Patient Details
Name :
A
Age :
13 months
Gender :
Male
Race :
Malay
Religion :
Muslim
Address :
Bandar Saujana Putra, Selangor
Informant :
Zamri (father)
Bed no :
7B (Ward KK2)
Date of Admission : 12 June 2018
Date of Clerking : 13 June 2018
Chief Complaint
Patient come to the hospital due to fever for 2 weeks.
History of Presenting
Illness
Patient was not known of any case. This is his first admission
due to fever.
Patient was previously well, until 2 weeks ago, patient
developed rise in body temperature. It was sudden and does not resolve with
medication. The mother had measured the temperature, it was 38.8°C. The fever was low grade, intermittent and persist for 2 weeks
and the temperature always rise at night and has night peak.
The
fever was associated with rash. The mother noticed rash initially at baby’s
chest then radiate to all parts of body. The rash was small, scattered and not
raise with red in color at all parts of body especially at his trunks, arm
extensors and legs. The rashes were red in color with no discharge.
After
2nd day of illness, they brought the baby to private clinic, then he
was prescribed syrup paracetamol. The doctor diagnosed him as chickenpox. Then,
he was prescribed with calamine lotion. The rash resolve after 5 days but not
the fever.
After
the rash resolve, the baby started to develop cough and runny nose. The cough
was intermittent, productive with yellow-greenish sputum and no blood. The
sputum was about 1 spoon. He coughed for about 5 times per day. After 1 week of
illness, he was brought to clinic and was prescribed with syrup paracetamol.
For
about 2 weeks of illness which is 1 day prior to admission, the baby has
bilateral eye discharge and high grade fever also poor feeding. Then, he was
brought to HKL.
During
admission, urine culture and sensitivity was done. The result was, his urine
contained Proteus spp. Antibiotic was given during admission.
System Review
No
vomiting
No
tachycardia/tachypnea
No
redness of mucosa
No
abnormal movement
Normal
bowel movement, no loose stool or straining.
Normal
urine output
Appetite
was reduced, he refused any meal intake
No
weight loss
Sleep
was not disturbed
Past Medical History
Nil
Birth history
For
perinatal history, during pregnancy of the mother, or prenatal, the mother had gestational
diabetes mellitus. For antenatal, he was delivered mature , normal without any
complication or problem. The weight was 3 kilogram. For postnatal, patient had
attack of jaundice 3 days after delivery for 1week. No admission due to
jaundice.
Past Admission History and Surgical
History
No
admission before. No significant surgical history.
Immunization History
He
did not complete the vaccine upto 1 year because he was having fever.
Feeding History
The
child was purely breastfeeding until age of 6months. Then, he started to have
mix meals which are breastfeed and solid food. Formula milk was given. After
delivery, the child was breastfed immediately within 2hours. The bottle hygiene
is good. The mother sterilized the bottle after usage.
Developmental History
Gross motor
: walking without support at 1year and practicing to run.
Fine motor : able
to scribble, mature pincing
Social :
no strangers anxiety
Speech :
understands many phrases, able to call the father and mother
Drugs and Allergy History
Syrup
paracetamol. No cough syrup was given during illness. No food allergy.
Family history
Patient
is 5th among 5 siblings. His 4th sibling which is sister is 3 years
old, known asthmatic. No history of asthma during childhood. No eczema runs in
the family.
Social History
The
child is living with his family in a flat house Bandar Saujana Putra, Selangor.
The mother is a housewife, and take care of the child herself. The father is a
technician, a smoker, but smokes outside the house. Patient is a non-passive
smoker. No travel history was noted. The area was known as hotspot area of
dengue. The drainage is good. And water supply is clean. They did not use
filter but they boil water for drinking. No contact with person with same
illness. But before the illness, they did take meal from outside.
Summary
A 13 months old
child presented with fever for 2 weeks. He had fever, cough and runny nose 2
weeks prior to admission. Fever was sudden and low grade. It was not resolve by
medication. The runny nose was sudden and continuous. It becomes increase of
flow and mucous turns from clear to greenish. The cough was sudden and
productive cough. It was on and off, and wet cough. He had chickenpox 1 week
prior to admission. The patient was brought to HKL for treatment and admitted
in KK2.
PHYSICAL EXAMINATION
General Examination
On inspection,
the patient was alert, conscious, communicative and active. Patient appeared
well nourished and well hydrated. The child appeared pink. There was a sign of
breathlessness and he was tachypneic. There was no accessory muscles were used
during respiration.
Vital signs-
Blood pressure : 98/54 mmHg (normal
90-105/55-70)
Pulse rate : 100bpm (normal 80-140),
good volume and
regular
rhythm
Respiratory rate : 35/min (normal 25-30)
Temperature : 38.2
C
Face-
Patient’s
conjunctiva were pink on both sides, and
there were no sign of jaundice at the sclera of both eyes. There was no nasal
flaring but positive nasal discharge. There was no central cyanosis at the
tongue, no ulcers and the lips were moist. There were rashes scar on the face.
The face shows no toxic-ill look.
Neck-
There
were no sign of enlarged lymph nodes and no raised jugular venous pressure.
Trachea cannot be assessed because patient was not cooperative.
Hands-
There
were no signs of pallor at the palmar crease, no peripheral cyanosis, no nail
clubbing and no palmar erythema. The capillary filling was normal (less than 2
seconds). There was no scars on the hand.
Legs-
No
pitting edema was seen in both legs. The pulses of the dorsalis pedis artery
were felt in both legs. There were scar rashes.
Weight : 8.5kg (below 5th
percentile)
Height : 85cm (below 5th
percentile)
Head circumference : 47.5cm (at 25th
percentile)
SYSTEMIC EXAMINATION
Respiratory system-
On
inspection, there were no scars, no deformities and no masses can be seen on
the anterior and posterior chest. There were no hyperpigmentation, no rashes
seen. The chest was symmetrical. The subcostal recession and Harrison sulci
were seen. Percussion of the chest was not done since the child is still under
5 years old. Upon auscultation, normal vesicular breath sounds were heard.
There was generalized rhonchi heard in both lungs during expiration with
prolonged expiratory phase with bilateral crepitation.
Cardiovascular system-
On
inspection of the chest, there were no surgical scars or any deformities. No
dilated veins and no visible pulsations were seen. Upon auscultation, both
first and second heart sounds were heard. No abnormal murmur sound was heard.
Gastrointestinal system-
On
inspection, the abdomen was symmetrical and there was no distention. The
umbilicus was inverted and centrally located. No smiling umbilicus (denoting
ascites) was seen. There was no dilated veins and no caput medusa. No visible
peristalsis or pulsations were seen. There were no scars, no hyperpigmentation
and no spider nevi seen. Upon palpation, there was no tenderness. On
percussion, there were no shifting dullness and no fluid thrills.
PROVISIONAL DIAGNOSIS
Urinary
tract infection
DIFFERENTIAL DIAGNOSIS
Atypical Kawasaki disease
The
patient has fever more than 5 days together with rashes but no redness of
mucosa layer.
Dengue Fever
The
patient has prolonged fever with rash but no hepatomegaly.
INVESTIGATIONS
Based
on the history and physical examination, a provisional diagnosis was made. In
order to confirm the diagnosis, a few laboratory investigations were requested.
A full blood count to look for infection (raised white blood cell) and urine
culture & sensitivity was ordered.
Full blood count-
|
Test
|
Patient’s value
|
Normal range
|
Interpretation
|
|
White blood
cell (x10^9/L)
|
11.0
|
4.0-9.0
|
High
|
|
Red blood cell
(x10^12/L)
|
5.31
|
3.8-6.0
|
Normal
|
|
Haemoglobin
(g/dL)
|
11.6
|
10.5-14.0
|
Normal
|
|
Haematocrit
)%)
|
37.5
|
29-59
|
Normal
|
Urine culture & sensitivity
Proteus
spp was detected in the urine.
MANAGEMENT
1. Antibiotic therapy
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