Interesting case

conference

Identification data
4
. .



24 2557

Chief complaint
6

Present illness
1 40 c

6

Past history

Beta- Thalassemia trait (Hb typing A2A %A2 4.8% )
Gouchers disease S/P Splenectomy
1 6 CBC Bicytopenia (Hct 23.7, Platelet
90,000, WBC 10,200) Family history BMA for
smear Multiple tissue like paper histiocyte cell
2 10 (16/11/55) Pneumovac 1 amp IM Consult
SxPED
4/12/55 Splenectomy : Gaucher disease

Past history

AGE 1 Streptococcus pneumoniae
septicemia 1
3 7 S. pneumoniae septicemia

CBC WBC 15,000, PMN 50 Lymp 35

H/C Strep. Pneumo (26,29 , 1,3 ), H/C No growth (6 )
MIC Cefotaxime 0.5 microgram/ml, Erytho,PenG R
Antibiotic :
Amikacin (24/8/56 x 3 d)
Meropenam (27/8/56 x 6 d)
Vancomycin (28/8/56 x 14 d)
Cefotaxime (3/9/56 x 14 d)

Past history
: 3 1-2
13 kg 94 cm

: Term delivery by C/S due to previous C/S

Past history
:
:
: DTP, OPV (Age 4 yr)
: Gaucers disease S/P splenectomy age 7 yr
:
:

Review of systems
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Review of systems

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PHYSICAL EXAMINATION
Vital sign : BT 38.9 oC , Pulse 135 /min, RR 48/min, BP 110/60 mmHg,
BW: 13 Kgs(10-25%), HT: 94 cms (5-10%)

GA : A Thai male infant , looked drowsy, no cyanosis,

HEENT : no pale conjunctiva, no icteric sclera, mild dry lips, no sunken eyeball.
Heart : no active precordium, PMI at 5 Lt ICS MCL, no heaving, no thrill, normal S1 S2, regular
rhythm, no murmur, pulse full and regular 4 extremities, capillary refill < 2 secs

PHYSICAL EXAMINATION
Lung : Normal chest wall, no subcostal retraction, secretion sound
Abdomen : normal contour, old surgical scar at midline,no distention, active bowel
sound, soft, not tender, no rebound tenderness, liver and cannot be palpated.
Extremities : no deformity, no clubbing finger, capillary refill time < 2 sec

 Neurologic examination:
Consciousness: drowsy
GCS: E3 VT M5

Meningeal sign:
stiff neck- positive
Brudzinski sign: positive,
Kernig sign: positive

Long tract signs:

Clonus : negative both legs
Babinski sign : negative both legs

Physical examinations

Muscle tone : normal tone both extremities,

Muscle volume: normal muscle volume, no atrophy
Motor power : at least 3
Sensory cannot evaluated
Reflex:
Cerebellar signs: cannot be evaluated

Neurological examination
Cranial nerves:
CN I :not performed

CN II : pupil diameter 2mm, RTLBE. No visual field defect,RAPD negative.

CN III, IV, VI :no ptosis, no limitation of ocular movements.
CN V : cannot be evaluated
CN VII : normal corneal reflex

CN VIII:cannot be evaluated
CN IX, X : normalgag reflex, no uvula deviation.
CN XI :cannot be evaluated
CN XIl : no tongue atrophy, no fasciculatation.

PROBLEM LIST
Acute fever with localizing sign
U/D: Gauchers disease

INVESTIGATION

CBC

WBC
RBC
Hb
Hct
MCV
MCH
RDW
Platelet

14,900 /ul
4.78x 106 /ul
8.9 g/dl
29.1 %
80.7fl
30.6 pg
19.9 %
318,500 /ul

Neutrophil
Lymphocyte
Monocyte
Eosinophil
Basophil

78 %
19 %
3%
0%
0%

Hemoculture
Sterptococcus pneumonia
Antimicrobial Sensitivity:
Sensitive: Clindamycin, Levofloaxacin, vancomycin, erythromycin

Epsilometer(E)-test
MIC for PenG
0.5 microgram/ml - R

MIC for Cefotaxime

0.25 microgram/ml S

CSF examination
Color: colorless
Characteristic: Turbid
Cell count: 172 cells
Neutrophil: 32
Lymphocyte: 68
RBC: rare
Protein: 336.7 mg/dl
Glucose: 10 mg/dl (DTX:)
Bacteria: moderate

Bacterial meningitis latex/

agglutination: Positive for
S.pneumoniae

Electrolyte
BUN 5 mg/dl
Cr 0.22 mg/dl
Na:
K:
Cl:
HCO3 :

137
3.8
107
21

LFT
Total protein
Albumin
Globulin
TB
DB
AST
ALT
ALP

6.9 g/dl
4.0 g/dl
2.9 g/dl
1.2 mg/dl
0.5 mg/dl
134 IU/L
55 IU/L
327 IU/L

U/A
Color: yellow
Sp. Gr : 1.010
Sugar: neg
Albumin: neg
PH; 6.5
Ketone:neg
WBC: 0-1
RBC: not found
Epithelial cells: 0-1

U/C: NG

Management
Admit

NPO

Record V/S, I/O

If Bp< 80/50, BT> 39, PR< 60 or >120,
RR<20 or >30, )2 sat < 95% pls. notify
Record Neurosign q 2 hrs. If GCS
drop 2, seizure, unequal pupils pls.
notify
If urine output <50 or >210 ml/4hr pls.
notify

Valium 1.3 mg iv. stat X II doses

Fentanyl 15 mcg iv. stat
On ETT no. 4.5 depth 17 cms
CBC, DTX,BUN,Cr, Electrolyte,LFT
CXR
H/C
LP : CSF for cell diff, cell count,
protein, sugar, Gram stain, C/S, latex
agglutination for S.pneumonia, E.coli,
N. meningitides, H.influenza

Management
U/A, U/C
DTX
On ventilator: P/C, A/C
PIP 16, PEEP 5, FiO2: 0.7
RR 25

Cefotaxime(275MKDose)
1.2 g iv. q 8 hrs
Amikin (15MKDay)
65 mg iv. drip in 1 hrs q 8
hrs ( 2 )

Vancomycin (60 MKDay)

200mg iv. drip in 1 hr q 6hrs
Paracetamol (250mg/5ml)
3 ml O prn q 4-6 hrs