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Re: New Case for valuable comments

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  • adhikarikm
    The case appears to be ABM, agreed. Very fact that the perfusion has been normal when you saw him even after 4-5 days of illness indicates that this 04 month
    Message 1 of 18 , Jan 31, 2008
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      The case appears to be ABM, agreed. Very fact that the perfusion has
      been normal when you saw him even after 4-5 days of illness
      indicates that this 04 month old baby has been feeding well at least
      for last few hours! Losing a 04 month old baby to a florid pyogenic
      meningitis within few days is not at all unusual.The practitioner
      and MO could have missed the subtle features initially. Bacterial
      meningitis can have catastrophic consequences even with best of the
      empirical therapy. It would not be prudent to squarely blame the MOs
      in this case unless we have a definite evidence to do so. i have
      encountered a case in Vizag where a 6 year old girl came walking to
      OPD on my DMO duty with fever without localisation, to return back
      after 10 hrs with signs of coning. CSF study confirmed florid
      meningitis.This case was seen by me at MI room during DMO duty and i
      can confirm that she had no localising features. Had this case been
      seen by another MO few hours back, probably, even i would have
      thought that his findings were not reliable.

      Regarding sensitisation of MOs for picking up clues (Maj Ravi's
      comment), that sensitisation has to bloom from within. At this
      college we see students lamenting for having joined medicine, many
      of them want to persue MBA after results! You can not do justice to
      a profession unless you are loving the job you are
      doing.The "intusion", so called "Sujnana" in our vedas would
      automatically come after years of dedicated medical practice. No MO
      can claim that he can pick up all the cases on day 1 at an early
      stage of his/her career. If someone says that he/she can do it,
      please be careful before sending any case to him/her!!

      Have nice discussion time
    • sheila mathai
      Thapar, The imaging suggests some subacute/chronic ischaemic insult which does not fit into the picture of an acute meningitis. What exactly was the csf
      Message 2 of 18 , Jan 31, 2008
      • 0 Attachment
        Thapar,
        The imaging suggests some subacute/chronic ischaemic
        insult which does not fit into the picture of an acute
        meningitis. What exactly was the csf picture? Have you
        ruled out tubercular meningitis? (though I agree that
        the obstructive hydrocephalus is not suggestive).If
        basal ganglia are involved on imaging we could also
        consider Leigh's Disease.
        Regards,
        Sheila Mathai


        --- madhuri kanitkar <madhurikanitkar@...>
        wrote:

        > Thapar,
        > There seesm to be no doubt regarding meningitis with
        > the presentation and the CSF picture and therefore
        > the management appropriate. Was there any premorbid
        > problem. Because at 4 months the developmental
        > milestones may not have been observed too well
        > especially if not brought to the hospital earlier.
        > Was the baby preterm? How was the head
        > circumference? CT scan did not show any basal
        > exudates did it? 
        >
        >
        > On Tue, 29 Jan 2008 r_thapar@... wrote :
        > >Dear all
        > >i recently had a case, details of which i like to
        > share with the group for valuable comments.
        > >04 month female infant presented to my OPD with
        > mother compliaining that infant is not well for
        > last4-5 days . Infant has been having high grade
        > fever (4-5days) & irritability for last 2days &
        > not accepting feeds well for last one night. seen by
        > pvt practioner & treated with antibiotics with no
        > relief. seen in our facility by MO & advise counts
        > & antibiotic contined for 2 days. sensorium
        > commented as normal ( On my questioning later to the
        > MO)
        > >when seen in Peds OPD i found the infant febrile
        > with no interaction in the surroundings & having
        > abnormal movements of limbs. AF was level&
        > peripheral perfusion satisfactory. Suspecting CNS
        > infection i immedtlly took the infant to ward &
        > started on parenteral fluids & antibiotics preceded
        > by Dexamethasone dose& did the LP.Infant was loaded
        > with Phenobarbitone& put on maintenance doses
        > parenterally As suspected CSF proved my diagnosis
        > of Pyogenic Meningitis, gram result was
        > inconclusive, PBS had toxic granules. Infant was
        > given Inj Ceftriaxone , Amikacin & Vancomycin added
        > from word go.Progress over next 2 days was equivocal
        > with not much change in sensorium. had some facial
        > twichings after 48 hrs of therapy .Rpt LP & CT
        > planned.
        > >
        > >worsened clinically with irregular respirations&
        > required manual positive ventilation before the
        > ultimate.
        > >
        > >Ct scan after 72 hrs of admissiont showed
        > obstructed hydrocephalus with dilated ventricles &
        > chinked 4th ventricle alongh withB/L hypodense
        > cerebellar regions, brain stem regions. Radiologist
        > also opined about periventricular hypodensities, B/l
        > subdural collections in fronto parietal regions.
        > Reported as sequalae to Hypoxic Ischemic insult
        > involving posterior circulation. Evidence of
        > meningitis was equivocal on Ct Scan.
        > >
        > >request for valuable comments on management & CT
        > findings!
        >



        ____________________________________________________________________________________
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      • daljit
        Dear Thapar, You are giving your replies at the end of the comments. Pl give these at the beginning. Otherwise as in this reply of yours to Wg Cdr John, unless
        Message 3 of 18 , Feb 1 9:14 AM
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          Dear Thapar,
          You are giving your replies at the end of the comments. Pl give these at the beginning. Otherwise as in this reply of yours to Wg Cdr John, unless one scrolls down fully, he or she may miss your reply.
          Daljit
          ----- Original Message -----
          Sent: Thursday, January 31, 2008 1:45 PM
          Subject: Re: [defencepeds] New Case for valuable comments


          ----- Original Message -----
          From: biju john <drbmj1972@yahoo. com>
          To: defencepeds@ yahoogroups. com
          Sent: Wed, 30 Jan 2008 22:41:01 +0530 (IST)
          Subject: Re: [defencepeds] New Case for valuable comments

          Sir,
          1.It does seem to be pyogenic meningitis.Perhaps, came to you a little late in the disease process.Was the infant immunised with hiberix.CSF could have been sent for the antigen (latex`based )detection of common bacteria offered by popular labs for a possible etio agent.
          2.Could the infant have been shunted(VP shunt) if the hydrocephalus was significant.
          3.What about the subdural effusion.Could it have been a empyema,was it significant to be tapped.
          bmjohn

          r_thapar@indiatimes .com wrote:
          Dear all
          i recently had a case, details of which i like to share with the group for valuable comments.
          04 month female infant presented to my OPD with mother compliaining that infant is not well for last4-5 days . Infant has been having high grade fever (4-5days) & irritability for last 2days & not accepting feeds well for last one night. seen by pvt practioner & treated with antibiotics with no relief. seen in our facility by MO & advise counts & antibiotic contined for 2 days. sensorium commented as normal ( On my questioning later to the MO)
          when seen in Peds OPD i found the infant febrile with no interaction in the surroundings & having abnormal movements of limbs. AF was level& peripheral perfusion satisfactory. Suspecting CNS infection i immedtlly took the infant to ward & started on parenteral fluids & antibiotics preceded by Dexamethasone dose& did the LP.Infant was loaded with Phenobarbitone& put on maintenance doses parenterally As suspected CSF proved my diagnosis of Pyogenic Meningitis, gram result was inconclusive, PBS had toxic granules. Infant was given Inj Ceftriaxone , Amikacin & Vancomycin added from word go.Progress over next 2 days was equivocal with not much change in sensorium. had some facial twichings after 48 hrs of therapy .Rpt LP & CT planned.

          worsened clinically with irregular respirations& required manual positive ventilation before the ultimate.

          Ct scan after 72 hrs of admissiont showed obstructed hydrocephalus with dilated ventricles & chinked 4th ventricle alongh withB/L hypodense cerebellar regions, brain stem regions. Radiologist also opined about periventricular hypodensities, B/l subdural collections in fronto parietal regions. Reported as sequalae to Hypoxic Ischemic insult involving posterior circulation. Evidence of meningitis was equivocal on Ct Scan.

          request for valuable comments on management & CT findings!

          thanks BM
          i donot think infant was immunised with Hiberix. Anyhow not many people get the opportunity & neceessary info esp Jawans to get immunizes with Hiberix
          I have not sent the CSF for Latex for specific bacteria. i should have done , noted for future reference
          Too early for shunting of hydrocephalus
          subdural effusions were small
          thanks
          bye
          Thapar

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        • daljit
          ... From: adhikarikm To: defencepeds@yahoogroups.com Sent: Thursday, January 31, 2008 9:54 PM Subject: [defencepeds] Re: New Case for valuable comments The
          Message 4 of 18 , Feb 1 9:56 AM
          • 0 Attachment
             
            ----- Original Message -----
            Sent: Thursday, January 31, 2008 9:54 PM
            Subject: [defencepeds] Re: New Case for valuable comments

            The case appears to be ABM, agreed. Very fact that the perfusion has
            been normal when you saw him even after 4-5 days of illness
            indicates that this 04 month old baby has been feeding well at least
            for last few hours! Losing a 04 month old baby to a florid pyogenic
            meningitis within few days is not at all unusual.The practitioner
            and MO could have missed the subtle features initially. Bacterial
            meningitis can have catastrophic consequences even with best of the
            empirical therapy. It would not be prudent to squarely blame the MOs
            in this case unless we have a definite evidence to do so. i have
            encountered a case in Vizag where a 6 year old girl came walking to
            OPD on my DMO duty with fever without localisation, to return back
            after 10 hrs with signs of coning. CSF study confirmed florid
            meningitis.This case was seen by me at MI room during DMO duty and i
            can confirm that she had no localising features. Had this case been
            seen by another MO few hours back, probably, even i would have
            thought that his findings were not reliable.

            Regarding sensitisation of MOs for picking up clues (Maj Ravi's
            comment), that sensitisation has to bloom from within. At this
            college we see students lamenting for having joined medicine, many
            of them want to persue MBA after results! You can not do justice to
            a profession unless you are loving the job you are
            doing.The "intusion", so called "Sujnana" in our vedas would
            automatically come after years of dedicated medical practice. No MO
            can claim that he can pick up all the cases on day 1 at an early
            stage of his/her career. If someone says that he/she can do it,
            please be careful before sending any case to him/her!!

            Have nice discussion time


            Internal Virus Database is out-of-date.
            Checked by AVG Free Edition.
            Version: 7.5.432 / Virus Database: 268.14.12/544 - Release Date: 11/21/2006 4:59 PM
          • r_thapar@indiatimes.com
            Madam, thanks for the response Precisely that was the reason for sharing the case details CSF was opalescent & i could take bare minimum samples becos flow
            Message 5 of 18 , Feb 2 6:38 AM
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              Madam,
              thanks for the response
              Precisely that was the reason for sharing the case details
              CSF was opalescent & i could take bare minimum samples becos flow was poor CSF cytology showed 900 WBC ( Polys predominant) with 700 RBCs, biochemistry revealed 190 mgs of Proteins with 20 mgs of sugar against BS of 88 mgs (concomitant) with increased globulins. Gram stain & Culture was noncontributory. Basal ganglia do showed some calcification confusing the picture further. I believe parents did not reveal any premorbid condition probably( they thought not significant ) for them to communicate.

              With regards
              R K Thapar
              ----- Original Message -----
              From: sheila mathai <sheilamathai@...>
              To: defencepeds@yahoogroups.com
              Sent: Thu, 31 Jan 2008 23:08:04 +0530 (IST)
              Subject: Re: [defencepeds] New Case for valuable comments

              Thapar,
              The imaging suggests some subacute/chronic ischaemic
              insult which does not fit into the picture of an acute
              meningitis. What exactly was the csf picture? Have you
              ruled out tubercular meningitis? (though I agree that
              the obstructive hydrocephalus is not suggestive).If
              basal ganglia are involved on imaging we could also
              consider Leigh's Disease.
              Regards,
              Sheila Mathai


              --- madhuri kanitkar <madhurikanitkar@...>
              wrote:

              > Thapar,
              > There seesm to be no doubt regarding meningitis with
              > the presentation and the CSF picture and therefore
              > the management appropriate. Was there any premorbid
              > problem. Because at 4 months the developmental
              > milestones may not have been observed too well
              > especially if not brought to the hospital earlier.
              > Was the baby preterm? How was the head
              > circumference? CT scan did not show any basal
              > exudates did it? 
              >
              >
              > On Tue, 29 Jan 2008 r_thapar@... wrote :
              > >Dear all
              > >i recently had a case, details of which i like to
              > share with the group for valuable comments.
              > >04 month female infant presented to my OPD with
              > mother compliaining that infant is not well for
              > last4-5 days . Infant has been having high grade
              > fever (4-5days) & irritability for last 2days &
              > not accepting feeds well for last one night. seen by
              > pvt practioner & treated with antibiotics with no
              > relief. seen in our facility by MO & advise counts
              > & antibiotic contined for 2 days. sensorium
              > commented as normal ( On my questioning later to the
              > MO)
              > >when seen in Peds OPD i found the infant febrile
              > with no interaction in the surroundings & having
              > abnormal movements of limbs. AF was level&
              > peripheral perfusion satisfactory. Suspecting CNS
              > infection i immedtlly took the infant to ward &
              > started on parenteral fluids & antibiotics preceded
              > by Dexamethasone dose& did the LP.Infant was loaded
              > with Phenobarbitone& put on maintenance doses
              > parenterally As suspected CSF proved my diagnosis
              > of Pyogenic Meningitis, gram result was
              > inconclusive, PBS had toxic granules. Infant was
              > given Inj Ceftriaxone , Amikacin & Vancomycin added
              > from word go.Progress over next 2 days was equivocal
              > with not much change in sensorium. had some facial
              > twichings after 48 hrs of therapy .Rpt LP & CT
              > planned.
              > >
              > >worsened clinically with irregular respirations&
              > required manual positive ventilation before the
              > ultimate.
              > >
              > >Ct scan after 72 hrs of admissiont showed
              > obstructed hydrocephalus with dilated ventricles &
              > chinked 4th ventricle alongh withB/L hypodense
              > cerebellar regions, brain stem regions. Radiologist
              > also opined about periventricular hypodensities, B/l
              > subdural collections in fronto parietal regions.
              > Reported as sequalae to Hypoxic Ischemic insult
              > involving posterior circulation. Evidence of
              > meningitis was equivocal on Ct Scan.
              > >
              > >request for valuable comments on management & CT
              > findings!
              >



              ____________________________________________________________________________________
              Be a better friend, newshound, and
              know-it-all with Yahoo! Mobile. Try it now. http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ
            • r_thapar@indiatimes.com
              Madam, thanks for the response Precisely that was the reason for sharing the case details CSF was opalescent & i could take bare minimum samples becos flow
              Message 6 of 18 , Feb 2 6:39 AM
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                Madam,
                thanks for the response
                Precisely that was the reason for sharing the case details
                CSF was opalescent & i could take bare minimum samples becos flow was poor CSF cytology showed 900 WBC ( Polys predominant) with 700 RBCs, biochemistry revealed 190 mgs of Proteins with 20 mgs of sugar against BS of 88 mgs (concomitant) with increased globulins. Gram stain & Culture was noncontributory. Basal ganglia do showed some calcification confusing the picture further. I believe parents did not reveal any premorbid condition probably( they thought not significant ) for them to communicate.

                With regards
                R K Thapar
                ----- Original Message -----
                From: sheila mathai <sheilamathai@...>
                To: defencepeds@yahoogroups.com
                Sent: Thu, 31 Jan 2008 23:08:04 +0530 (IST)
                Subject: Re: [defencepeds] New Case for valuable comments

                Thapar,
                The imaging suggests some subacute/chronic ischaemic
                insult which does not fit into the picture of an acute
                meningitis. What exactly was the csf picture? Have you
                ruled out tubercular meningitis? (though I agree that
                the obstructive hydrocephalus is not suggestive).If
                basal ganglia are involved on imaging we could also
                consider Leigh's Disease.
                Regards,
                Sheila Mathai


                --- madhuri kanitkar <madhurikanitkar@...>
                wrote:

                > Thapar,
                > There seesm to be no doubt regarding meningitis with
                > the presentation and the CSF picture and therefore
                > the management appropriate. Was there any premorbid
                > problem. Because at 4 months the developmental
                > milestones may not have been observed too well
                > especially if not brought to the hospital earlier.
                > Was the baby preterm? How was the head
                > circumference? CT scan did not show any basal
                > exudates did it? 
                >
                >
                > On Tue, 29 Jan 2008 r_thapar@... wrote :
                > >Dear all
                > >i recently had a case, details of which i like to
                > share with the group for valuable comments.
                > >04 month female infant presented to my OPD with
                > mother compliaining that infant is not well for
                > last4-5 days . Infant has been having high grade
                > fever (4-5days) & irritability for last 2days &
                > not accepting feeds well for last one night. seen by
                > pvt practioner & treated with antibiotics with no
                > relief. seen in our facility by MO & advise counts
                > & antibiotic contined for 2 days. sensorium
                > commented as normal ( On my questioning later to the
                > MO)
                > >when seen in Peds OPD i found the infant febrile
                > with no interaction in the surroundings & having
                > abnormal movements of limbs. AF was level&
                > peripheral perfusion satisfactory. Suspecting CNS
                > infection i immedtlly took the infant to ward &
                > started on parenteral fluids & antibiotics preceded
                > by Dexamethasone dose& did the LP.Infant was loaded
                > with Phenobarbitone& put on maintenance doses
                > parenterally As suspected CSF proved my diagnosis
                > of Pyogenic Meningitis, gram result was
                > inconclusive, PBS had toxic granules. Infant was
                > given Inj Ceftriaxone , Amikacin & Vancomycin added
                > from word go.Progress over next 2 days was equivocal
                > with not much change in sensorium. had some facial
                > twichings after 48 hrs of therapy .Rpt LP & CT
                > planned.
                > >
                > >worsened clinically with irregular respirations&
                > required manual positive ventilation before the
                > ultimate.
                > >
                > >Ct scan after 72 hrs of admissiont showed
                > obstructed hydrocephalus with dilated ventricles &
                > chinked 4th ventricle alongh withB/L hypodense
                > cerebellar regions, brain stem regions. Radiologist
                > also opined about periventricular hypodensities, B/l
                > subdural collections in fronto parietal regions.
                > Reported as sequalae to Hypoxic Ischemic insult
                > involving posterior circulation. Evidence of
                > meningitis was equivocal on Ct Scan.
                > >
                > >request for valuable comments on management & CT
                > findings!
                >



                ____________________________________________________________________________________
                Be a better friend, newshound, and
                know-it-all with Yahoo! Mobile. Try it now. http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ
              • r_thapar@indiatimes.com
                Madam, thanks for the response Precisely that was the reason for sharing the case details CSF was opalescent & i could take bare minimum samples becos flow
                Message 7 of 18 , Feb 2 6:39 AM
                • 0 Attachment
                  Madam,
                  thanks for the response
                  Precisely that was the reason for sharing the case details
                  CSF was opalescent & i could take bare minimum samples becos flow was poor CSF cytology showed 900 WBC ( Polys predominant) with 700 RBCs, biochemistry revealed 190 mgs of Proteins with 20 mgs of sugar against BS of 88 mgs (concomitant) with increased globulins. Gram stain & Culture was noncontributory. Basal ganglia do showed some calcification confusing the picture further. I believe parents did not reveal any premorbid condition probably( they thought not significant ) for them to communicate.

                  With regards
                  R K Thapar
                  ----- Original Message -----
                  From: sheila mathai <sheilamathai@...>
                  To: defencepeds@yahoogroups.com
                  Sent: Thu, 31 Jan 2008 23:08:04 +0530 (IST)
                  Subject: Re: [defencepeds] New Case for valuable comments

                  Thapar,
                  The imaging suggests some subacute/chronic ischaemic
                  insult which does not fit into the picture of an acute
                  meningitis. What exactly was the csf picture? Have you
                  ruled out tubercular meningitis? (though I agree that
                  the obstructive hydrocephalus is not suggestive).If
                  basal ganglia are involved on imaging we could also
                  consider Leigh's Disease.
                  Regards,
                  Sheila Mathai


                  --- madhuri kanitkar <madhurikanitkar@...>
                  wrote:

                  > Thapar,
                  > There seesm to be no doubt regarding meningitis with
                  > the presentation and the CSF picture and therefore
                  > the management appropriate. Was there any premorbid
                  > problem. Because at 4 months the developmental
                  > milestones may not have been observed too well
                  > especially if not brought to the hospital earlier.
                  > Was the baby preterm? How was the head
                  > circumference? CT scan did not show any basal
                  > exudates did it? 
                  >
                  >
                  > On Tue, 29 Jan 2008 r_thapar@... wrote :
                  > >Dear all
                  > >i recently had a case, details of which i like to
                  > share with the group for valuable comments.
                  > >04 month female infant presented to my OPD with
                  > mother compliaining that infant is not well for
                  > last4-5 days . Infant has been having high grade
                  > fever (4-5days) & irritability for last 2days &
                  > not accepting feeds well for last one night. seen by
                  > pvt practioner & treated with antibiotics with no
                  > relief. seen in our facility by MO & advise counts
                  > & antibiotic contined for 2 days. sensorium
                  > commented as normal ( On my questioning later to the
                  > MO)
                  > >when seen in Peds OPD i found the infant febrile
                  > with no interaction in the surroundings & having
                  > abnormal movements of limbs. AF was level&
                  > peripheral perfusion satisfactory. Suspecting CNS
                  > infection i immedtlly took the infant to ward &
                  > started on parenteral fluids & antibiotics preceded
                  > by Dexamethasone dose& did the LP.Infant was loaded
                  > with Phenobarbitone& put on maintenance doses
                  > parenterally As suspected CSF proved my diagnosis
                  > of Pyogenic Meningitis, gram result was
                  > inconclusive, PBS had toxic granules. Infant was
                  > given Inj Ceftriaxone , Amikacin & Vancomycin added
                  > from word go.Progress over next 2 days was equivocal
                  > with not much change in sensorium. had some facial
                  > twichings after 48 hrs of therapy .Rpt LP & CT
                  > planned.
                  > >
                  > >worsened clinically with irregular respirations&
                  > required manual positive ventilation before the
                  > ultimate.
                  > >
                  > >Ct scan after 72 hrs of admissiont showed
                  > obstructed hydrocephalus with dilated ventricles &
                  > chinked 4th ventricle alongh withB/L hypodense
                  > cerebellar regions, brain stem regions. Radiologist
                  > also opined about periventricular hypodensities, B/l
                  > subdural collections in fronto parietal regions.
                  > Reported as sequalae to Hypoxic Ischemic insult
                  > involving posterior circulation. Evidence of
                  > meningitis was equivocal on Ct Scan.
                  > >
                  > >request for valuable comments on management & CT
                  > findings!
                  >



                  ____________________________________________________________________________________
                  Be a better friend, newshound, and
                  know-it-all with Yahoo! Mobile. Try it now. http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ
                • r_thapar@indiatimes.com
                  Dear Adhikari, I have not put up the case to blame the MOs.I certainly had no such intentions in my wildest dreams . infact both the MOs came to see the
                  Message 8 of 18 , Feb 2 6:58 AM
                  • 0 Attachment
                    Dear Adhikari,
                    I have not put up the case to blame the MOs.I certainly had no such intentions in my wildest dreams . infact both the MOs came to see the infant in the ward & were surprised to see the turn of changes to such a bad state.( Nice Of them )
                    young infants do behave differently & picking up subtle features do come with experience & of course with zeal for the same
                    I do agree with u 100 % percent that "intusion" do come after putting long dedicated medical practice & doing the job with u r heart ( of Course using Brain !)& getting involved fully.This has to come from "self"

                    Nice interaction
                    Thapar

                    ----- Original Message -----
                    From: adhikarikm <adhikarikm@...>
                    To: defencepeds@yahoogroups.com
                    Sent: Thu, 31 Jan 2008 21:54:27 +0530 (IST)
                    Subject: [defencepeds] Re: New Case for valuable comments

                    The case appears to be ABM, agreed. Very fact that the perfusion has
                    been normal when you saw him even after 4-5 days of illness
                    indicates that this 04 month old baby has been feeding well at least
                    for last few hours! Losing a 04 month old baby to a florid pyogenic
                    meningitis within few days is not at all unusual.The practitioner
                    and MO could have missed the subtle features initially. Bacterial
                    meningitis can have catastrophic consequences even with best of the
                    empirical therapy. It would not be prudent to squarely blame the MOs
                    in this case unless we have a definite evidence to do so. i have
                    encountered a case in Vizag where a 6 year old girl came walking to
                    OPD on my DMO duty with fever without localisation, to return back
                    after 10 hrs with signs of coning. CSF study confirmed florid
                    meningitis.This case was seen by me at MI room during DMO duty and i
                    can confirm that she had no localising features. Had this case been
                    seen by another MO few hours back, probably, even i would have
                    thought that his findings were not reliable.

                    Regarding sensitisation of MOs for picking up clues (Maj Ravi's
                    comment), that sensitisation has to bloom from within. At this
                    college we see students lamenting for having joined medicine, many
                    of them want to persue MBA after results! You can not do justice to
                    a profession unless you are loving the job you are
                    doing.The "intusion", so called "Sujnana" in our vedas would
                    automatically come after years of dedicated medical practice. No MO
                    can claim that he can pick up all the cases on day 1 at an early
                    stage of his/her career. If someone says that he/she can do it,
                    please be careful before sending any case to him/her!!

                    Have nice discussion time
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