case write up 2

8/9/2019 case write up 2

1/16

HISTORY TAKING

PATIENT DETAILS

Name : Nur Hayati Bin Mohamad Ridwan

Date of birth : 13 June 2014

Age : month!

"ender : #ema$e

Re$igion : Mu!$im

Ra%e : Ma$ay

Addre!! : &B" 333' Ja$an (g) Beti*' &e$u* "adong' 41000 *$ang' (e$angor)

+nformant : Mother ,re$iab$e-

ADMISSION DETAILS

Bed no) : 20

.ard no) : /B

Regi!tration no) : H&AR 124/

Date of admi!!ion : 13 January 201

Date of %$er*ing : 14 January 201

CHIEF COMPLAINTS

A month! o$d gir$ re!ented with feer for 3 day! and 1 ei!ode of fit! on the day of

admi!!ion at Ho!ita$ &eng*u Amuan Rahimah ,H&AR-)


2/16

HISTORY OF PRESENTING ILLNESS

A%%ording to mother' the %hi$d wa! aarent$y we$$ 3 day! rior to admi!!ion unti$ !he

dee$oed feer) atient ha! feer for 3 day! of duration' %hara%teried a! high

grade feer of !udden on!et and intermittent in nature whi%h a!!o%iated with %hi$$!'

%ough' and diarrhoea) +t wa! not a!!o%iated with omiting or ra!he!) &he

temerature do%umented at home wa! 3567) Mother brought the %hi$d to 8$ini*

8e!ihatan &e$u* "adong on the ne9t morning after the on!et of feer) &he %hi$d wa!

gien antiyreti% ,iburofen- and antibioti%) #eer !ub!ided with !weating) Howeer'

feer doe! not !ub!ide %om$ete$y and the %hi$d dee$oed feer and one ei!ode of

fit! ye!terday ,1301201- for the fir!t time and her arent! immediate$y brought her

to 8$ini* 8e!ihatan &e$u* "adong)

atient dee$oed 1 ei!ode of fit in the eening ,4)00 )m)- whi%h $a!ted for

minute!) During re;i%ta$ ha!e' the %hi$d wa! $ying on the bed) During the i%ta$

ha!e' both the uer and $ower $imb! had


3/16

&he %hi$d to$erate! $e!! ora$$y where !he doe! not een %om$ete 3 oun%e of mi$*

and u!ua$$y !he drin*! 5;10 oun%e of mi$* a day) Howeer' there wa! no !ignifi%ant

weight $o!!) (he wa! $e!! a%tie a! we$$)

&here wa! no !i%* %onta%t at home) Re%ent$y trae$$ed to Banting to re$atie@! hou!e'

there wa! a !i%* %hi$d with feer and %ough)

SYSTEMIC REVIEW

"enera$ No ra!he! or weight $o!!) Less active)

Re!iratory !y!tem No !hortne!! of breath and no noi!y breathing or raid

breathing)7ardioa!%u$ar

!y!tem

No b$ui!h di!%o$ouration on feeding and no hi!tory of murmur)

>ar' no!e throat No ear di!%harge or eara%he and no !ore throat)

"a!trointe!tina$

!y!tem

No omiting' %on!tiation or abdomina$ ain)

"enitourinary

!y!tem

Not %rying on mi%turition) Less urine ut!ut ,on$y %hange!

amer! twi%e a day-) rine %o$our wa! ye$$owi!h)

Mu!%u$ar !*e$eta$

!y!tem

No $imb !we$$ing and no fun%tiona$ abnorma$itie!)

HISTORY OF PAST ILLNESS

&hi! wa! her fir!t ho!ita$iation)

a!t medi%a$ hi!tory: No any !ignifi%ant a!t medi%a$ hi!tory)

a!t !urgi%a$ hi!tory: No hi!tory of !urgery) &rauma: No hi!tory of trauma)

Medi%ation: 7urrent$y' atient i! on !yru ara%etamo$ and antibioti% to redu%e

feer and !uo!itory re%ta$ diaeam to reent re%urrent ei!ode! of

!eiure) (he i! not on any $ong;term medi%ation!)

"IRTH HISTORY

a# Antenata$%


4/16

&hi! wa! 4thgraida and 3rdarity) Hea$th of mother during regnan%y wa! good

a! !he had !ueri!ed antenata$ %he%*;u! and antenata$ fo$$ow;u!) Anti;

tetanu! to9oid in


5/16

mother !tarted to wor*) !ua$$y 4 !%oo! with / oun%e of water for eery 2;3 hour!)

7urrent$y' 2 oun%e of mi$* of 2 !%oo! for 5 time! a day) 7om$ementary feeding

!tarted on / month! of age' orridge with ma!hed %hi%*en' %arrot and otato)

IMM)NI*ATION

+mmuniation i! u;to;date a! er !%hedu$ed in Nationa$ +mmuniation !%hedu$e for

Ma$ay!ia) Be$ow !tated a! in immuniation re%ord boo*:

i- B7": 1!t do!e gien at birth

ii- Heatiti! B: 1!t do!e at birth and 2nd do!e at fir!t month of age

iii- D&a' +C and Hib: 1!t do!e wa! gien at 2 month! o$d' 2nd do!e wa! gien

at 3 month! o$d and 3rd do!e wa! gien on month! o$d)

i- Heatiti! B: 3rd do!e gien at / month! of age)

&here are no otiona$ or additiona$ a%%ine! were gien)

DEVELOPMENTAL HISTORY

Grss +tr%

(it! with !uort) Bear! weight on $eg!)


6/16

rone ; (uort! weight on hand of %he!t' uer abdomen off %ou%h) Ro$$!

rone to !uine and ro$$! from !uine to rone)

Visin an' Fine +tr%

a$mar gra! of %ube' u$nar aroa%h) Moe! head' eye! in a$$ dire%tion!) No

!?uint)

#eed! !e$f with bi!%uit!)

&ran!fer ob


7/16

&here i! no hi!tory of hyerten!ion' diabete! me$$itu!' ma$ignan%y and other geneti%

i$$ne!! in the fami$y)

SOCIAL HISTORY

&he rimary %areta*er i! the baby!itter together with her brother) Both arent@!

edu%ation unti$ !e%ondary !%hoo$ $ee$) #ather wor*ing a! de!at%h and mother i! a

genera$ wor*er in "ardenia 7omany) +n%ome i! RM200) Hou!e ha! ade?uate

ba!i% amenitie!) No et! or %aret at home) No !mo*er in the fami$y)

PHYSICAL E/AMINATION

GENERAL INSPECTION


8/16

&he %hi$d wa! in* in the room air' a$ert and %on!%iou!) &he %hi$d wa! !$eeing in the

!uine o!ition with one i$$ow !uorted and not on re!iratory di!tre!!) &he RN

tag wa! on her $eft dor!um of hand and %annu$a on the right hand)

VITAL SIGNS

&emerature F 367 ,afebri$e-

u$!e rate F 1G beat!minute ,Mi$d ta%hy%ardia-

B$ood re!!ure F 1024mmHg ,Normoten!ie-

Re!iratory rate F 3 breath!minute ,Norma$-

E9ygen !aturation F G5

ANTHROPOMETRIC MEAS)REMENT

.eight F 5 8g , er%enti$e-

Height F 2 %m , er%enti$e-

Head %ir%umferen%e F 44 %m , er%enti$e-

GENERAL E/AMINTION

a# E/TREMITIES

&he eriherie! are warm and moi!t) 7ai$$ary fi$$ing time ,7#&- i! $e!! than 2 !e%ond!)

No deformity' oedema' %yano!i! or %$ubbing

SKIN

No ra!he!)

c# HEAD

(hae of the head i! norma$)

Anterior frontane$ i! oened)


9/16

'# EYES

No i%teru! on !%$era)

&he %on


10/16

En a9i$$ary !u!en!ion' baby bear! weight)- ower: (ub;ma9ima$ moement again!t re!i!tan%e)- 7oordination: Not done)

Ref$e9e!

- er imb!:

- ower imb!:

Meningea$ +rritation &e!t

- 8ernig@! !ign: Negatie- Brudin*i !ign: Negatie

(en!ation: Not erformed)

Impression: Physiologically normal.

CARDIOVASC)LAR SYSTEM

+n!e%tion: &he %he!t wa$$ i! !ymmetri%a$ and norma$ in !hae) &here

wa! no !%ar' no re%ordia$ bu$ging and no abnorma$ u$!ation)

a$ation: &he ae9 beat wa! $o%ated in the 4thinter%o!ta$ !a%e' at the

mid;%$ai%u$ar $ine) &here wa! no thri$$ and heae) &he erihera$

u$!e! were re!ent with norma$ rhythm and o$ume)

Au!%u$tation: &he fir!t and !e%ond heart !ound! were norma$) &here

were no murmur! heard) +n%rea!ed heart rate wa! noted)


11/16

Impression: Physiologically normal.

%- RESPIRATION SYSTEMa- +n!e%tion: &he %he!t moed !ymmetri%a$$y with re!iration with no

deformity !een) &here wa! no !ign of re!iratory di!tre!!) &here were

no !%ar' rominent di$ated)b- a$itation: &ra%hea %entra$$y $o%ated) &he %he!t e9an!ion wa! e?ua$

anterior$y and o!terior$y at a$$ three one! of the $ung!) No area of

tenderne!!)%- er%u!!ion: &he $ung wa! re!onant bi$atera$$y' anterior$y and

o!terior$y) &here were norma$ $ier and %ardia% du$$ne!!)

d- Au!%u$tation: Bi$atera$ air entry wa! noted) &here were e!i%u$ar breath

!ound anterior$y and o!terior$y at a$$ three one!) No added !ound!

heard)

Impression: Lungs clear.

'# A"DOMEN

+n!e%tion: No !urgi%a$ !%ar) No abdomina$ di!ten!ion) No


12/16

on hy!i%a$ e9amination' atient ha! no !tiffne!! of the body and no mu!%$e bu$*

on e9tremitie!) >a!y to moe


13/16

RB7

di!tribution

width

32)3 30)0;

100)0

Norma$

Hemog$obin 12)0 10);14)0 Norma$

Hemato%rit 3/)4 33)0;42)0 Norma$

Mean %e$$ Hb 2) 2)0;31)0 Norma$

Mean %e$$

o$ume

2)0 0)0;4)0 Norma$

Mean %e$$ Hb

%on%entratio

n

34)5 25)0;34)0 Norma$

$ate$et! 43 110;40 Norma$

Interpretation: Normal

E$ectr$3tes

7a$%ium 2)4 2)20;2)/ Norma$

Magne!ium 0)5/ 0);1)1 Norma$

ho!hate 1)43 0)14;1)2 Norma$

Interpretation: Normal level of ca2+,Na2+ mg2+, PO42, random glucoseindicate that there is no metaolic derangement in this patient.

c# Rena$ Pr0i$e

rea 4)5 1);/)4 Norma$

(odium 13 13;10 Norma$

ota!!ium 3) 3);)0 Norma$

7reatinine 4)0 2)0;/2)0 Norma$

7h$oride 10)0 G5)0;10)0 Norma$

Interpretation: Normal renal profile and this result e!clude any dehydration as

she had reduced in oral inta"e #fluids and solid food$.

'# Lu+&ar Puncture


14/16

umbar un%ture i! erformed to obtain %erebro!ina$ f$uid ,7(#- to ru$e out

any 7N( infe%tion) Howeer' arent! of thi! atient refu!ed $umbar un%ture

to be done to her daughter) &herefore' 7N( infe%tion wa! fai$ed to be ru$ed

out)

PLAN OF MANAGEMENT

i- #it! %hartii- (uo!itory ara%etamo$ ,M7- !tatiii- (yru ara%etamo$i- (tri%t urinary inutoutut %hart

- (too$! for in!e%tioni- Monitor ita$ !ign! for temerature !i*e!ii- (tart +C f$uid ,3%%hour- with fu$$ maintenan%e)iii- arenta$ edu%ation on #ir!t aid mea!ure! during !eiure)

DISC)SSION

De0initins%

#ebri$e fit! ,#)7)- are defined a! fit! o%%urring in a!!o%iation with feer in %hi$dren

between 3 month! and / year! of age' in whom there i! no eiden%e of intra%rania$

atho$ogy or metabo$i% derangement that %ou$d be the %au!e of the fit) #ebri$e fit!'

febri$e %onu$!ion! and febri$e %onu$!ion! are !ynonymou! term!) 7hi$dren with

reiou! afebri$e fit! are e9%$uded from thi! definition)

Ma,nitu'e 0 Pr&$e+%

&here i! no %omrehen!ie $o%a$ eidemio$ogi%a$ data) (tudie! in .e!tern >uroe

?uote a figure of 3;4 of %hi$dren


15/16

ei!ode) #ebri$e fit! that are either ro$onged ,>1 minute!- uni$atera$ or re%ur within

a !ing$e febri$e ei!ode are %$a!!ified a! %om$e9)

Issues in +ana,e+ent 0 Fe&ri$e Fits%

&he ma>"-)

, Need for rohy$a%ti% treatment)

. &ye of rohy$a%ti% treatment to be u!ed)

Current Rec++en'atin%

Ba!ed on the aboe di!%u!!ion' the fo$$owing aroa%hed i! re%ommended:

a arent! of %hi$dren with febri$e fit! !hou$d be %oun!e$$ed on the benign nature of

thi! %ondition)

b &hey !hou$d be taught effe%tie mea!ure! of temerature %ontro$ !u%h a! teid

!onging with ta water and antiyreti% admini!tration) ara%etamo$ i! !ti$$ the

!afe!t antiyreti% and %an be gien at a do!e of 1 mg*g / hour$y) A$ternate$y

N(A+D! %an a$!o be u!ed4 &he me%hani!m of a%tion of teid !onging name$y

heat $o!! from the body !urfa%e !hou$d be e9$ained to the arent!)

% &he arent! !hou$d a$!o be adi!ed on fir!t aid mea!ure! during a fit' if thi! wa!

to re%ur name$y:

i i- Do not ani%' remain! %a$m) Note time of on!et of fit)

ii- oo!en the %hi$d@! %$othing e!e%ia$$y around the ne%*

ii iii- $a%e the %hi$d in the $eft $atera$ o!ition with the head $ower than the body)

iii i- .ie any omitu! or !e%retion from the mouthi - Do not in!ert any ob


16/16

i- Do not gie any f$uid! or drug! ora$$y

i ii- (tay near the %hi$d unti$ the fit i! oer and %omfort the %hi$d a! he!he i!

re%oering)

ii iii- &he %aregier 0 c.i$'ren 5it. a .i,. ris6 0 recurrence- ie +re t.an 7

ris60actrs' !hou$d be !u$ied with a rearation of diaeam re%ta$ !o$ution at

0) mg*g of the %hi$d@! weight) &hey !hou$d be adi!ed on how to admini!ter thi!

in %a!e the fit $a!t more than minute!)

iii i9- Recta$ Dia1e!a+ s$utin is a $ist C ite+ in t.e Ministr3 0 Hea$t.8s 'ru,

$istand hen%e !hou$d be aai$ab$e in a$$ goernment hea$th fa%i$itie!)

i9 9- +n the eent that the fit i! not aborted by re%ta$ diaean they !hou$d !ee*

urgent medi%a$ he$ to !to the fit before !tatu! ei$eti%! dee$o!)

9 9i- +f the fit i! aborted' they !hou$d a$!o !ee* medi%a$ adi%e to determine the

%au!e of the feer)

%hese recommendations apply oth to children &ho have had a simple or a comple!

ferile fit.

REFERENCE

1) 7$ini%a$ e9amination by Ni%ho$a! J &a$$y and (imon E@7onnor' / th edition'

2010' ub$i!hed by >$e!ier)

2) aediatri%! and 7hi$d hea$th' 2ndedition by Mary Rudo$f and Ma$%o$m eene

ub$i!hed by B$a%*we$$ on 200/ of age! 1 to 41)

3) htt: emedi%ine)med!%ae)%omarti%$eG5/4;oeriew

4) htt:www)adhb)got)n!tar!hi%$ini%a$guide$ine!IDo%ument!7onu$!ion!

20;20#ebri$e20)df

5. &he New >ng$and ng$ J Med 1G52

30:22;25Augu!t 2/' 1G52DE+: 10)10/N>JM1G52052/300G03
http://www.adhb.govt.nz/starshipclinicalguidelines/_Documents/Convulsions%20-%20Febrile%20.pdfhttp://www.adhb.govt.nz/starshipclinicalguidelines/_Documents/Convulsions%20-%20Febrile%20.pdfhttp://www.nejm.org/toc/nejm/307/9/http://www.nejm.org/toc/nejm/307/9/http://www.adhb.govt.nz/starshipclinicalguidelines/_Documents/Convulsions%20-%20Febrile%20.pdfhttp://www.adhb.govt.nz/starshipclinicalguidelines/_Documents/Convulsions%20-%20Febrile%20.pdf