PMP 5

5 yo malay h/o fever and headache 3 days. Noted to be weak and lethargy 1d PTA.
On admission, develop fit and become drowsy.
On examination, febrile and drowsy. Do not recognize his parents. There were increased muscle tone
and reflex on both upper and lower limbs.

1. Prov Dx : UMNL secondary to Brain Abscess

(unexplained fever, altered sensorium, headache, localized neurological findings)
Etiology : anaerobic org, streptococcus aureus, pneumococci, proteus and haemophilus influenza

2. Ddx :
* Encephalitis
* Space occupying lesion
* Brain Tumour – Medulloblastoma, Neuroblastoma, Brain stem glioma, astrocystoma
* Traumatic Intracranial Hematoma
* Tuberculoma
* Subdural hygromas
* Arachnoid cyst
* Epilepsy

3. Further hx

Chief complaint: Fever

Fever -high/low grade
Headache -a/w chills and rigors?, rashes, nausea and vomiting, abdominal pain, joint pain,
diarrhea,
-risk factors : living in dengue prone area, travelling to jungles, waterfalls or
rivers, sick contact among family members

Headache
-onset, nature, site, localized/ radiating, severity (morning- increased ICP), pain
score, frequency, changes in head position may exacerbates (intracranial mas)
-Premonitory sx in migraine headache (irritability, fatigue, changes in facial
expression), migraine with aura (zigzag lines, light)
-a/w nausea, projectile vomiting, blurring of vision, lethargy, dizziness, sleep
disturbances, gait disturbances or difficulty in walking, neck pain or stiffness
(meningeal irritation), seizures, syncopal attack, hx of trauma/fall, loss of
consciousness, recent hx of persistent URTI (sinus headache)
-aggravated by sneezing, coughing or straining (increased ICP), medications
overuse headache (>10d/month)
PM Hx Hospitalization? (multiple admission-immunosuppressed), Has ever been
diagnosed with neurological problems (cerebral palsy, epilepsy), If yes, Any
interventions done or Medications given?,

* Children with a prior history of epilepsy may have a generalized or focal

headache after a seizure. Headaches may also accompany the aura prior to a
seizure.
Birth Hx Complications during prenatal, antenatal and postnatal period.
Mode of delivery, Term or preterm, Birth weight,
NICU admission?
Dev Hx Disturbance or delay in growth? (Gross motor, Fine motor, Social )
Family Hx Non consanguineous marriage?
Family members have been diagnosed with neurological problems (migraine),
congenital abnormalities?
Social Hx Mother and father’s occupation, income, involved in high risk behavior?, Living
area
4. Signs to elicit
* Cutaneous lesions (eg, petechiae, purpura, ash-leaf spots, café-au-lait spots).
* Hematomas or other signs of trauma on head region
* Papilledema, Nystagmus
* Neurologic examination should be performed to assess the level of consciousness hypertonia
hyperreflexia, hemiparesis, or hemiplegia.
* Cranial nerve dysfunction (nerve palsy; 6th nerve-diplopia)
* Ataxia, aphasia
* Motor deficit

5. Complications of no (1)
* Permanent neurological damage may include:
- hemiparesis, cranial nerve palsy, hydrocephalus, intellectual and behavioral disorders, ataxia,
spasticity, visual defects, and optic atrophy.
* Recurrent seizures develop in about 10-30% of survivors

6. Inx
* CBC – Leukocytosis (infection)
* ESR – elevated
* Serum CRP
* Blood Culture
* CSF C+S – tro bacterial meningitis (elevated protein level)
* CT Scan – look for abnormalities (abscess, mass, hematoma,)
* MRI – useful in doubtful cases

7. Advice to parents (want to seek tx from bomoh)

* From the very beginning, mankind has had a desire to maintain wellness, seek cures for ailments,
and prolong life expectancy.

* As the best Muslims, faith and the beliefs on Allah is important. In fact, the basic principles of
faith that frame the Muslim's attitudes include:

•Believing in ‘qadar’, which is ‘the belief in preordination (fate or destiny), which supports the
idea that what is meant to be, will be, and what is not meant to happen, can never occur’
(Hasnain et al., 2008).

* As early intervention is crucial in most cases of diseases, parents who refuse to treat their children
as a result of false beliefs may cause their children great harm by delaying their access to seek further
treatment

* The Prophet said: ‘There is no disease that Allah has created, except that He also has created its
treatment’ (Ibn Qay'em, 2003, p. 18).

*The following Hadith, taken from Sunan Abu Dawud, also clarifies and stresses the importance of
medication:
I came to the Prophet (Peace Be Upon Him) and his Companions were sitting as if they had birds on
their heads. I saluted and sat down. The desert Arabs then came from here and there. They asked:
'Apostle of Allah, should we make use of medical treatment?' He replied: 'Make use of medical
treatment, for Allah has not made a disease without appointing a remedy for it, with the exception of
one disease, namely old age. (Abu-Dawud, n.d., no. 3855)

* In conclusion, all patient's should be seen first by a practitioner of conventional medicine for the
initial evaluation and treatment.