Case:Congenital Hypothyroidism

A boy of 7 months, 4.9 kg wt of nonconguinous parents presented with coarse facies,horse cry and constipation. He has also history of prolong jaundice after birth. The pateint has developmental delay- he has social smile but no neck control.

On examination, in addition to coarse facies and horse cry, the patient has lathergy, rough skin, mild anaemia, abdominal distention and least interaction.

X-ray of the lower end of the femur has shown the presence of epiphysis but the hormone assay shows TSH 100 mIU/L(N:0.7-64mIU/L) and T4 3.0 microgm/dl( N: 6.1-14.9 microgm/dl.The blood Hb 10gm/dl,TC DC ESR normal.

The patient is given thyroxine which will be gradually increased and will be continued throughout life. The patient is showing sign of improvement even after few days treatment.

Dr. Badrud Doza

Links:
Congenital hypothyroidism-e-medicine

Guest Post: Common Birth Defects and Their Causes

The birth of a baby is a joyous occasion, one that brings smiles to the faces of the parents, friends and family and cheer all around. But there are times when things go wrong and children are born with some defect or the other and the parents are devastated. The questions that are normally asked include:

• Is my baby ok?
• What’s wrong with him/her?
• Is it our fault or is it something we did that our child was born like this?
• Is there anything we can do now to make things right?
• How soon can any correctional procedure be done?
• How much will it cost?
• What are our child’s chances of coming through it successfully?
• Will our child be able to lead a normal life?
• If not, what can we do to make it as normal as possible?

Of course, the questions differ from family to family, and the decisions vary accordingly too.

The most common birth defects are those related to missing, extra or deformed limbs – some children are born with a club foot, deformed hands/legs, and missing or extra fingers. The next highest occurring defect relates to the heart with children being born with holes in their heart. Other common defects include those that affect the spinal cord, the face (cleft lip and palate), the intestines and stomach, sexual organs, and chromosomal problems like Down’s and Klinefelter’s syndromes where the presence of an extra chromosome or the absence of an essential one contribute to make the child different.

Birth defects are mainly caused by genetic factors, with known conditions causing 25 percent of all abnormalities. The parents may not have the same affliction because they may be just carriers, and depending on various factors, the symptoms manifest themselves in the newborn child.

Some defects are caused by environmental factors like drugs, exposure to radiation and chemicals, smoking (by the mother), the age of the mother, and illnesses. Sometimes, it’s a combination of the environment and genes – people with some genes, when exposed to a certain kind of environment, are likely to give birth to special needs children. The same gene, away from the environment that augments the possibility of the deformity, is passive and does not manifest in the child as an abnormality.

Pregnant women can reduce their risks of giving birth to babies with defects by getting themselves tested in each trimester and by avoiding exposure to environmental factors that are known to cause abnormalities.


• Heart abnormalities represent the next most common category of defect. Common heart defects include 'holes in the heart' where blood can pass from one side of the heart to the other. Again, these may not all be detected at birth.
• The third most common kind of defect affects the spinal cord, such as spina bifida.
• Other defects commonly observed include those affecting the face (such as cleft lip and palate), problems with the development of the intestines and stomach, and problems affecting the sexual organs.
• Major chromosomal problems such as Down's syndrome (Trisomy 21) are found in about 0.15 per cent of births (about three babies in every 2000).

By-line:

This article is contributed by Sarah Scrafford, who regularly writes on the topic of Radiology Technician Schools. She invites your questions, comments and freelancing job inquiries at her email address: sarah.scrafford25@gmail.com.

Case: A newborn with nasty hemangioma

I was called in by a Obstetrician to attend a baby immediately after birth in a clinic.
The baby was delivered at 35 weeks by caesarian section.wt was 2.3 kg.
She had a gross extensive hemangioma on the right leg extending from the foot almost completely covering upto the knee and then extending into the thigh. The overlying skin was devitilised and turns to black.The baby had tendency to bleed at points.

My pediatric surgeon collegue was also called in. A light pressure bandage was put on the hemangioma to stop the bleeding which was later released when the bleeding stopped.

The right leg was also grossly abducted, an orthopedician lebelled it as Unilateral congenitakl dislocation of Hip joint.

The baby overcame the initial difficulties and the pediattric surgeopn suggested for skin grafting for the area after child grow a little more.


Dr.Badrud Doza
Dr.Tahera

Link:
Infantile hemangioma-e-medicine

Case: A boy of 4 yrs with Langerhans Cell Histocytosis

Mushfiq, a boy of 4 yrs presented with fever for 7 days, gradual pallor for 2 months, and multiple swelling over the scalp for 1 month.

On admission, he was febrile, toxic and pale. He was undernourished, his pulse was 110/m,BP -105/65 mmHg,respiration 25/m, temp-103 degree F, anaemia +++, jaundice-absent,no bleeding tendency, no lymphadenopathy, no bony tenderness and no hepatosplenomegaly.

The swelling over the skull are multiple,firm, non tender and fixed with the underlying structure.

on investigation, Hb-4.5 gm/dl, RBC-2.06m/cmm, MCV-85.4 fl, MCH 21.8 pg, MCHC 25.6 g/dl, WBC-7500/cmm, Neutrophil-60%,Lymphocytes -32%,Monocytes-04%,Eosinophil-04%. PBF shows anisosytosis and anisocromia with roulex formation, WBC mature with a few myelocytes, platelet suggestive of chronic disorder/infection.



X-ray of the skull shows focal scalp swelling in frontal and parietal region, pepper-potlucencies in the vault and subtle erosion on the outer tables of vault underneath the swelling and sutural diastasis suggestive of Langerhans cell histocytosis with raised intracranial pressure.

FNAC from the scalp growth shows hypercellualr material containing small round to oval cells having lobulated and folded nuclear with opened up chromatin;these cells are arranged diffusely and the cells show mild cellular atypia; the backgrond shows necrotic tissue debris suggestive of 'small round cell tumour' where Langerhans cell histocytosis may be considered.

CT scan of the brain shows extensive intracranial hyperdense massesshowing distribution along dura and frontal parenchyma. No mass effect or midline shift is present; there are multiple scalp swelling , some of them show underlying outer table erosion; there is splitting of sagital and coronal suture. The impression is of Langerhans cell histocytosis.

The patient was refered to special cancer center for further management.


Dr. Badrud Doza
Dr. Harun

Link:
Langerhan's Cell Histocytosis- Boston Children Hospital
Langerhan's Cell Histocytosis-Medscape.com

Case: Ewing's Sarcoma with metastsis to the lung in a boy of 7 yrs

Child Abu Bakhr, 7 yrs male child was admitted into our hospital on 24/10/08 with the complaints of cough for 15 days , low gradw fever for the same period and respiratory distress for last 4 days and swollen edematous right leg for 3 months.

On admission, the child was dyspnic , ill-, pulse -100/m, Respiratory rate-30/m, Temparature -99 d f . on auscultation, pt had bilataeral crepitations all over the lung.

On local examination, skin was erythematous,swollen and tender without any discharging sinus or pus point- the child was a previously diagnosed case of Ewing’s Cell Carcinoma of the tibia and histopathological report was suggestive.

The Child received one cycle of chemotherapy and Radiotherpy 3 months back. On admission, CXR was done which showed wooly ball appearance.

The patient is lebelled as Ewing's Sarcoma with Metastasis to the Lung.


badrud doza
fahim

Link:
Ewing's Sarcoma- Wikipedia

Case: Tubereculoma of the brain

The patient, a boy of 3 years presened with low grade fever for 2 months , neck bending for a week and convulsion for a few times in the last 48 hours.
There was history of contact with the open case of tuberculosis.

On examination, the patient was drowsy, malnourished, neck rigidity and kernig's sign are positive, reflexes are exxagerated.

CSF studies show mild lymphocytosis, sligtly increased protein and decreased noraml sugar.Gm stain and AFB staiin were negative.







The CT scan of the patient reveals multiple small cercular shadows of the brain , the radiologist identified them as Tuberculoma.

The patient was lebelled as a case of Tuberculoma of the brain.

He was given 4 drug antitubercular regimen and gradually improved and dischsrged after 1 month staying in the hospital.

badrud doza

Link:
Tuberculoma of the brain by Bhaskara Reddy & V. Kameswararao
An interesting account on Tuberculoma of the brain by Maurry H. Cambell MD writhhen in 1945

Case: a girl of 4 months with osteogenesis imperfecta

The girl, 4 months of age admitted in our hospital for Pneumonia. But her history reveals # of the rt upper arm at the age of 7 days for which she was taken admission in the other hospital of the city. They made multiple x-rays and found # in other sites also.




She was labelled as a case of Osteogenesis imperfecta and advised the parents to take precaution to handle the baby and provide necessary counselling.



badrud doza

Link:

Osteogenesis Inperfecta Foundation

Case: Neuroblastoma with severe anaemia

Atunu Acharjee, 1 yr 4 months from Chittagong admitted in our hosspital for severe anemia. On examination , a huge mass on the left side of the abdomen, firm, non tender with no notch likely kidney and multiple small masses all over the abdomen were found . Liver was also enlarged 6 cm from the costal margin, firm and non tender.

On evaluation of history, it was found that the patient was consulted in Kolkata 2 months back and CT scan there suggest abdominal neuroblastoma, diffuse tumour infiltration of the left kidny and encasement of large vessels like aorta by the tumor mass.

Laparotomy was done in a hospital there and excised leftsided mass including part of the left kidney.The histopathology suggests Neuroblastoma. Patient was discharged on palliative treaatment from there.

In our ward, we have given the patient blood transfusion and refered the patient to oncologist.


Dr. Badrud Doza
Dr. Abu Sayeed

Link:

Neuroblastoma in Children in Cancerbackup/Uk
Neuroblastoma in NIH

Case: a boy of 11 months with scleroderma

Minhaj, aged 11 months, Male baby was lying stiff on the bed. On first look , I first mistook it as a case of cerebral palsy –spastic quadriplegia.

But his birth history is normal and the spasticity is of 7 months duration and gradually progressing. Both the extremities are markedly affected and the facial muscles are also affected and it could not cry with his full mouth open.

His skin is thick like sclerema but in almost all the body and he has no sign of infection.
.
Clinically we suspect the case as “Scleroderma’.

We arranged skin biopsy for him. The sample was taken the thigh. The report narrates increased fibrosis and moderate numbers of chronic inflammatory cells around the periappendigeal region in the dermis. The subcutaneous fat is partly replaced by collagen. The overlying epidermis shows no significant changes and concludes that the features are compatible with scleroderma.

Dr. Badrud Doza
Dr. Fahim

Link:
Screloderma Foudation

Case: Solid mass in the left Iliac fossa with acute abdomen

The patient was seen at my chamber in practice. The girl of 11 years presented with severe abdominal pain and intermittent fever of two days duration.
Menustartion yet not started.

On examination, moderate tenderness was present in the left iliac fossa but no mass could be palpated. The patient was admitted on emergency and given conservative treatment for Acute Abdomen. Later, on evaluation a solid mass of 5cmX 4 cm was found in the left Iliac fossa on ultrasonography.
The patient was improved on conservative treatment of antibiotic, fluid, antipyretic and analgesic.
The follow up X-ray also showed a solid mass pushed the uterus to upward and to the right.
Laparotomy was done. The mass was found to be of ovarian origin and brown in color.
The change of color and solidity of the mass is likely due to haemorrhage into the overy due to torsion of the ligament of the overy.

News: we organised workshops on management of severe malaria

We have organised training programs for the physicians of the malaria prone areas in our hospital from 1st June 2008 in three batches, each bach having 5 day course. About 60 doctors from mainly from government health centres and some of our hospital attended the program.

The program was sponsored by GFATM and cordinated by the Malaria Control Program of Bangladesh Health Directorate and supported by WHO.

In the program, case defination of malaria, clinical presentation, diagnosis and assessment, management, recovery and follow up of severe malaria were elaborately discussed.

In addition, picture quiz were interesting and also there was multiple case studies. In the hospital real cases were seen,examined and recoded and then presented by the participants.

There was special session for microbiology- microscopic identification of malarial parasite, Rapid diagnostic test and preparation of thickand thin film.

The whole program was in micro-teaching format and participatory in nature.

Professor Emran bin Yunus, who is working as monitor in different countries of Africa and Asia on Malaria Research Program was focal person of the programs in our hospital, a private one and Chittagong Medical College Hospital, the public hospital.

I worked as the resouce person and the co-ordinatorof the program that is organised in our hospital.

We are happy that the program ended successfully on 18th June, 2008.

Case: Near Drowning

A boy of 13 months admitted in our hospital after 4 days of drowning with unconsciousness and repeated convulsion.

He was drowned in salt water pond four days back and stayed drowned for half an hour. After recovery from the pond, he was admitted in the local health centre but with no improvement.

On admission in our hospital he was unconscious and hypotonic. his GCS score was 4/15,
Hr-136/m, BP-120/70 mmHg, He was dysnoec but there was no other chest finding.
Opthalmoscope finding was normal.

His CBC, electrolytes was found normal.X-ray chest -normal.

He was labeled as a case of Near Drowning.

His convulsion was difficult to control. After repeated trial with Inj Phenobarbitone, Phenytoin and mannitol , it was controlled after after 2 days. By the next, few days though he regained his consciousness, but he developed spasticity of the limbs, visual impairment and hearing defect.


Dr. Badrud Doza
Dr. Fahim

Link: Drowning

Case: Ectodermal dysplasia-anhydrotic type

The mother with worry in her face told me in the outdoor setting that the boy, 10 months old, has no sweating and shoots to high rise of temperature especially in hot environment.

He was normally delivered, breast fed, immunized with normal milestone development, first child of a non-consanguineous parents of a upper middle class family, had no other major illness in the past.
On examination, the child is otherwise healthy, alert, well nourished. But his hair is sparse, scant eyebrow, no eruption of tooth, dry skin, little deformed nail. IQ normal.
His systemic examination reveals normal.
Provisionally we diagnosed the patient as Ectodermal Dysplasia-anhydrotic type

His skin biopsy was done which indicates the absence of epidermis and absence of sweat glands that conforms to the diagnosis.


Badrud Doza

Selected links for ED : 1) National Foundation for Ectodermal Dysplasia

Case: Spleenectomy with postoperative convulsion and impaired consciousness in a case of Thalassemia

A boy of 11 years was suffering from Thalassemia major. He was advised for spleenectomy as the huge spleen was causing respiratory embarrassment.

He was operated without any trouble. But he developed convulsion in the mid night which was focal in the right hand. He was given anticonvulsants and Inj Calcium. His electrolytes and the calcium show normal level. His convulsion was continuing intermittently. His convulsion become generalized and he GCS falls to 8. He was given Inj phenobarbitone and Sodium Valproate orally.

Convulsions were controlled and his consciousness was gradually improving. His speech was initially slurred which was also later improved.

We had a plan for CT scan but as the patient improved completely patient took the discharge.

We level the case as Thalassemia major with post operative convulsion due to emboli.

Dr. Badrud Doza
Dr. Shoma Chowdhury
Related link:
1) Thalassemia Foundation
2)International Thalasemia Foundation

Case: Pulmonary atresia with VSD and PDA

A girl of 8 years admitted in our hospital with hyperpyrexia of 3 days duration.

She is well built, of good nutrition, no pallor, but had cyanosis and clubbing
Precordial examination reveals cardiomegaly and a murmur in the pulmonary area with both systolic and diastolic in component with radiation to the clavicle. Other systems found normal

Her X-ray shows cardiomegaly with right vetricular enlargement. ECG shows right ventricular hypertropy and Echo shows Pulmonary Atresia, VSD and PDA.

The patient traveled to India earlier and was seen by great cardiac surgeon Dr. Devi Sethi.
The fever was of viral origin. After it subsided, patient was discharged and the parents were taking preparation to have the operation done at Bangalore shortly.


Dr. Badrud Doza
Dr. Fahim

Link : Pulmonary Atresia

Case: Hematoma of the liver

Sumon, 10 yrs of age from chittagong, was admitted with the complaints of fever for 7 days and passage of blood in the vomiting and stool for 3 days. He had a h/o trauma 15 days back.

Patient was alert but irritable, no jaundice, had rapid pulse and low pressure, was moderately pale. Patient had hematomegaly(4 cm) with severe tenderness.

Initially doctors was under the impresion of hepatitis. But his clinical condition was not fully correlating with hepatic failure to explain the hematomesis and melena.

His Hb was 3.4 gm/dl, ESR 82 mm/1st hour, TC of WBC-16000/cmm, Neutrophil-76%, Lympho -10%, Platelet 400,000/cmm, pheripheral blood film shows polymorphonuclear leaucocytosis.

His serum bilirubin was 1%, SGPT-157.5 unit/L, HbsAg negative, PT -normal.

USG reveals that hematoma/Abcess in the Rt love with approx. 5 cm X 6 cm in size.

We managed the patient with 2 units of blood and antibiotics.

Dr. Badrud Doza
Dr. Saiful Islam

Link: Hematoma of the Liver

News: we observed World Malaria Day

A malaria awareness program was organised in our hospital on 27th,2008 April in observance of first World Malaria Day. Different sections of people including doctors,nurses,technicians,general staffs of the hospital, students of medical college and general public attended the program.

Prof Dr. Emran bin Yunus, a neprologist and internist and a malaria expert who is also working as monitor of malaria program in WHO international panel present the key note speech on 'World situation of malaria and Malaria Control Program in Bangladesh'. It was a nice presentation and enjoyed by all.
Dr. Abdul Mannan Bangali, National Professional Officer,Vector born control program, WHO, Dr. Musfiqur Rahman, Conultant, VBCP,WHO and Dr. Ekramul Islam, Project Manager, BRAC Operation Health, Bangladesh also spoke on the occassion. BRAC is the largest NGO in bangladesh and the world and doing good work in the health sector in rural areas.

Posters were displayed, leaflets were distributed and students of the medical college produced a Wall Paper with clips from papers and journals on the occassion.

In Bangladesh, though malaria was once 'eradicated' due to effect of DDT, it resurged back after 1971. Now 15 million people are at risk along its hilly eastern and east-northern borders. The no of cases per year is about 300,000 and deaths per year is about 2000. Malaria control program is in effect with the public and private partnership with the support of WHO and Global Fund. The target is to reduce the case and death to 50% of 2005 by the year 2012.
Bangladesh is striving hard to achieve this with success in many community programs in the bacground.


Badrud Doza
Co-ordinator, Malaria Control Program,
Chittagong Maa-Shishu O General Hospital

Related link: 1 ) Roll Back Malaria Program http://www.rollbackmalaria.org/worldmalariaday/

Case: Diaphragmatic Hernia

Baby of Fatima, 2 days old male Neonate coming from Patiya , admitted in NICU with the complaint of respiratory distress since birth. The baby delivered at home by normal vaginal delivery at the gestational age of 40 weeks.
The baby was cyanosed, dyspnoic, respiratory rate- 68/m, reflex and tone –normal, length 46cm, OFC-32 cm. Chest was bulged, mediastinum shifted to the right, breath sound absent and bowel sound present in the left. Abdomen is scaphoid in shape and no organomegaly.

CXR shows bowel loops in the left side of the chest and mediastinum shift to the right.

The Baby was diagnosed as a case of Diaphragmatic Hernia.

Thoraco-abdominal laparoscopic approach with laparotomy and laparoscopic repair of the diaphragram and ileal –peritoneal approach repair was done by our Pediatric Surgery Department.

Dr. Badrud Doza

Dr. Rasel

link:

Diaphragmatic hernia

Diaphragmatic hernia suppot group

Child care issues: problem with absolute breast feeding

Recently I am encountering many mothers who are reluctant to continue absolute breast feeding for the first six months. This is happening even after repeated counselling.
Other than conventional reasons such as ignorance, lack of proper counselling, working nature of mother, advocacy by the Formula producing companies for early weaning by 4 months, a reason mothers are citing is 'the difficulty to switching over to non breast milk items once the baby is too habituated with the breast feeding'. So they are preferring to accustom the baby to one or two feeds of artificial milk from early months.

We need to examine the problem more closely. Any comment or suggestion on the issue will be appreciated.

Badrud Doza

Link:
WHO on breast feeding
CDC on breast feeding
AAP on breast feeding

Case: A Massive Empyema Thoracis drained by VATS (Video Assisted Thoracoscpic Surgery)

The boy Abid, 1 and 1/2 years of age from Chittagong had fever and cough for 15 days, respiratory distress for 10 days which increases to severe degree for a day for which he was compelled to take admission in our hospital.

He was dyspnic, no cyanosis, no clubbing, H/R-160/m, R/R-80/m, temp-100◦ F, BP 90/60 mmHg.
His intercostal spaces were full, chest movement was restricted, expansibility was diminished on the right side, trachea and apex beat shifted to the left, vocal fremitus was decreased, percussion note dull, breath sound was absent and there was no added sound on the right side.

His CBC was normal, Blood culture shows no growth, X-ray shows – massive homogeneous opacity on the right side with shifting of the trachea and mediastinum on the left side.


Pleural fluid study shows- out of 4800 cell/cmm 400 are pus cells and 800 lymphocytes, sugar-28.1 mg/dl, protein-3.6 gm/dl, gram stain –gram +staphylococci , culture shows –staphylococcal aureus.




Video assisted thoracosurgery was done on 13/3/08 by our colleague Dr. Jafrul Hannan and intrathoracic tube was left for few days to clear out the accumulating pus.

Patient was given ceftriaxoneand and cloxaacillin and antibitotics.
The patient was improved and discharged on oral antibiotics.


Dr. Badrud Doza
Dr. Saiful
Dr.Fahim

link:
1) VATS
2) VATS

Case: Subdural Effusion with ARI

Imtiaz Mahmud, age 4 yrs from Chittagong presented with respiratory distress, cough, bulging fontanelle, fever and vomiting of 2 – 3 days duration.

His birth history is normal; he is breast fed, immunized with normal milestone and from a low socioeconomic group.He has no definite history of head injury.

On examination,his fontanelle was found wide and budged, OFC- 43cm.
Heart rate 100/m, temp-102, respiration 40/m, Lungs –creps and rhonchi, no papilloedema.

On investigation, peripheral blood picture was normal, MP negative, CSF- normal, ICT for malaria – negative, Urine R/E normal, a repeatt CSF also shows normal finding. US of the brain–shows mild hydrocephalus.

CT scan – shows subdural effusion.

The patient is labeled as Subdural Effusion with ARI.

No precipitating factor was identified

Our surgical colleague Dr. Jafrul Hannan was consulted. He preferred not to intervene.

The patient gradually improved.


Dr. Badrud Doza,
Dr. Saiful,
Dr. Fahim

Thoughts:Privatization of Medical Education

As the time passing by, no of private medical institutes (schools of colleges) are increasing in different countries. With the addition of this Medical schools/colleges ,the medical education is affected in many ways.
Let us consider Bangladesh as a test case (as I am from Bangladesh but the condition here may simulate the state in many countries)

First rivate medical college in Bangladesh started in 1988 in Dhaka by the name Bangladesh Medical College with the promulgation of an ordinance by the name ‘ Bangladesh Private Medical College ordinance’ The medical college started to develop in many parts of the country like mashrooms. There are more private medical colleges than public ones.

Bangladesh Medical and Dental Council is responsible for regulation of the quality , curriculum, manpower and structure of the medical colleges in Bangladesh. But the primary permission is to be taken from the Ministry of Health. The medical Colleges are to affiliate with the local Public Universities which are responsible to conduct the professional examinations.

As the system shown, its looks sound. But the real scenario is a little bit different.
The private medical colleges developed as a business venture to earn money not with the good intention of imparting special knowledge to the students.
The initial admission fee is also not dictated by the national authorities rather the individual colleges charge exuberant fees as admission fee and the fees are mainly taken at a time for 5 years and not on term/semester basis. So the opportunity remains open only for the affluent.

Among the private medical colleges, most are not yet recognized but they are continuing their admission and education with the hope that one day they will get recognition with retrospective effect..

The quality of the students during admission is also compromised.

Ultimately the graduates who will come out of these institutions will be undereducated and ill trained.

The respective Government should look into matter and take necessary steps to prevent the medical education to degrade further.


Badrud Doza

Thoughts: Professionalism in Medical Practice

In the complexity of increasing materialism, growth of the medical service as an industry,commercialization of medical practice,compromise in ethics and decay in moral attitude, a look into the professionalism will not be an unworthy exercise.

The highest sense of professionalism has been tried to be induced in the physician with the Hippocratic Oath which every physical have to take at the start of his career.

Professionalism means commitment to one’s profession.
It means ones’ endeavor to attain excellence in knowledge
It means attaining maturity in clinical evaluation.
It means attaining highest judgment in clinical diagnosis.
It means developing empathy for your patients
It means sharing knowledge with your colleagues.
It means convey necessary information to your patients.
It means not to be dogmatic.
It means listenening with patience to others opinion.
It means ability to understand the logic of others content.
It means considering ethics in your practice and research.
It means respect to your patient and not to abuse your patients in any form.
It means keep your morality intact and not to sexually harass your patients.
It means to serve the humanity as the prime motive of your profession.
It means earning money as a secondary consideration.
It means to avoid temptation for indirect earning that is not ethically acceptable.
It means not to be benefited from the promotion products of the pharmaceutical companies and not to be personally benefited from them in other ways.
It means not to take commission on the pathological tests.

It means many things that words can not express but conscious can tell and it means always to be true to your conscious.


Badrud Doza




.

Case: A boy of 2 months with congenital hydrocephalus, Meningomyelocele and incidental diagnosis of Pyogenic Meningitis

A boy of 2 months presented admitted to the Hospital with increasing head size and a swelling on the back at the lumber region.
The patient is normally delivered and there was no history of perinatal insult.

On examination, OFC was 43 cm, anterior fontanelle was wide open, no sun set sign, no papilloedema,

Reflexes were normal, no paraplegia, no bladders or bowel involvement. US confirms the ventricular dilatation.

The patient was operated to institute V-P Shunt. During operation, ventricular fluid was collected and studied and incidentally CSF was found to have pus cell- 7600/cmm, sugar-10.6mg/dl, Protein 430.6 mg/dl., Xray chest and Electrolytes normal.

So the patient is labeled as Congenital Hydrocephalus with Meningomyelocele with Pyogenic Meningitis.

After incidental diagnosis of Meningitis, the patient is sent our special care unit. He is now under antibiotic coverage for meningitis and is slowly improving.

We have a plan to do the CT scan to exclude any intracranial malformation.


Dr. Badrud Doza

Dr. Fahim

Psychological problem in children:a case of faecal soiling

His mother is worried –the boy of 7 years from a affluent family soiling his pants with feces 8 to 10 times a day for the last 1 month. His first symptoms developed actually 1 year back but the frequency increased in the last one month. His friends became aware of his problems because of the foul smell he emits and they started to avoid him. Mother also suspicious that similar situation is arising in the school as feacal soiling is present in her child after coming from school.

He is giving a history of constipation in his early years and avoidance of vegetable in his diet. His stool is otherwise formed

He is healthy, built and nutrition is above average. His abdomen is normal and per rectal examination anal grip is alright.

In psychological assessment, he is found under academic stress in his school and at home and get frequent punishment from parents especially mother who looks after the study of the child.

So, this is a case of Encopresis and the family needs to understand the situation, psychological support, change in attitude and behavioral adjustment.

Judging clinically: A case with prolong vomiting, bulging fontanelle and unconsciousness

The boy was laying in the bed unconscious when I first saw the patient. He is a two year old boy with history of vomiting over 2 months and impaired consciousness for 3 days.
The vomiting was mainly in the early morning.
He was seen by his local physician and more than one pediatrician over the weeks.

On admission his GCS score was 8/15, he has braycardia, mild hypertension and bulging anterior fontanelle and mild papilloeema.

His CSF study was normal. MP was negative. US of the brain shows ventricular dilatations. CT scan shows homogeneous opacity in the cerebellum extending into the 4th ventricle and obstructing the CSF pathway causing hydrocephalus and the mass is labelleled as medulloblastoma

So, the case diagnosed as a case Medulloblastom of the Brain and referred to the Neurosurgeon for further management.

There was clue for the brain tumor in this patient- the vomiting persisting over days an dmostly in the morning and afebrile state of the child go in favour of brain tumour. The child should have been evaluated earlier by the CT scan to explore the possibility of brain tumour and the condition could have been diagnosed earlier.

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Judging clinically: A case of bleeding from mouth, ecchymosis, pallor and shock

The boy was brought to the ward with profuse and fresh bleeding from the mouth for a day. His mother told that he had the same episodes of bleeding 5 to 6 times since birth but never so profuse and no history of hemarthrosis. One of his maternal uncles died from uncle bleeding at the age of 25 years.

He was deadly pale and in shock Few ecchymoses were also found on the lower limbs of the body. He had no fever, no lymphadenopathy, no hepatospelomegaly and no bony tenderness.

We thought the case as Hemophilia. The patient recovered after getting two bags of fresh blood.

Patient’s investigations revealed normal BT, CT and Platelet Count. He had leucocytosis and neutrophilia probably due to acute hemorrhage. Blood his blood film reveals Plasmodium Vivax. Our MRCP Colleague preferred to give him a course of Chloroquine at the same time.

With normal BT, CT the patient may be a case of von Willebrand Disease, Type –I, instead Hemophilia.

The patient was also given inj caprolysin locally in the oral cavity. The patient was also given Trianexamic acid orally. Cryprecipitate containing VWF is not available here as well Desmopressin.

Regarding malarial infection, malaria will not cause bleeding unless it produces DIC in extremely critical cases, that is also related with Plasmodium falciparum, not related with vivax. Could there be a concomitant infection of malaria along with bleeding diathesis? There must have been warning sign such as fever, headache, voming etc for malaria to be present as a parallel disorder in this particular patient.


Badrud Doza.

Judging clinically: A case of prolong fever, jaundice, hepatospenomegaly and ascites

Age of the child is about 2 years. I came across the patient on 9th day as the patient is a relative of one of our doctor. He is suffering from fever which is intermittent in nature, occasionally rising to 103 degree F. The patient has mild jaundice. His abdomen is distended, has mild ascites, liver is moderately enlarged and tender. The patient is anorexic and irritable.

His peripheral blood picture was normal, Mp- negative, TO titre of widal test was 1:320, Urine R/E normal, US reveals mild Asites, hepatosplenomegaly. His Hb-12.3 gm/dl, Serum bilirubin -4.5 mg/dl, ALT -936 U/L, AST 312U/L, Alk phosphatase 1028 U/L. IgG and IgM for Dengue were negative, Serum Albumin 3.3 .Prothombin time 22 secs against control of 14 seconds, His HBsAg was negative. IgG and IgM against Dengue were negative.

Because of prolong fever, endemicity of enteric fever and suggestive titre, my senior colleague who is an MRCP in Paediatrics from UK was suspecting the case as an Enteric fever and giving him Ceftriaxone.

He also covered malaria by giving Quinine as the fever is high and as malaria is also prevalent in this area though his Blood for MP and ICT for plasmodium was negative. In Bangladesh one cannot rely hundred percent on the laboratory finding.

He also excluded the possibility of dengue by doing the serological test for dengue as Dengue may present with fever, ascites and jaundice.

We level the case as Acute Viral hepatitis. In Enteric fever, the lever may be involved but more in the second week and it will take time for the liver to be grossly enlarged by 9 days. It is not malaria as jaundice in malaria is rare and occurs only in sever cases and hemolytic and prehepatic in nature. Hepatic enzymes will not be increased in malaria. Liver may be enlarged in malaria due proliferation of reticulo-endothelial cells with malarial parasites entrapped inside and the spleen will be more enlarged. Present Epidimiological reports goes against Dengue at present.

We stopped quinine and other hepatotoxic drugs and patiet was given lactoluse, Inj Konakion, avoid paracetmol and sedatives. Now the patient is gradually recovering.

Badrud Doza