Meningitis : Long Case

CONTENTS

1. History
2. Examination
3. Summary
4. List of problems
5. Management plan
6. Possible questions that could be asked during the discussion 

Meningitis is one of the commonest long case topics. It is more commonly given in Pediatrics than in Medicine. The format includes the history, examination, summary, list of problems and management.  First, a proper history should be taken.

HISTORY

• Introduction of the patient
• Name
• Sex
• Age
• From
• Occupation
• History is taken from .................... who is educated up to .................. and the history is reliable
• Presenting Complaint

The typical presentation of a child with meningitis is fever with drowsiness. As usual, first the presenting complaint should be written with the duration.

• History of presenting complaint

History of presenting complaint should start from the last time where the child was OK. Then the the sequence of event should be told like a story. Make sure to mention all the medications the child was given as well. Each and every presenting symptom should be analyzed thoroughly. For example, if we take fever, the following aspects should be asked.

• Onset
• Is it intermittent, remitent or persistent
• The time it takes for the fever to rise up to the maximum level
• How long the fever stays at its peak
• How long does it takes the fever to settle down
• How many fever spikes a day
• Does the fever responds to paracetamol
• Presence of any associated symptoms? (arthralgia, myalgia, chills and rigors)
• Nausea, vomiting
• Associated skin rash 

Meningitis is common among infants and it cause a lot damage to the developing brain. Therefore, whenever an infant comes with fever, meningitis lies high in the list, because it should be identified and treated as soon as possible to minimize the damage to the brain.

If the parents say that the child is drowsy, describe the level of consciousness according to the parents. After analyzing the presenting symptoms, the next thing is to have a list of differential diagnosis. A child can have fever with altered level of consciousness for several reasons. They are,

1. Encephalitis
2. Meningitis
3. Drugs
4. Electrolyte imbalances
5. Dehydration
6. Hypoglycemia
7. Seizures
8. Toxins
9. Delirium due to high fever

The analysis of the presenting symptoms may give a clue to the diagnosis, but you will have to ask specific questions to find specific symptoms that could support the diagnosis. If the child is having meningitis, he will have other features of meningitis such as photophobia and phonophobia. They might have associated nausea, vomiting, etc. If the child have severely altered conscious level, he is more likely to have encephalitis more than meningitis. 

Then you will have to ask questions to exclude or confirm other above mentioned differential diagnoses. Ask whether the child has access to any drugs. If the child has vomited or has had severe diarrhea, he can be having electrolyte imbalances. Ask about level of hydration. Also inquire whether the parents have noticed any abnormal movements in the child's body. Toxins are also a common cause of altered level of consciousness, so ask about the presence of toxins in the house. Sometimes the fever itself can cause altered level of consciousness. Therefore, ask whether the child had very high fever. 

In the history, you should ask things that could affect your management. If the child is having meningitis he can have increased intracranial pressure as a complication. If the child is having increased intracranial pressure, lumbar puncture cannot be done to obtain cerebrospinal fluid. Therefore, you should ask for features of increased intracranial pressure such as nausea, vomiting, etc.

Inquire about all other systemic symptoms to exclude or to confirm the diagnosis. Then complete other parts of the history.

• Past medical history

Specifically ask about seizures and febrile fits. 

• Birth history
• Surgical history
• History of head injury
• Allergic history
• Immunization history
• Development
• Family history
• family history of fits
• Social history 
• Dietary history

Examination

General examination

Since the child is having fever, a thorough head to feet examination should be carried out to find out whether there is any septic focus. 

• Temperature
• Ear discharge
• Skin rashes 
• seen in meningococcal meningitis
• Neck stiffness - Meningitis is inflammation of the meninges. When the neck is flexed the inflammed meninges are stretched, causing pain. So, the child will have pain when you bent his neck anteriorly. In very little children neck stiffness is not present, therefore meningitis cannot be excluded with absence of neck stiffness. 
• Kernig's sign - This also checks the presence of meningial inflammation. The child is kept in the supine position. Then his hip is flexed slowly with fully flexed knees. When the hip is fully flexed, the knee is slowly extended. If the child feels pain when the knee is extended, the kernig's sing is said to be positive. 
• Also check the hydration level of the child by looking at the capillary refill time. 
• BCG scar

Cardiovascular System Examination

Do a thorough cardiovascular system examination to find out the features of septicemia such as tachycardia, hypotention, etc.

Respiratory System Examination

• Tachypnea
• Features of respiratory tract infection - respiratory tract is one of the commonest sites of spread of organisms to the blood. 

Nervous System Examination

• Especially check the fundi for papilloedema to find out the presence of increased intracranial pressure.
• Look for features of focal neurological signs. 

Abdominal Examination

Abdominal examination may reveal hepatosplenomegally due to septicemia in meningitis. 

SUMMARY

The summary should include the most important parts of the history and examination. Important positive and negative findings should be included in the summary. Usually a summary should not be longer than 4 to 5 sentenses.

PROBLEM LIST

The aim of taking a history and examination is to formulate a comprehensive list of problems. Identify your patient's problems and categorize them as follows. Formulation of a comprehensive list of problems is the key to successful management of your patient.

• Medical Problems 
• Acute problems
• Chronic problems
• Psychological Problems
• Social Problems

MANAGEMENT

Address each and every problem in your problem list, through your management plan. Form a list of investigations that you would like to perform for your patient. Be prepared to justify why you are doing each and every investigation in your list. During the presentation of the case, make sure to mention the investigations along with reasons to do them before the examiner ask you.

• Cerebrospinal Fluid analysis (full report and culture) - to find out the etiological organism. 
• CT scan of the brain to visualize the changes and to exclude increased intracranial pressure.
• Full blood count to see the signs of infections. If there is a bacterial infection, there will be neutrophil lekocytosis. If there is a viral infection, there will be lymphocytic leukocytosis. 
• Blood culture
• Random blood sugar to see whether the child is hypoglycemic
• Serum electrolytes to see whether there is any electrolyte imbalances that might have given rise to altered level of consciousness.

DISCUSSION

Possible questions during discussion are,

1. How do you manage this patient?
2. How do you perform lumbar puncture in this patient?
3. What are the contraindications for lumbar puncture?
• Cardiopulmonary instability
• Focal neurological signs
• Signs of increased intracranial pressure (high blood pressure, bradycardia, coma)
• Coagulapathy
• Thrombocytopenia
• Local infection at the site of lumbar puncture
4. What are the things that you are going to look for in a CSF analysis report?
5. How do you diagnose the type of organism by the CSF report?
6. What are the features of CSF report in a partial treated meningitis?
7. What are the organisms that can be the cause of meningitis in this child?
8. How do you calculate the fluid requirement of the child? The child is not given all the fluid required because he is at risk of developing syndrome of inappropriate ADH (SIADH) secretion. So, he will be given only 2/3 rd of his fluid requirement.
9. What are the antibiotics you are going to give him? How long?
10. What is the role of dexamethosane in meningitis?
11. How do you assess the patient during daily ward round?
12. How do you give prophylaxis for contacts of a patient with meningococcal meningitis?
13. What are the complications of meningitis?

Hemophilia : Long Case

CONTENTS

1. History
2. Examination
3. Summary
4. List of problems
5. Management plan
6. Possible questions that could be asked during the discussion 

Hemophilia is one of the commonest long case topics. It is more commonly given in Pediatrics than in Medicine. The format includes the history, examination, summary, list of problems and management.  First, a proper history should be taken.

HISTORY

• Introduction of the patient
• Name
• Sex
• Age
• From
• Occupation
• History is taken from .................... who is educated up to .................. and the history is reliable
• Presenting Complain

If you are given a patient with hemophilia, the parents or the guardians know the diagnosis. The aim of the history in a patient with hemophilia is mainly to find management difficulties, to inquire about complications of the illness and to find out other problems. The diagnosis has already been made and the parents often know the type of hemophilia the child has. Therefore, history may not be taken to diagnose the disease. Therefore, the presenting complaint can be begun as "This is a diagnosed patient with hemophilia A, present to hospital for routine factor transfusion". Sometimes, patients with hemophilia presents with episodes of bleeding. 

• History of presenting complaint (HPC)

Do not start the history by saying that the child is a product of consanguineous marriage as usual. Hemophilia is an X linked recessive disorder. Therefore, consanguinity doesn't have any effect on the disease. You can start the history by saying that the child is with a history hemophilia from the mothers side of the family. 

Start from birth and tell what happened since then like a story. Make sure to focus on the followings.

• Onset of symptoms
• Sites of bleeding
• Severity of bleeding 
• Bleeding during crawling period
• Whether the bleeding occurred spontaneously or after trauma
• Time taken to bleed after trauma
• What was done and how the child was diagnosed
• History of seizures indicating intracranial bleeding
• Presence of a target joint - target joint is a joint where repeated bleeding has occurred. With repeated attacks of bleeding ultimately cause osteoarthritis of the joint and bony spike formation which ultimately lead to joint deformity.
• History of muscle bleeding - disabilities and treatments taken should be explained
• Spontaneous appearance of echymotic patches
• History of hematuria
• Also explain the treatments the child is on. Mention the frequency of factor transfusion. Most parents know if the child has developed inhibitors. If the child has developed inhibitors, say what has been done regarding them.
• Then describe the present problem. If the child is presented with another attack of bleeding, describe the circumstances, severity of bleeding. Also mention what was done at home. 
• Past medical history
• blood group
• blood transfusion related complications
• infections - HIV, hepatitis B and C, malaria
• Past surgical history - bleeding after tooth extraction
• Immunization history - bleeding after intramuscular injections
• Allergic history
• Social history
• Hemophilia requires regular factor transfusion. This can interfere with schooling of the child. 
• Mention about the education level of the parents and their understanding regarding the illness.
• Other siblings affected
• Income
• Nearest hospital
• Transport facilities
• Most people now know that hemophilia is a disease that you inherit from your mother. This can give rise to many social obstacles. For example, the farther's side relatives of the child can blame the mother for bringing a defective gene in to the family. 

Other than hemophilia, there are other bleeding disorders that can be given as your long case. Most of the time this is the first presentation of the disease. In such situations you should take to exclude each and every diagnosis. The history will be the same but some aspects of the history should be altered accordingly. Von willebrand disease, Idiopathic thrombocytopenic purpura, liver disease and SLE  are some of the common bleeding disorders that can be presented to you as your long case. Therefore, read about them and be prepared to answer the questions that can arise  during the discussion. 

Examination

General Examination

• General appearance - depressed, in pain
• Pallor
• Petechiae 
• Purpura
• Echymosis
• Gum bleeding 
• Features of systemic lupus erythematosus
• Joint swelling, deformity, contractures, level of disability
• Look for any hidden sites of bleeding

Complete system examination and note down any abnormalities found. Nervous system examination is important in cases of intacranial bleeding.

Summary

A comprehensive summary should be prepared to show the main problems.

List of Problems

Categorize the problems as,

• Medical problems
• acute
• chronic
• Psychological problems
• Social problems

Management Plan

Address each and every problem you have identify.

• List the investigations that you will order.
• Full blood count to know the degree of anemia, platelet count and white cell count

Possible Questions that could be Asked During Discussion

1. Does the child has a target joint?
2. The factor level requirement of the child.
3. Factor requirement of the child if the child were to undergo a major surgery
4. If the child presents with features of intracranial bleeding, what is your initial management?
5. The place of gene therapy

Thalassemia: Long Case

CONTENTS

1. History
2. Examination
3. Summary
4. List of problems
5. Management plan
6. Possible questions that could be asked during the discussion 

Thalassemia is one of the commonest long case topics. It is more commonly given in Paediatrics than in Medicine. The format includes the history, examination, summary, list of problems and management.  First, a proper history should be taken.

HISTORY

• Introduction of the patient
• Name
• Sex
• Age
• From
• Occupation
• History is taken from .................... who is educated up to .................. and the history is reliable
• Presenting Complain

If you are given a thalassemia patient, the parents or the guardians know the diagnosis. The aim of the history in a patient with thalassemia is mainly to find management difficulties, to inquire about complications of the illness and to find out other problems. The diagnosis has already been made and the parents often know the type of thalassemia and the type of medication which the child is on. Therefore, history may not be taken to diagnose the disease. Therefore, the presenting complaint can be begun as "This is a diagnosed patient with thalassemia major, present to hospital for routine blood transfusion". 

• History of presenting complaint (HPC)

Start the HPC by mentioning whether the child is a product of a consanguineous marriage or not. Then, start telling the story from the birth up to the diagnosis of the disease with special emphasis on the following details. If there are other affected family members, mention about them too.

• Was the child normal at birth
• What were the initial symptoms and the age of onset of symptoms - children with thalassemia major show symptoms at the age of 6 months. This is the age at which most of the red blood cells with fetal hemoglobin are replaced by red blood cells with adult hemoglobin. Children with thalassemia intermedia have a late presentation.
• The presenting symptoms at the time of diagnosis could be pallor, poor appetite, failure to thrive, vomiting, sleeplessness, irritability, jaundice, etc.
• Then describe how the diagnosis was made and the treatment the child is on. 
• Describe the frequency of blood transfusion, iron levels just before each blood transfusion, the type of chelator the child is on, last ferritin level. Ideally, the hemoglobin level just before blood transfusion should be around 10 g/dl. If it is low, it indicated inadequate blood transfusion.The ferretin levels should not exceed 1000ng/ml. If it is >1000ng/ml, iron chelation should be started. 

Then you should focus on the complications of the disease, complications of blood tranfusion and side effects of iron chelators. 

• Complications of the disease - bone deformities, growth retardation, complications of splenomegaly (discomfort in the left upper abdomen, bleeding manifestations, anemic features), complications of chronic anemia (palpitation, heart failure)
• Complications of blood transfusion - presence of blood borne diseases (hepatitis B, hepatitis C, malaria, etc.)
• Complications due to iron overload (the excess iron go and deposit in the hypothalamus, the thyroid, the pancreas and the heart and gives rise to following complications)
• Hypothalamus - hypogonadism (ask about delayed puberty), growth hormone deficiency (growth retardation)
• Thyroid - ask about features of hypothyroidism such as lethargy, cold intolerance, weight gain, increased sleepiness, etc.
• Pancreas - the excess iron destroy the beta cells that produce insulin and give rise to diabetes mellitus (ask about features of diabetes such as polydypsia, polyuria and polyphagia)
• Heart - the iron goes and deposits in the heart. The excess iron form free radicals which destroy the myocardium. As a result, the heart enlarges. This can even lead to heart failure.
• Side effects of iron chelators 
• Desferrioxamine - impaired vision and hearing, reduced growth, skeletal lesions, increased risk of infections (Yersinia enterocolitica, Yersinia pseudocolitica)

Then fill the rest of the history.

• Past medical history 
• Past surgical history - splenectomy (If splenectomy has been done, describe about immunization against capsulated organisms), pathological fracutres
• Family history - family members with similar illness, any deaths involving anemia among relatives, incidence of malaria in the family (carriers of thalassemia has a certain level of protection against malaria)
• Immunization history
• hepatitis B
• capsulated organisms
• Hib vaccine
• pneumococcal vaccine
• immunization against meningococcus
• Drug history
• is the child using an infusion pump to deliver desferrioxamine
• oral iron chelating drugs (deferepfone)
• oral penicillin prophylaxis after splenectomy
• Allergic history -
• allergic reaction during blood transfusion
• allergy to Desferrioxamine
• Dietary history
• were the parents instructed not to give any iron rich foods to the child
• promote drinking tea and reduce intake of vitamin C.
• Social history

Social history plays a very important part in the history. Thalassemia is a chronic disease requiring frequent hospital admissions. Sometimes more than one child can be affected by the disease. This can be a huge burden to the family. It might have caused a lot psychological, economical and physical stress to all family members. Therefore, these problems should be asked and described clearly. Also note down the following information.

• Distance from the home
• Transport facilities (bus fees - some examiners always ask whether you know th bus fee, because they have to come to hospital several times a month which will cost them alot)
• Family income
• Education level of the parents
• Schooling of the child
• Genetic counselling given or not
• Whether the parents understand about the nature of the disease

Examination

General Examination

• Height, weight - plot on a chart and comment on it. Also mention that you would like to know the mid parental height to find out whether there is  growth retardation.
• Dysmorphic features (prominent maxilla, frontal bossing, malocclusion of teeth, dental caries, recurrent ottitis media)
• Dyspnoec or not
• The child may not be pale because he is most probably transfused already, but you should look for features of chronic anemia such as angular stomatitis, smooth tongue, etc. 
• Jaundice - thalassemic patients are mildly jaundiced. You might not notice yellowish discoloration of eyes at first sight. Therefore, you should ask the child to turn the eye to a side to see jaundice clearly. 
• Look for deformities due to pathological fractures
• Hyperpigmentation
• Leg ulcers - common in hemoglobinopathies
• Desferrioxamine mark on the abdomen
• Pubertal stage
• you may not be able to examine the child's genitalia during the exam, but make sure to say that you would like to examine the child's genitalia to find the pubertal stage.
• Axillary hair
• Pubic hair
• Ankle edema

Cardiovascular System Examination

• Look for features of cardiomegally

Abdominal Examination

• Desferrioxamine mark
• Splenomegally
• Hepatomegally

Nervous System Examinatio

• Consciousness
• Orientation
• Fundus
• Focal neurological signs

Summary

In the summary you should include the important aspects of the history and examination.

List of Problems

• Medical problems
• Acute problems - Anemia, fractures
• Chronic problems - hypothyroidism, growth retardation
• Psychological problems
• depression
• parental understanding regarding the illness
• anxiety
• Social problems
• Economical problems

Management Plan

Management plan should be targeted to address all the problems that you have listed above.

• Arrange blood transfusion sessions to keep the hemoglobin levels >10g/dl. Frequent blood transfusion prevents bone malformation, cardiac failure, splenic complications and iron overload from increased absorption.
• Types of blood for transfusion. 
• washed red cells
• packed red cells
• frozen blood
• If hemoglobin level is <8 g/dl blood transfusion is necessary
• Iron chelation is started when serum ferritin level exceeds 1000 ng/ml.
• desferrioxamine - 
• administration is via subcutaneous route through a syringe pump, 3-4 times a week depending on the level of iron overload, infused at an average rate of 20-60 mg.kg
• dosage - depends on the prevailing iron overload
• role of vitamin C
• measure serum ferritin levels every 6 months
• Defereprone
• side effects - hepatic fibrosis, bone marrow suppression
• Splenectomy
• indications for splenectomy - 
• hypersplenism
• annual blood requirement >300ml/kg/year
• spleen palpabel >6 cm from the left costal margin
• Give pneumococcal vaccine 2 weeks before splenectomy
• Also vaccinate against meningococcus and Hemophilus inflenza
• After splenectomy, child is given life long penicillin prophylaxis
• Avoid overcrowded places.
• Record height and weight of the patient 3 monthly
• Measure Ca levels, phosphorus levels, blood sugar levels and thyroid and liver functions 6 monthly.
• Evaluate the growth, development, and iron balance yearly.
• Provide psychological support.

Possible Questions that could be Asked During Long Case Discussion

1. Do you think the child is adequately transfused? If not why?
2. Do you think the child is having iron overload? Why?
3. Is the child is grown adequately?
4. What are the reasons for growth retardation in this child? It is multifactorial. Hypogonadism, frequent hospital admission, chronic anemia, depression can cause growth retardation.
5. What is the reason for cardiomegally in this child? What is the mechanism of cardiomegally in this child?
6. Does the child requires splenectomy?
7. Can you delay splenectomy?
8. What are the aspects you should consider if you are going to remove the spleen of this child?