXAMINATION 7 years old male child of normal build and average height, with no petechiae, bruises, dysmorphic features or any signs of respiratory distress, cannulated on right arm, having following vitals and anthropometrics: VITALS BP = 110/70 mmHg (Sys= 90 th percentile) ( Diast : 90 th percentile) H/R = 88 bpm R/R = 26 b/m Temp = 98.4 F SO2 = 97 % SUB-VITALS A+ E - J - C - D - ANTHROPOMETRICS Height = 120 cm (25 th percentile) Weight = 21 kg (25 th percentile)

17. HEAD TO TOE FINDINGS HEAD : Normal size and shape, normal hair. EYES : Visual acuity Normal; no signs of vitamin A deficiency. No squint, drooping of eyelids or redness. EARS : Normal shape and position, no draining pus or abscesses present. NOSE : Normal shape and patency. MOUTH : Normal with no oral ulcers , cheilosis , glossitis, dark lips. however Mouth Angle Deviated towards Right side. NECK : No visible mass HANDS : Normal in size and shape with no edema or extra digits or any deformity PERIPHERIES : Warm and perfused ABDOMEN : Centrally placed inverted umbilicus, no prominent veins, no scar mark, normal abdomen with only spleen just palpable. GENITALIS : Normal.

18. CENTRAL NERVOUS SYSTEM: HMF = Oriented with time, place & person GCS = 15/15 Spine = Normal SOMI = Negative Clonus = Negative Superficial Abdominal Reflexes = Intact Cerebellar Signs = intact on left side, Could not assess on right side. DTR = 3+ Cranial Nerves = All Intact.

19. LUL LLL RUL RLL BULK NORMAL NORMAL NORMAL NORMAL TONE N N POWER 5/5 5/5 3/5 4/5 REFLEXES N N PLANTER Downgoing Upgoing MOTOR & SENSORY Examination SENSORY SYSTEM Unremarkable

20. Tone & Reflexes Hypertonia: Clasp-Knife Response Reflexes: 3+ (Brisk and Hyperactive DTR.)

21. Abdominal examination: INSPECTION : Normal in shape , moving with respiration, Umbilicus centrally placed , No visible veins, Pulsations, scar marks or spider nevi. PALPATION : No localized Mass/Tenderness/Rebound/Guarding, Liver, Spleen Kidneys and Bladder are not palpable. PERCUSSION : Shifting dullness - ve Fluid Thrill –ve AUSCULTATION : Bowel sounds are audible. No Bruit heard.

22. Chest Examination: INSPECTION : Normal shape, No visible veins, pulsations, scar marks or deformity. PALPATION : No tenderness/Crepitus, Trachea centrally placed, Apex beat at 4 th ICS 1cm medial to Mid-clavicular line, Chest movements are equal B/L. PERCUSSION : Resonant all over the chest except in ® 6 th ICS (marking liver border) AUSCULTATION : B/L vesicular breathing, Air Entry normal.

23. CARDIOVASCULAR SYSTEM: INSPECTION : Shape of precordium is normal , no scar , pulsation visible over precordium. PALPATION : Apex beat palpable in 5 th ICS medial to midclavicular line. AUSCULTATION : S1 + S2 Audible. No added sounds.

24. Hx: 7 y/o, fever=5d & Rt sided weakness= 3d O/Ex: 7 years old male child of normal build and average height, cannulated on right arm, with no signs of respiratory distress, On CNS Ex: GCS: 15 /15 (E4 V5 M6) SOMI - VE Tone increased on right side , Power 4 /5 in RLL and 3/5 in RUL, Reflexes Increased on Right Side , Planters upgoing on right side, Sensory System normal . Abd := spleen just palpable Rest of systemic examination was unremarkable. EX: SUMMARY

25. DIFFERENTIALS

26. LABS/INVESTIGATIONS :

27. CBC REPORT & MP: Hb: 9.2 g/dl Wbcs : 7 .1 Plts : 375 x 10 9 /l Interpretation: Microcytic Hypochromic Anemia. MP: + (Vivax) .

28. Interpretation Haemostasis Profile: PT: 12.7sec Normal INR: 1. Normal APTT: 26.3 sec: Normal

29. Lipid Profile Cholesterol: 126mg/dl Normal HDL Cholesterol: 33 mg/dl Normal LDL Cholesterol: 97 mg/dl Normal S. Triglycerids : 184 mg/dl VLDL Cholesterol; 36 mg/dl

30. Hemoglobin quantification Interpretation Hemoglobin A 96.30% Hemeglobin A2 3.70% High A2 consistent with THALASSEMIA MINOR.

31. CT-Scan Brain Suggestive of: Mild edema Otherwise Normal

32. X-ray Chest Right lung: UnRemarkable Left Lung: UNRemarkable .

33. FINAL DIAGNOSIS

34. Malaria complicated by CVA.

35. BIRTH HISTORY : Antenatal Consangious marriage 32y old mother Normal height & built 4 th issue, vaccinated Booked case with 3 antenatal visits. NKCM No hx of maternal fever rash, headache, fits, edema, blurring of vision, vaginal discharge or bleeding, burning micturition. Normal fetal movements. Natal 38 weeks Term / AGA Baby was delivered by NVD PROM -ve APH -ve Post natal Cord cut by new shaving Blade Baby cried immediately after birth No prelacteal feed given Breast feeding started on first day within one hour. Birth weight & length normal No h/o neonatal jaundice, apnea, fits. Passed meconium after 5 hrs of birth