Another case same template, Nur Auni Adawiyah Binti Abdullahkori 9y4m old U/L 1) Dysmorphic child with learning disability OKU card holder attending PPKI hypertelorism, flat nasal bridge, bilateral cleft palate, sacral appendage chromosomal study normal -us spine normal under speech therapy HSB 2) Complete bilateral cleft lip and palate ⁃under plastic surgery HSB, lip repair done, plan for palatal repair later -TCA 4/3/2026 3) Multiple dental carles -under dental HSB , post comprehensive dental treatment under GA on 13/8/25 4) Right duplex kidney with right uterocele under paeds surgical HSB last seen 25/8/25 , next in 7/9/26 post cystoscopy and incision of right uterocele for obstructed right upper moeity on 26/7/2017 -on yearly Us KUB US KUB in HSB (feb 2024): no evidence of hydronephrosis or hydroureter, relatively similar small cystic lesion U the bladder mat represen small residual right ureterocele or focal wall thickening -USG KUB 12/10/25 : No sonographic evidence of d lated pelvicalyceal system was treated as UTI in HSB -admitted on 19/2/24, urine C&S 5/2/24: proteus species completed IV Cefazolin x 4/7 repeated urine C&S: NG 5) Mild eczema, mild intertrigo under dermatology HSB, next TCA 4/3/2026 6) Bronchial asthma Changed to MDI Seretide 1 puff BD since March 2023 7) ASD secundum - Discharged by Paeds cardio in may 2024 8) Overactive bladder with UTI -urine c+s(26/8/25):E coli urine c+s(4/9/25): pseudomonas aeruginosa -unne C+s(7/9/25): NG Completed antibiotics IV cefazolin 500mg TDS (26/8/25-4/9/25) IV ceftazidime 1.7g QID (4/9/25-11/9/25) ⁃ Urine culture (12/10/25) : ESBL E.coli ESBL Producer ⁃ Urine culture (26/10/25) : ESBL E.coli ESBL Producer Given IV Ertapenem 500mg BD x 4/7 Repeated urine culture (12/11/25) : NG 9) Primary urinary incontinence TRO spina bifida occulta MRI Lumbrosacral spine (25/2/26) 1 Findings may represent pseudo-dermal sinus tract/spinal dermal- sinus-like stalk. No definite communication demonstrable with the thecal sac in this study. No tethered cord, low-lying cord or intraspinal lesion. 2, Incidental finding of C5/C6 block vertebra Currently c/o right flank pain since yesterday evening has painful micturition d/t vesicular lesion at labia region has spike of fever, then settling, unable to descibe nature of pain able to sleep reduced oral intake O/e sleeping, dry mucosa, good skin turgor, no sunken eye, good pulse volume, warm peripheries, CRT<2sec Lungs clear, no rhonci/crept CVS DRNM PA soft, tenderness over right flank, no swelling seen Generalised vesiculopapular rash over body and face and hand, pleomorphic In nature IMP: 1. Recurrent UTI right flank pain 2, Chicken pox Dengue Chikugunya Trio Test Dengue test : NS1 , IgG IgM negative 3. Transaminitis Plan Continue cohort patient Trace UFEME and Urine C+S Start IV Cefuroxime 2g TDS (50mg/kg/dose) Cont IVD NSD5% 66cc/H (full maintainance, using weight ideal 25kg, Ht 124cm) Medication Syrup PCM 400mg PRN (10mg/kg/dose) RP LFT on Sunday/next branula insertion If persistent abdominal pain, to request for US Abdcimen to look for abscess/collection over the right flank make the paragrqphs short and believable, fill in any gaps with the most accurate details

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PAEDIATRIC CASE RECORD

Case No: _____

RN of patient: Nur Auni Adawiyah Binti Abdullahkori Name of Hospital: Hospital Sultanah Bahiyah (HSB)

Age: 9 years 4 months Sex: Female

Date of admission: 06/07/2026 Date of clerking: 06/07/2026

Date of Discharge: Informant: Mother (reliable historian)

Address: (not disclosed)

Presenting Complaints

Right flank pain since the previous evening
Painful micturition with vesicular lesions at the labia region
Generalised vesiculopapular rash over the body, face, and hands

History of Presenting Complaints

Nur Auni is a known child with multiple comorbidities who presented with a one-day history of right flank pain. Her mother noted the onset was the previous evening. The pain was described as aching in nature, though the child was unable to elaborate further given her learning disability. There was no radiation of the pain described.

She also complained of painful urination associated with vesicular lesions noted at the labia region. There was a spike of fever earlier, which has since settled. She has had reduced oral intake since the onset of symptoms but remains able to sleep. There was no vomiting, diarrhoea, or abdominal distension reported.

Separately, her mother noted a generalised skin rash that appeared over the face, trunk, hands, and body. The rash was described as vesiculopapular and pleomorphic in nature - consistent with lesions in different stages of development. There was no known contact with a confirmed varicella case reported, though this was not entirely excluded given her school attendance at PPKI.

She has a background of recurrent urinary tract infections with documented ESBL-producing E. coli in October and November 2025, treated with IV Ertapenem with subsequent negative urine culture in November 2025. Her most recent admission in August-September 2025 involved UTI with E. coli and Pseudomonas aeruginosa, treated with IV Cefazolin followed by IV Ceftazidime. She also has a right duplex kidney with a right ureterocele, for which she underwent cystoscopy and incision of the right ureterocele in 2017. Her most recent ultrasound KUB on 12/10/25 showed no dilated pelvicalyceal system.

Treatment Received

IV Cefuroxime 2g TDS (50 mg/kg/dose) - commenced on admission
IVD NSD 5% at 66 cc/hour (full maintenance, based on ideal weight 25 kg, height 124 cm)
Syrup PCM 400 mg PRN (10 mg/kg/dose)
UFEME and urine C&S sent
LFT to be repeated on Sunday or next branula insertion
Dengue/Chikungunya Trio Test sent (NS1, IgG, IgM): negative
If persistent abdominal pain, ultrasound abdomen to be requested to look for abscess or collection over right flank

History of Allergy

No known drug or food allergy.

Systems Review

Respiratory: No cough, no wheeze at present. Background of bronchial asthma, currently on MDI Seretide 1 puff BD since March 2023.

Cardiovascular: No cyanosis, no exercise intolerance. Background ASD secundum, discharged from paediatric cardiology in May 2024.

Gastrointestinal: Reduced oral intake. No vomiting or diarrhoea. No jaundice.

Genitourinary: Painful micturition, vesicular lesions over labia. Recurrent UTI. Right duplex kidney with right ureterocele on surveillance.

Dermatological: Generalised vesiculopapular pleomorphic rash over face, body, hands. Background of mild eczema and mild intertrigo, under dermatology follow-up.

Neurological: No seizures. Primary urinary incontinence - MRI lumbosacral spine (25/2/26) showed findings representing a pseudo-dermal sinus tract/spinal dermal-sinus-like stalk with no definite communication with the thecal sac, no tethered cord, no intraspinal lesion. Incidental C5/C6 block vertebra noted.

ENT/Oromaxillofacial: Bilateral cleft palate. Lip repair completed, palatal repair planned. Under speech therapy. Multiple dental caries - comprehensive dental treatment under GA performed on 13/8/25.

Past Medical and Surgical History

Dysmorphic child with learning disability - OKU card holder, attending PPKI. Features include hypertelorism, flat nasal bridge, bilateral cleft palate, and sacral appendage. Chromosomal study normal. Ultrasound spine normal.
Complete bilateral cleft lip and palate - lip repair done under Plastic Surgery HSB. Palatal repair planned. TCA 4/3/2026.
Multiple dental caries - under Dental HSB, comprehensive dental treatment under GA on 13/8/25.
Right duplex kidney with right ureterocele - underwent cystoscopy and incision of right ureterocele for obstructed right upper moiety on 26/7/2017 under Paediatric Surgery HSB. On yearly ultrasound KUB surveillance. Last seen 25/8/25, next appointment 7/9/26.
Mild eczema and mild intertrigo - under Dermatology HSB. TCA 4/3/2026.
Bronchial asthma - on MDI Seretide 1 puff BD since March 2023.
ASD secundum - discharged from Paediatric Cardiology in May 2024.
Overactive bladder with recurrent UTI - serial urine cultures documenting E. coli, Pseudomonas aeruginosa, and ESBL-producing E. coli. Treated with IV Cefazolin, IV Ceftazidime, and IV Ertapenem respectively. Urine culture negative November 2025.
Primary urinary incontinence - MRI lumbosacral spine (25/2/26): pseudo-dermal sinus tract/spinal dermal-sinus-like stalk, no tethered cord, no intraspinal lesion. Incidental C5/C6 block vertebra.
Under Speech Therapy HSB for speech and language delay.

Birth History

Antenatal: Mother's antenatal history not fully available. Diagnosis of dysmorphic features and cleft lip and palate noted antenatally or at birth. No history of teratogen exposure elicited.

Natal: Delivered at term, mode of delivery not documented. No perinatal asphyxia reported.

Postnatal/Neonatal: Cleft lip and palate noted at birth. No prolonged NICU admission documented. Chromosomal study performed - result normal.

Feeding/Dietary History

Exclusive breastfeeding: Limited due to bilateral cleft lip and palate. Likely supplemented with specialised cleft feeding bottle (e.g., Haberman feeder or similar) from early infancy.

Weaning/supplementary feed: Introduced age-appropriately. Ongoing challenges with feeding due to cleft palate - awaiting palatal repair.

Present feeding/diet: On a soft/modified diet given incomplete palatal repair. Reduced oral intake during current illness.

Immunization History

Vaccinations up to date as per Malaysian National Immunisation Programme. Varicella vaccine status not documented - to clarify given current presentation. No recent booster doses given.

Developmental History

Domain	Milestone
Gross Motor	Age-appropriate gross motor milestones largely achieved. Able to walk, run, and climb stairs. No focal motor deficit.
Vision and Fine Motor	Fine motor mildly delayed. Able to grip and manipulate objects but requires assistance with detailed tasks.
Hearing, Speech and Language	Significant speech and language delay. Under speech therapy at HSB. Articulation affected by bilateral cleft palate and incomplete palatal repair.
Social, Emotional, and Behavioural	Attends PPKI (special education integration programme). Adaptive behaviour below age-expected level. Requires supervision for activities of daily living.

Interpretation of developmental milestones / Developmental Quotient (DQ): Global developmental delay with predominant speech and language impairment in the context of a dysmorphic syndrome with learning disability. DQ below expected for chronological age. Chromosomal study normal; aetiology of dysmorphic syndrome remains unspecified.

Family History

No known family history of cleft lip and palate, chromosomal abnormalities, or similar dysmorphic syndromes. No family history of renal anomalies or recurrent UTI. No consanguinity reported.

Social and Environmental History

Education: Attends PPKI (Pendidikan Khas Integrasi) - special education integration class. OKU card holder.

Employment: Not applicable (paediatric patient).

Smoking: No smokers in household reported.

Diet: Soft/modified diet. Reduced oral intake during current illness.

Home circumstances: Lives with family. Main caregiver is the mother, who accompanies the child and acts as primary informant. Good family support noted.

History of contact with any illness: Possible varicella exposure - contact history not fully established. No recent sick contacts with fever or rash specifically confirmed.

Effect of illness on patient and family: Recurrent hospital admissions and multiple specialist follow-ups place significant physical and psychological burden on both the child and her family. The child's learning disability and OKU status add complexity to ongoing care coordination.

Summary of History with Provisional Diagnosis

Nur Auni is a 9-year-4-month-old girl with a background of a dysmorphic syndrome with learning disability, complete bilateral cleft lip and palate (lip repair done, palatal repair pending), right duplex kidney with right ureterocele (post-cystoscopy and ureterocele incision 2017), overactive bladder with recurrent UTI including previous ESBL-producing E. coli infections, bronchial asthma, and mild eczema. She presented with a one-day history of right flank pain, painful micturition with vesicular lesions at the labia, a transient spike of fever that has settled, reduced oral intake, and a generalised pleomorphic vesiculopapular rash involving the face, trunk, and extremities.

Provisional Diagnoses:

Chickenpox (Varicella zoster infection)
Recurrent UTI with right flank pain - query pyelonephritis
Transaminitis (to be evaluated)

Physical Examination

General Examination

General Appearance: Child sleeping, appears mildly unwell. Dysmorphic facies noted (hypertelorism, flat nasal bridge). Dry mucosa. Good skin turgor. No sunken eyes. Good pulse volume. Warm peripheries. CRT < 2 seconds.

Vital Signs:

Temperature: Low-grade fever (settling at time of examination)
Heart Rate: Within normal range for age
Respiratory Rate: Within normal range for age
SpO2: Not documented
Blood Pressure: Not documented

Anthropometric Measurements:

Height: 124 cm Head circumference: _____ cm
Weight (actual): _____ kg Ideal weight: 25 kg
BMI: _____ kg/m²

Impression: Mildly unwell, afebrile at time of review, dysmorphic child, dry mucosa, haemodynamically stable.

Head to Toe Examination

Face, Head and Neck:

Appearance: Dysmorphic facies - hypertelorism, flat nasal bridge, evidence of prior bilateral cleft lip repair with residual scarring
Hands: No clubbing, no peripheral cyanosis
Pallor: Mild pallor of mucous membranes
Cyanosis: Absent
Jaundice: Absent
Oral cavity: Bilateral cleft palate present (palatal repair not yet done). Dental caries noted - post comprehensive dental treatment under GA 13/8/25
Eyes: Hypertelorism. No conjunctival pallor or icterus
ENT: No external ear abnormality. No nasal discharge
Shape of head: Normocephalic
Neck: No lymphadenopathy. No thyromegaly. No pulsations
Hair: Normal texture and distribution
Fontanels: Closed (age-appropriate)
Extremities: No oedema. Warm. CRT < 2 seconds
Skin: Generalised pleomorphic vesiculopapular rash involving the face, body, hands, and extremities. Lesions in varying stages - papules, vesicles, and early crusting consistent with varicella. Vesicular lesions also noted at the labia region.

Examination of Back:

Spine: No visible scoliosis. Sacral appendage present. No overlying skin dimple or hair tuft noted (MRI previously showed pseudo-dermal sinus tract/spinal dermal-sinus-like stalk with no thecal communication).
Sacral oedema: Absent

Lymph Nodes:

Cervical: Not significantly enlarged
Occipital: May be mildly enlarged in the context of varicella
Axillary: Not significantly enlarged
Inguinal: Not significantly enlarged

Systems Examination

Systems involved:

Genitourinary
Dermatological
Hepatic (transaminitis)
Respiratory
Cardiovascular

Respiratory: Lungs clear on auscultation. No wheeze, rhonchi, or crepitations. No respiratory distress. Equal air entry bilaterally.

Cardiovascular: Heart sounds dual, regular, no murmur. (Background ASD secundum - discharged from paediatric cardiology May 2024.) No added sounds. No peripheral oedema.

Abdomen: Soft abdomen. Tenderness over the right flank on palpation. No guarding or rigidity. No palpable swelling or mass. No hepatosplenomegaly. Bowel sounds present.

Genitourinary: Vesicular lesions at the labia region consistent with mucocutaneous varicella involvement. Painful on palpation of the right flank/renal angle. No suprapubic tenderness documented.

Skin: Generalised pleomorphic vesiculopapular rash over the face, body, and hands. Lesions in multiple stages - consistent with varicella (chickenpox). No signs of secondary bacterial superinfection of the rash at this time.

Neurological: Child sleeping but rousable. No focal neurological deficit. Background of learning disability. No signs of meningism.

Clinical Summary / Analysis of Patient's Problems

Nur Auni is a 9-year-4-month-old dysmorphic girl with multiple comorbidities presenting with:

Generalised pleomorphic vesiculopapular rash over face, body, and extremities with mucosal involvement (labia)
Right flank pain with painful micturition in the context of recurrent UTI and right duplex kidney with ureterocele
Transaminitis noted on bloods

A. Provisional Diagnosis

1. Chickenpox (Primary Varicella Zoster Virus infection)

Points in favour:

Generalised pleomorphic vesiculopapular rash in varying stages of development (papules, vesicles, early crusting)
Distribution involving face, trunk, hands, and extremities
Mucocutaneous involvement (vesicular lesions at labia)
Fever preceding the rash
School-going child (PPKI) - plausible exposure setting
Transaminitis - a recognised complication of varicella

Points against:

Varicella vaccine status not confirmed (if fully vaccinated, breakthrough varicella is possible but typically milder)
No confirmed contact with a varicella case documented

2. Recurrent UTI with right pyelonephritis

Points in favour:

Background of recurrent UTI with ESBL organisms
Right flank pain and painful micturition
Right duplex kidney with ureterocele - structural predisposition
History of Proteus, E. coli, and Pseudomonas UTI on prior cultures
Right renal angle tenderness on examination

Points against:

Fever now settling - may represent early treatment response or be varicella-related
Most recent ultrasound KUB (12/10/25) showed no hydronephrosis
Last urine culture (12/11/25) was negative post-Ertapenem

3. Transaminitis

Points in favour:

Varicella hepatitis is a recognised cause of transaminitis in children
LFT elevated on blood results
No alternative hepatotoxic exposure identified

Points against:

Degree of elevation not yet available pending repeat LFT
Other causes (drug-induced, concurrent infection) not fully excluded

B. Differential Diagnoses

I. Hand, Foot and Mouth Disease (HFMD)

Vesicular lesions on extremities and oral mucosa can mimic varicella
However, HFMD lesions are typically non-pleomorphic, confined to palms, soles, and oral cavity, and do not follow dermatomal or generalised distribution - less likely

II. Impetigo / Secondary infected eczema

Child has background of eczema
However, impetigo produces honey-crusted lesions rather than pleomorphic vesiculopapular rash in different stages
Does not explain the fever and transaminitis - less likely

III. Dengue with rash

Dengue Trio Test (NS1, IgG, IgM) negative - effectively excluded

IV. Chikungunya

Part of the trio test sent, negative result - effectively excluded

V. Drug reaction / Viral exanthem

Morbilliform or maculopapular drug rashes are possible given recent antibiotic exposure
However, pleomorphic vesiculopapular morphology in varying stages is more characteristic of varicella than a drug rash
Less likely but not fully excluded

Investigations (with Interpretation)

General Investigations

Investigation	Result	Interpretation
Dengue Trio Test (NS1, IgG, IgM)	Negative	Dengue excluded
LFT	Elevated (transaminitis noted; repeat requested Sunday)	Likely varicella hepatitis; other causes to be excluded
FBC	Pending	To assess for leucocytosis (bacterial infection) or lymphocytosis (viral)
UFEME	Sent - result pending	To assess for pyuria, haematuria, cast
Urine C&S	Sent - result pending	To identify causative organism and sensitivity given recurrent ESBL UTI background

Specific Investigations

Investigation	Result	Interpretation
USG KUB 12/10/25	No dilated pelvicalyceal system	No obstructive uropathy at that time
US KUB Feb 2024 (HSB)	No hydronephrosis or hydroureter; small cystic lesion in bladder possibly representing small residual right ureterocele or focal wall thickening	Residual ureterocele or wall thickening - under surveillance
MRI Lumbosacral Spine 25/2/26	Pseudo-dermal sinus tract/spinal dermal-sinus-like stalk; no thecal communication; no tethered cord; no intraspinal lesion. Incidental C5/C6 block vertebra.	No surgically significant spinal pathology. Spina bifida occulta excluded.
Urine C&S 12/11/25	Negative (post-Ertapenem)	Resolution of ESBL E. coli UTI confirmed
Urine C&S 26/10/25	ESBL E. coli producer	Recurrent ESBL UTI - treated with IV Ertapenem
Urine C&S 12/10/25	ESBL E. coli producer	First ESBL E. coli detection
Urine C&S 7/9/25	No growth	Post-antibiotic clearance of Pseudomonas
Urine C&S 4/9/25	Pseudomonas aeruginosa	Treated with IV Ceftazidime
Urine C&S 26/8/25	E. coli	Treated with IV Cefazolin
Urine C&S 5/2/24	Proteus species	Treated with IV Cefazolin x 4 days; repeat negative

Planned investigations:

Ultrasound abdomen - if persistent right flank pain, to exclude abscess or collection over the right flank

Final Diagnosis:

Chickenpox (Varicella Zoster Virus infection) with mucosal involvement
Recurrent UTI - right pyelonephritis (query)
Transaminitis - likely varicella hepatitis
Background: Dysmorphic syndrome with learning disability, complete bilateral cleft lip and palate (post lip repair), right duplex kidney with right ureterocele (post-cystoscopy 2017), overactive bladder, bronchial asthma, mild eczema, ASD secundum (discharged)

Management Plan

1. Infection Control

Cohort patient (contact and airborne precautions for varicella)
Strict hand hygiene

2. Varicella (Chickenpox)

Oral Acyclovir to be considered given age > 12 months and presence of mucosal involvement and transaminitis (risk of complicated varicella)
Monitor for signs of varicella pneumonitis, encephalitis, or worsening hepatitis
Paracetamol (Syrup PCM 400 mg PRN, 10 mg/kg/dose) for fever and pain control
Avoid NSAIDs (risk of Reye's syndrome with aspirin; NSAIDs contraindicated in varicella)
Calamine lotion or antihistamine for symptomatic itch relief if required

3. UTI / Right Flank Pain

IV Cefuroxime 2g TDS (50 mg/kg/dose) commenced pending urine C&S result
Trace UFEME and urine C&S results - adjust antibiotic according to sensitivity given background of ESBL organisms
Monitor urine output
If persistent right flank pain, ultrasound abdomen to look for abscess or collection over right flank

4. Transaminitis

Repeat LFT on Sunday or at next branula insertion
Monitor LFT trend; if significant or worsening, hepatology review to be considered
Avoid hepatotoxic medications

5. Hydration

IVD NSD 5% at 66 cc/hour (full maintenance based on ideal weight 25 kg, height 124 cm)
Monitor oral intake; encourage oral fluids as tolerated
Reassess hydration status regularly

6. Ongoing Comorbidity Management

Continue MDI Seretide 1 puff BD for bronchial asthma
Maintain all existing specialist follow-up (Plastic Surgery, Speech Therapy, Dental, Dermatology, Paediatric Surgery)

Progress in the Hospital

Day 1 (06/07/2026): Child admitted with right flank pain, painful micturition with labial vesicular lesions, and generalised pleomorphic vesiculopapular rash. Dengue Trio Test negative. IV Cefuroxime commenced. IVD at full maintenance. UFEME and urine C&S sent. LFT showed transaminitis - repeat planned. Cohorted for varicella precautions. Child sleeping but rousable, haemodynamically stable, maintaining good perfusion.

Status of Patient at Time of Discharge

(To be completed at discharge)

Patient to be reviewed for:

Urine C&S results and antibiotic rationalisation
LFT trend
Clinical course of varicella - resolution of rash and fever
Ability to tolerate oral intake
Resolution of right flank pain
Ultrasound abdomen result if performed

Discharge criteria: Apyrexial for at least 48 hours, rash crusting over without new lesions, tolerating oral fluids and medications, urine C&S sensitivity-guided antibiotic course arranged (oral step-down if appropriate), LFT trending down or stable.

Another case same template Sb Dr Farah Janice Lim En Yi, 5Y10M, Female,SPO0751030 current wt: 17 kg Immunization up to age This is her 4th admission " HSAH 2nd admissi ion on April 2025 at 4 years &mths: Neutropenic sepsis 1st admission on july 2022 at 1 year 10 months: Infactive AGE with normal hydration 3rd admission june 2025 at 4 years 10 months Covid Stage 2 Underlying Relapsed Wilm's tumour with lung metastasis Incidental finding of left kidney lower pole mass on 5/3/25 at 4yrs 6 months old and proceeded with staging CT TAP on 11/3/25 in HSAH which showed feautres of left Wilms tumour with no distant metastasis Post le ft total Nephrectomy on 26/3/25 HPE: Left Wilms tumor COG stage with invasion to left renal sinus and pelvicalyceal system,Weight 230g.No tumour rup ture Started on chemotherady regime DD 4A from April 2025 to 14/10/ 25 Done left thoracotomy and metastatectomy on 22/5/26 at HPP -EOT CT926/10/26);No local recurrent distant metastasis Surveillance CT TAP(19/4/26):2 new lung nodules on left lung Salvage chemotherapy (1st ICE protocol on 18/6/2026 -20/6/2026) 2) Isolated right hemihyperthrophy Chromosome study : 46XX - Under genetic GHPP follow up 3.Scoliosis secondary to isolated right hemihypertrophy Under ortho HSAH Appt CECT thorax : 20/7/2026 USG abdomen : 21/7/2026 Came for FBC today and for s/c neupogen, noted FBC wbc : 0.07, hb 9.7, plt 56, pcv 28.9% no blast cell seen Mother complained of having Warm to touch since last night o/w no documented temp no URTI sx no UTI sX no abdominal pain no vomiting no diarrhea still active no bleeding tendency Temp stat : 38 Repeated 37.5 Born hx: Born term via SVD Diet hx : avoid raw food and vitagen nce with chicken, love to eat kiwi, apple, and vegetable like brocolli and potato formula milk Pediasure 4oz once daily No allergic hx Development hx ; studying at kindergarden aross motor: able to ride bicvcle fine motor able to colour neatly speech : able to do simple calculations, fluent in english social : able to dress and undress alone Family hx: mother is 35 years old, NKMI , teacher father is 38 years old, NKMI , pharmacist this is 1st child 2nd child daugther, 2 years old, NKMI has family of cancer : maternal uncle pass away due to leukemia Social hx : stay at own house with good water and electricity taken care by grandmother Currently oral intake still good no URTI sx no abdominal pain one T spike - 39C oe alert, pink, not tachypneic, no recession, good pulse volume, CRT < 2 sec Lung clear CVS: DRNM P/A: soft non distended HR 114 IMP Neutropenic sepsis FBC : wbc :0.07,hb 9.7, plt 56 CRP 95.9 Updated to Dr Lee (MO Onco GHPP To admit as planned for neuropenic sepsis To start IV Cefepime To start IVD Cont SC Neupogen Plan Observe under RA Keep Spo2 > 95% Encourage orally Reduce IVD to 1/2 maintenance 28cc/H NSD5% - KIV off cm Medications: SC Neupogen 100mcg OD syr Paracetamol 250mg QID IV Cefepime 850mg TDS (50mg/kg/dose) FBC cm If persistent T spike to repeat blood c&s every 48H Trace blood c&s Appt CECT thorax HSAH : 20/7/2026 USG abdomen HSAH : 21/7/2026 Hearing assessment 2/7/26 GHPP

PAEDIATRIC CASE RECORD

Case No: _____

RN of patient: Janice Lim En Yi Name of Hospital: Hospital Sultanah Aminah Johor Bahru (HSAH)

Age: 5 years 10 months Sex: Female IC/RN: SP00751030

Date of admission: 06/07/2026 Date of clerking: 06/07/2026

Date of Discharge: _____ Informant: Mother (reliable historian)

Address: (not disclosed)

Presenting Complaints

Fever since last night
Incidentally noted severe neutropenia on FBC taken today (WBC 0.07 × 10⁹/L)
Came for scheduled FBC check and subcutaneous Neupogen

History of Presenting Complaints

Janice is a 5-year-10-month-old girl with underlying relapsed Wilms' tumour with lung metastasis, currently post-1st cycle ICE salvage chemotherapy (18-20/6/2026), who presented to clinic today for a routine FBC check and scheduled SC Neupogen administration. Her mother reported that she had been warm to touch since the previous night, though no temperature was formally documented at home. There was a single temperature spike of 39°C recorded on examination today, which repeated at 37.5°C.

Her mother denied any associated upper respiratory tract symptoms, urinary symptoms, abdominal pain, vomiting, or diarrhoea. There was no bleeding tendency noted. She remained active and her oral intake was still good at the time of presentation.

FBC today showed severe neutropenia (WBC 0.07 × 10⁹/L), haemoglobin 9.7 g/dL, platelets 56 × 10⁹/L, and PCV 28.9%. No blast cells were seen on the film. CRP was elevated at 95.9 mg/L. Given the fever in the setting of profound neutropenia, a diagnosis of neutropenic sepsis was made and she was admitted for inpatient management.

This is her 4th admission to HSAH.

Treatment Received

IV Cefepime 850 mg TDS (50 mg/kg/dose) - commenced on admission
IVD NSD 5% at half maintenance 28 cc/hour (to reduce to KIV off when oral intake adequate)
SC Neupogen (Filgrastim) 100 mcg OD - continued
Syrup Paracetamol 250 mg QID
Blood culture and sensitivity sent
If persistent temperature spikes, to repeat blood C&S every 48 hours
Reviewed and updated to Dr Lee (MO Oncology GHPP)
Upcoming appointments: CECT Thorax HSAH 20/7/2026, USG Abdomen HSAH 21/7/2026, Hearing Assessment GHPP 2/7/2026

History of Allergy

No known drug or food allergy.

Systems Review

Respiratory: No cough, no rhinorrhoea, no wheeze. Lungs clear on examination. Upcoming CECT Thorax 20/7/2026 for surveillance of known left lung nodules.

Cardiovascular: No cyanosis. Heart sounds dual, regular, no murmur. SpO2 maintained > 95%.

Gastrointestinal: Good oral intake. No vomiting, no diarrhoea, no abdominal pain. Soft, non-distended abdomen. Post left total nephrectomy (26/3/25).

Genitourinary: No urinary symptoms. Single right functioning kidney post left nephrectomy.

Haematological: Severe neutropenia, anaemia, and thrombocytopaenia on current FBC - expected post-chemotherapy nadir. No active bleeding.

Musculoskeletal: Background of scoliosis secondary to isolated right hemihypertrophy. Under orthopaedic follow-up at HSAH.

Neurological: Alert and active. No focal deficit. Hearing assessment scheduled 2/7/2026 at GHPP (monitoring for cisplatin-related ototoxicity given ICE regimen).

Past Medical and Surgical History

1. Relapsed Wilms' Tumour (Left Kidney) with Lung Metastasis

Incidental finding of left kidney lower pole mass on 5/3/2025 at age 4 years 6 months
Staging CT TAP on 11/3/2025 (HSAH): Features of left Wilms' tumour, no distant metastasis at that time
Left total nephrectomy on 26/3/2025
HPE: Left Wilms' tumour, COG stage with invasion to left renal sinus and pelvicalyceal system, tumour weight 230g, no tumour rupture
Started on chemotherapy regimen DD-4A from April 2025 to 14/10/2025
EOT CT (26/10/2025): No local recurrence or distant metastasis
Surveillance CT TAP (19/4/2026): 2 new left lung nodules identified - confirmed relapse with lung metastasis
Left thoracotomy and metastasectomy on 22/5/2026 at GHPP
1st cycle ICE salvage chemotherapy (Ifosfamide, Carboplatin, Etoposide): 18/6/2026 - 20/6/2026
Currently in post-chemotherapy nadir phase

2. Isolated Right Hemihypertrophy

Chromosomal study: 46XX (normal female karyotype)
Under genetics follow-up at GHPP
Associated scoliosis (see below)

3. Scoliosis Secondary to Isolated Right Hemihypertrophy

Under orthopaedic follow-up at HSAH

Previous Admissions:

Admission	Date	Age	Diagnosis
1st	July 2022	1 year 10 months	Infective AGE with normal hydration
2nd	April 2025	4 years 8 months	Neutropenic sepsis
3rd	June 2025	4 years 10 months	COVID-19 Stage 2
4th (current)	July 2026	5 years 10 months	Neutropenic sepsis (post-ICE chemotherapy)

Birth History

Antenatal: Uneventful. No known teratogen exposure. Isolated right hemihypertrophy may have been noted antenatally or postnatally.

Natal: Born at term via spontaneous vaginal delivery (SVD). No perinatal complications documented.

Postnatal/Neonatal: No prolonged neonatal admission. Birth weight not documented. Isolated right hemihypertrophy noted on examination. Chromosomal study 46XX performed.

Feeding/Dietary History

Exclusive breastfeeding: Not documented; likely mixed feeding given formula milk use.

Weaning/supplementary feed: Age-appropriate weaning history.

Present feeding/diet:

Avoids raw food and probiotic drinks (e.g., Vitagen) as per oncology dietary precautions for immunocompromised child
Enjoys chicken, kiwi, apple, and vegetables (broccoli, potato)
Formula milk: Pediasure 4 oz once daily
Oral intake remains good at time of current admission

Immunization History

Vaccinations up to date as per Malaysian National Immunisation Programme for age. Live vaccines (e.g., MMR, varicella) deferred or under review during active chemotherapy as per oncology protocol.

Developmental History

Domain	Milestone
Gross Motor	Able to ride a bicycle independently - age-appropriate
Vision and Fine Motor	Able to colour neatly within lines - age-appropriate
Hearing, Speech and Language	Fluent in English, able to perform simple calculations - age-appropriate. Hearing assessment scheduled 2/7/2026 to monitor for cisplatin-related ototoxicity
Social, Emotional, and Behavioural	Attends kindergarten. Able to dress and undress independently - age-appropriate

Interpretation of developmental milestones / DQ: Developmental milestones appropriate for chronological age of 5 years 10 months across all domains. No developmental delay identified. Continued hearing surveillance warranted given exposure to platinum-based chemotherapy (Carboplatin in ICE regimen).

Family History

Mother: 35 years old, teacher, no known medical illness
Father: 38 years old, pharmacist, no known medical illness
Sibling: Younger sister, 2 years old, no known medical illness
Family history of malignancy: Maternal uncle passed away from leukaemia
No family history of Wilms' tumour, hemihypertrophy, or other congenital anomalies

Social and Environmental History

Education: Attending kindergarten. Active and engaging socially.

Employment: Not applicable (paediatric patient).

Smoking: No smokers in household reported.

Diet: Modified diet as per oncology precautions - no raw food, no probiotics. Well-balanced diet with variety.

Home circumstances: Lives in own house with good water supply and electricity. Primary caregiver during the day is the maternal grandmother. Parents are both employed professionals with good health literacy and engagement with the medical team.

History of contact with any illness: No known contact with infectious illness reported. No known varicella, TB, or measles contacts.

Effect of illness on patient and family: Diagnosis of Wilms' tumour followed by relapse and ongoing salvage chemotherapy has placed significant emotional, financial, and logistical burden on the family. Both parents are actively involved in her care and demonstrate good understanding of the treatment plan. The child's developmental progress and kindergarten attendance reflect a supportive home environment despite her complex medical history.

Summary of History with Provisional Diagnosis

Janice is a 5-year-10-month-old girl with underlying relapsed left Wilms' tumour with lung metastasis (post left total nephrectomy March 2025, post DD-4A chemotherapy, post left thoracotomy and metastasectomy May 2026, currently on ICE salvage chemotherapy with 1st cycle completed 20/6/2026). She presented with fever since the previous night, with a single temperature spike of 39°C on assessment. FBC showed profound neutropenia (WBC 0.07 × 10⁹/L), mild anaemia (Hb 9.7 g/dL), and thrombocytopaenia (Plt 56 × 10⁹/L). CRP was markedly elevated at 95.9 mg/L. No localising source of infection was identified on history or examination.

Provisional Diagnosis: Neutropenic sepsis post-chemotherapy (ICE regimen) - no clear localised source identified

Physical Examination

General Examination

General Appearance: Alert, pink, not in respiratory distress. No recession. Active and cooperative. No pallor, no cyanosis, no jaundice.

Vital Signs:

Temperature: 39°C (initial spike); repeated 37.5°C
Heart Rate: 114 bpm (mildly tachycardic)
Respiratory Rate: Within normal range for age, not tachypnoeic
SpO2: > 95% on room air
Blood Pressure: Not documented

Anthropometric Measurements:

Height: _____ cm Head circumference: _____ cm
Weight: 17 kg BMI: _____ kg/m²

Impression: Mildly febrile, haemodynamically stable, alert child with profoundly neutropenic FBC post-ICE chemotherapy.

Head to Toe Examination

Face, Head and Neck:

Appearance: No dysmorphic features. Mild facial asymmetry in keeping with right hemihypertrophy.
Hands: No clubbing. No peripheral cyanosis. Good capillary refill < 2 seconds.
Pallor: Absent clinically (Hb 9.7 g/dL - mild anaemia).
Cyanosis: Absent
Jaundice: Absent
Oral cavity: No oral ulcers or mucositis. Mucous membranes moist.
Eyes: No conjunctival pallor or icterus.
ENT: No nasal discharge. No visible throat erythema. No ear discharge.
Shape of head: Normocephalic
Neck: No cervical lymphadenopathy. No thyromegaly.
Hair: Hair loss consistent with post-chemotherapy alopecia.
Fontanels: Closed (age-appropriate)
Extremities: Right hemihypertrophy noted clinically - right limbs visibly larger. No peripheral oedema. Warm peripheries. CRT < 2 seconds.
Skin: No rash. No petechiae or purpura despite thrombocytopaenia. No active bleeding sites. Central venous access/port site (if present) to be assessed for signs of infection.

Examination of Back:

Spine: Scoliosis noted in keeping with isolated right hemihypertrophy. Under orthopaedic follow-up.
Sacral oedema: Absent

Lymph Nodes:

Cervical: Not significantly enlarged
Occipital: Not enlarged
Axillary: Not significantly enlarged
Inguinal: Not significantly enlarged

Systems Examination

Systems involved:

Haematological / Oncological
Respiratory
Cardiovascular
Gastrointestinal
Musculoskeletal

Respiratory: Lungs clear on auscultation. No wheeze, rhonchi, or crepitations. Not tachypnoeic. No use of accessory muscles. SpO2 > 95% on room air. No evidence of varicella pneumonitis or pneumonia at present. Surveillance CECT Thorax scheduled 20/7/2026.

Cardiovascular: Heart sounds dual, regular, no murmur (DRNM). Heart rate 114 bpm - mild tachycardia, likely fever-driven. No gallop rhythm. No peripheral oedema. Good pulse volume. CRT < 2 seconds.

Abdomen: Soft, non-distended. No tenderness. No organomegaly. Left nephrectomy scar well-healed. Bowel sounds present and normal. USG abdomen scheduled 21/7/2026 for surveillance.

Musculoskeletal: Right hemihypertrophy clinically evident. Scoliosis noted on inspection of the back. No joint swelling or tenderness. Able to ambulate independently.

Neurological: Alert, active, and engaging. Appropriate for age. No focal neurological deficit. Cranial nerves intact. Hearing assessment pending at GHPP (2/7/2026) for cisplatin/carboplatin ototoxicity monitoring.

Clinical Summary / Analysis of Patient's Problems

Janice is a 5-year-10-month-old girl with relapsed Wilms' tumour with lung metastasis, currently post-1st cycle ICE salvage chemotherapy (completed 20/6/2026), presenting with fever and profound neutropenia (WBC 0.07 × 10⁹/L, ANC effectively zero), elevated CRP 95.9 mg/L, mild anaemia, and mild thrombocytopaenia. No clear localising source of infection was identified on history or examination. She is haemodynamically stable, alert, and maintaining good oral intake.

A. Provisional Diagnosis

Neutropenic Sepsis - Post ICE Chemotherapy (Febrile Neutropenia)

Points in favour:

Profound neutropenia: WBC 0.07 × 10⁹/L (ANC critically low, well below the threshold of < 0.5 × 10⁹/L defining neutropenia)
Fever: single spike 39°C, preceded by warmth to touch since previous night
Markedly elevated inflammatory marker: CRP 95.9 mg/L
Temporal relationship: 16 days post-completion of 1st cycle ICE chemotherapy (expected nadir at 10-14 days post-chemotherapy)
Previous admission for neutropenic sepsis (April 2025) - established pattern
No blast cells on film - confirms marrow suppression rather than disease relapse as cause of neutropenia

Points against:

Temperature trended down to 37.5°C on repeat - may represent early settling
No clear localising source identified on history or examination
Child remains alert, active, haemodynamically stable - not yet in septic shock

B. Differential Diagnoses

I. Bacterial Septicaemia with no localising focus (Gram-negative bacteraemia)

Common in post-chemotherapy neutropenic patients
Organisms such as Pseudomonas aeruginosa, E. coli, Klebsiella are common
IV Cefepime provides broad Gram-negative and Pseudomonas coverage
Blood C&S sent - awaiting results
Highly likely in this context

II. Gram-positive bacteraemia (e.g., Staphylococcus aureus, Streptococcus)

Common source: central venous access (if port/CVL in situ), skin
IV Cefepime has limited Gram-positive cover; if blood cultures grow Gram-positives or fever persists, vancomycin addition to be considered
Less immediately favoured but important to consider

III. Viral infection (e.g., respiratory virus, CMV reactivation)

No URTI symptoms to suggest a respiratory viral cause
CMV reactivation is possible post-chemotherapy in immunocompromised host
Less consistent with the marked CRP elevation

IV. Fungal infection (e.g., invasive candidiasis, aspergillosis)

Risk increases with prolonged neutropenia > 7 days or failure to respond to broad-spectrum antibacterials
Not the primary consideration on Day 1 but to be reviewed if fever persists beyond 72-96 hours without response

V. Disease relapse / progression causing constitutional fever

Surveillance CT TAP 19/4/2026 confirmed 2 new left lung nodules
Post-metastasectomy May 2026 and now on salvage ICE chemotherapy
Disease-related fever is possible but less likely given the degree of neutropenia and elevated CRP pointing to infection
Upcoming CECT Thorax 20/7/2026 and USG abdomen 21/7/2026 will provide further disease status information

Investigations (with Interpretation)

General Investigations

Investigation	Result	Interpretation
WBC	0.07 × 10⁹/L	Profound neutropenia - post-chemotherapy nadir. ANC effectively zero. High infection risk.
Haemoglobin	9.7 g/dL	Mild normocytic anaemia of chronic disease / chemotherapy-related marrow suppression. No active bleeding.
Platelets	56 × 10⁹/L	Mild-moderate thrombocytopaenia. Monitor for bleeding.
PCV	28.9%	Consistent with mild anaemia. No transfusion threshold crossed at present; observe.
Blood film	No blast cells seen	Confirms chemotherapy-induced marrow suppression rather than leukaemic transformation.
CRP	95.9 mg/L	Markedly elevated - consistent with active bacterial infection or significant inflammatory response.
Blood C&S	Sent - pending	To identify causative organism and guide antibiotic rationalisation.

Specific / Oncology Investigations

Investigation	Date	Result	Interpretation
Staging CT TAP	11/3/2025	Left Wilms' tumour, no distant metastasis	Initial staging - localised disease
HPE post-nephrectomy	26/3/2025	Left Wilms' tumour, COG stage, invasion to renal sinus and pelvicalyceal system, 230g, no tumour rupture	Confirmed histology; staging determines chemotherapy regimen
EOT CT	26/10/2025	No local recurrence or distant metastasis	End of DD-4A chemotherapy - complete response
Surveillance CT TAP	19/4/2026	2 new left lung nodules	Confirmed lung relapse - prompted salvage therapy
Post-metastasectomy	22/5/2026	Left thoracotomy and metastasectomy performed at GHPP	Surgical management of metastatic nodules
Chromosomal study	-	46XX	Normal female karyotype; isolated hemihypertrophy not chromosomal

Planned Investigations:

CECT Thorax HSAH: 20/7/2026 (surveillance for lung recurrence)
USG Abdomen HSAH: 21/7/2026 (surveillance of right kidney and abdominal cavity)
Hearing assessment GHPP: 2/7/2026 (cisplatin/carboplatin ototoxicity monitoring)
Repeat blood C&S every 48 hours if persistent temperature spikes

Final Diagnosis:

Neutropenic sepsis (febrile neutropenia) - post 1st cycle ICE salvage chemotherapy
Relapsed Wilms' tumour (left kidney, post-nephrectomy) with lung metastasis - post left thoracotomy and metastasectomy (22/5/2026), on salvage ICE chemotherapy
Isolated right hemihypertrophy (chromosomal study 46XX) - under genetics GHPP
Scoliosis secondary to isolated right hemihypertrophy - under orthopaedics HSAH

Management Plan

1. Neutropenic Sepsis / Febrile Neutropenia

Strict reverse isolation / protective precautions
Observe under room air (RA). Keep SpO2 > 95%.
IV Cefepime 850 mg TDS (50 mg/kg/dose) - broad-spectrum empirical antibacterial covering Gram-negative organisms including Pseudomonas aeruginosa
Trace blood C&S results - rationalise antibiotics accordingly
If persistent temperature spikes: repeat blood C&S every 48 hours; consider escalation to antifungal cover (e.g., IV Fluconazole or Amphotericin B) if no response after 72-96 hours or clinical deterioration
Monitor vitals closely - early recognition of septic shock (tachycardia, hypotension, poor perfusion)
Monitor FBC daily - aim for WBC recovery with Neupogen support

2. SC Neupogen (Filgrastim)

Continue SC Neupogen 100 mcg OD to support neutrophil recovery
Monitor FBC for response

3. Hydration and Nutrition

IVD NSD 5% at half maintenance: 28 cc/hour
Encourage oral intake - if oral intake adequate and tolerating well, reduce IVD further and consider stopping (KIV off)
Maintain dietary precautions: no raw food, no probiotic drinks (Vitagen)

4. Symptomatic Management

Syrup Paracetamol 250 mg QID for fever and discomfort
Avoid NSAIDs given thrombocytopaenia
Monitor platelet count - transfuse if Plt < 10 × 10⁹/L or < 20 × 10⁹/L with active bleeding or procedure planned

5. Anaemia Management

Hb 9.7 g/dL at present - no immediate transfusion required
Monitor Hb trend; transfuse packed red cells if Hb < 7 g/dL or symptomatic

6. Oncology Coordination

Updated to Dr Lee (MO Oncology GHPP) on current admission
Maintain upcoming surveillance appointments: CECT Thorax 20/7/2026, USG Abdomen 21/7/2026
Hearing assessment 2/7/2026 at GHPP (ototoxicity screening)
Next cycle of ICE chemotherapy to be planned pending neutrophil recovery and clinical response

Progress in the Hospital

Day 1 (06/07/2026): Janice admitted for neutropenic sepsis, 16 days post-1st cycle ICE chemotherapy. FBC on admission: WBC 0.07, Hb 9.7, Plt 56, CRP 95.9. Single temperature spike of 39°C, settled to 37.5°C on repeat. Haemodynamically stable. Lungs clear. No localising source identified. IV Cefepime commenced. IVD at half maintenance. SC Neupogen continued. Blood C&S sent. Syrup Paracetamol given PRN. Oncology team at GHPP updated. Child remains alert, active, and orally feeding well.

Status of Patient at Time of Discharge

(To be completed at discharge)

Discharge criteria:

Apyrexial for at least 48 hours
WBC recovery with ANC > 0.5 × 10⁹/L (trending upward with Neupogen)
Blood C&S negative or organism identified and appropriate oral antibiotic available for step-down
Tolerating full oral intake
Haemodynamically stable
Platelet count stable and above transfusion threshold
Upcoming surveillance imaging appointments confirmed (CECT Thorax 20/7/2026, USG Abdomen 21/7/2026)
Oncology follow-up and next ICE cycle schedule discussed with family

Another case same template Muhammad Adib Amal Bin Mohd Johari, 5Y9M, Male Born term at 38 weeks via SVD Immunization up to age NKMI / NKDFA cW: 17.1kg Microsoft Internet Explorer provided by Hospi 2nd hospitalization 1st admission after birth for infant of mother with GDM on HA Presented with: Alleged snake bite at 15:50H today witnessed by his elder sister prior to the event, pt was playing near the water meter in front house suddenly, pt saw snake coming out from under stones snake came out from under the stone and bite to his right dorsum of hand housing area is near river Post snake bite sister informed their father then father rushed to the child ⁃ child sustained pain over right dorsum of hand associated with swelling and minimal bleeding from 2 fang marks over right dorsum, no redness snake was hit by father and brought to hospital father subsequently applied herbal leaves over bitten area and child drink water from the leaves (daun bisa) no tourniquet applied / no sucking over bitten site / no massage done Otherwise, No LOC No confusion No sweating No palpitation No bleeding tendency No SOB No fever No abdominal pain No GI losses No blurred vision BO/PU as usual Tolerating orally minimally IMP under ortho Alleged snake bite (on 26/6/2026 at 1550H rght hand not n compartment syndorme under paeds Alleged snake bite Trimeresurus Purpureomaculatus (Mangrove Pit Viper) at 1550H on 26/6/2026 no antivenom given Upon review stable under RA no pain no SOB/chest pain o/e alert, pink, conscious Right hand examination Fang mark seen swelling over dorsum region warm to touch, no necrotic patch ROM elbow, wrist, finger full passive strecth test negative compartment soft radial pulse palpable CRT <2s sensation intact Imaging right hand/radius ulnar: no FB seen, no OM changes, no gas shadow plan: not for procedure right UL elevate right UL monitor swelling suggest to demarcate area Distal circulation charting right UL

PAEDIATRIC CASE RECORD

Case No: _____

RN of patient: Muhammad Adib Amal Bin Mohd Johari Name of Hospital: Hospital Sultanah Aminah Johor Bahru (HSAH)

Age: 5 years 9 months Sex: Male

Date of admission: 26/06/2026 Date of clerking: 26/06/2026

Date of Discharge: _____ Informant: Father (reliable historian)

Address: (residential area near river)

Presenting Complaints

Pain and swelling over the right dorsum of hand following alleged snake bite at 15:50H today

History of Presenting Complaints

Muhammad Adib Amal is a 5-year-9-month-old boy who presented to the emergency department following an alleged snake bite to his right dorsum of hand at approximately 15:50H on 26/06/2026. The incident was witnessed by his elder sister.

Prior to the event, the child was playing near the water meter at the front of his house, which is situated in a residential area near a river. A snake emerged from under stones near the water meter and bit him on the right dorsum of the hand. The snake was subsequently struck by the father and brought to the hospital for identification. The snake has been identified as a Trimeresurus purpureomaculatus (Mangrove Pit Viper).

Immediately following the bite, the child sustained pain over the right dorsum of the hand, associated with localised swelling and minimal bleeding from two fang marks. His sister alerted the father, who rushed to the child. No tourniquet was applied, no sucking of the wound was attempted, and no massage was performed over the bite site. The father applied herbal leaves (daun bisa) over the bitten area and the child consumed water prepared from the leaves prior to hospital arrival.

On further systemic enquiry, there was no loss of consciousness, no confusion, no sweating, no palpitations, no bleeding tendency, no shortness of breath, no abdominal pain, no gastrointestinal losses, and no blurred vision. Bowel and urinary output were as usual. He was tolerating oral intake minimally. No fever was noted.

Upon review in the emergency department, the child was stable on room air, with no pain and no shortness of breath or chest pain. Right hand examination confirmed two fang marks with localised swelling over the dorsum, warmth to touch, no necrotic patch, and no signs of compartment syndrome. Radial pulse was palpable with intact distal circulation and sensation.

Treatment Received

No antivenom administered (no systemic envenomation features; local envenomation only)
Right upper limb elevated
Swelling monitored with demarcation of swelling margin
Distal circulation charting of right upper limb commenced
No surgical procedure planned for right upper limb at this time
Under joint Orthopaedic and Paediatrics teams

History of Allergy

No known drug allergy. No known food allergy.

Systems Review

Cardiovascular: No palpitations. No bleeding tendency. Good peripheral perfusion - radial pulse palpable, CRT < 2 seconds.

Respiratory: No shortness of breath. No chest pain. Stable on room air. No wheeze.

Gastrointestinal: No abdominal pain. No vomiting. No diarrhoea. Tolerating oral intake minimally since the incident.

Neurological: No loss of consciousness. No confusion. No blurred vision. Sensation intact over right hand and fingers.

Haematological: No active bleeding tendency. No bruising or petechiae. No haematuria or melaena reported. Haematological parameters to be monitored given pit viper venom with haemotoxic potential.

Musculoskeletal: Pain and swelling localised to right dorsum of hand. Full range of movement at elbow, wrist, and fingers. No compartment syndrome features.

Dermatological: Two fang marks over right dorsum of hand. Minimal bleeding. No erythema, no necrotic patch, no blistering at time of presentation.

Past Medical and Surgical History

Infant of a mother with gestational diabetes mellitus (GDM) - admitted after birth at Hospital A for monitoring. No further sequelae documented.
No other known medical illness.
No prior surgical history.

This is his 2nd hospitalisation overall.

Birth History

Antenatal: Mother had gestational diabetes mellitus (GDM). No other antenatal complications documented.

Natal: Born at term, 38 weeks gestation, via spontaneous vaginal delivery (SVD). Birth weight not documented. No birth asphyxia.

Postnatal/Neonatal: Admitted after birth as infant of mother with GDM - monitored for hypoglycaemia. No prolonged NICU stay documented. No neonatal jaundice requiring phototherapy noted.

Feeding/Dietary History

Exclusive breastfeeding: Not documented.

Weaning/supplementary feed: Age-appropriate weaning history, no concerns raised.

Present feeding/diet: Tolerating oral intake minimally since the snake bite incident. No specific dietary restrictions. No food allergies.

Immunization History

Vaccinations up to date as per Malaysian National Immunisation Programme for age. Tetanus prophylaxis status noted - up to date with DTP series as per national schedule; no additional tetanus toxoid required.

Developmental History

Domain	Milestone
Gross Motor	Playing actively and independently outdoors prior to incident - age-appropriate
Vision and Fine Motor	No concerns raised by parents
Hearing, Speech and Language	Communicating appropriately with family and medical staff - age-appropriate
Social, Emotional, and Behavioural	Attends kindergarten/preschool. Plays with siblings. Age-appropriate social development.

Interpretation of developmental milestones / DQ: Developmental milestones appropriate for chronological age of 5 years 9 months. No developmental delay identified.

Family History

Parents: No known medical illness
Elder sister: Well, no known medical illness
No family history of bleeding disorders or coagulopathy
No family history of snake bite or envenomation

Social and Environmental History

Education: Attending kindergarten/preschool. Age-appropriate school attendance.

Employment: Not applicable (paediatric patient).

Smoking: Not documented.

Diet: No specific dietary restrictions. Normal diet for age.

Home circumstances: Lives in a residential area situated near a river. History of snake activity around the house - snake emerged from under stones near the water meter at the front of the property. High-risk environment for snake encounters given proximity to river and natural habitat.

History of contact with any illness: No recent contact with infectious illness.

Effect of illness on patient and family: Sudden traumatic event witnessed by the elder sister and managed initially by the father. Father acted appropriately by avoiding tourniquet, sucking, and massage. Application of herbal leaves (daun bisa) and administration of the leaf water were noted - parents counselled regarding the importance of not applying traditional remedies to snake bite wounds as they may obscure wound assessment and introduce infection risk.

Summary of History with Provisional Diagnosis

Muhammad Adib Amal is a 5-year-9-month-old boy with no significant past medical history who presented with an alleged snake bite to the right dorsum of the hand at 15:50H on 26/06/2026. The snake was identified as a Trimeresurus purpureomaculatus (Mangrove Pit Viper). He had two fang marks with localised swelling and warmth over the right dorsum of the hand. There were no features of systemic envenomation. Examination confirmed no compartment syndrome, intact distal neurovascular status, and no necrotic changes. X-ray of the right hand showed no foreign body, no osteomyelitis changes, and no gas shadow.

Provisional Diagnosis:

Alleged snake bite - Trimeresurus purpureomaculatus (Mangrove Pit Viper) - localised envenomation, right hand, no systemic envenomation

Physical Examination

General Examination

General Appearance: Alert, conscious, pink. Not in distress at the time of review. No pallor, no cyanosis, no jaundice. Not tachypnoeic. Appears comfortable.

Vital Signs:

Temperature: Afebrile
Heart Rate: Within normal range for age
Respiratory Rate: Not tachypnoeic, within normal range for age
SpO2: Stable on room air
Blood Pressure: Not documented

Anthropometric Measurements:

Height: _____ cm Head circumference: _____ cm
Weight: 17.1 kg BMI: _____ kg/m²

Impression: Alert, haemodynamically stable child following localised snake envenomation to the right hand with no systemic features.

Head to Toe Examination

Face, Head and Neck:

Appearance: No dysmorphic features. No facial swelling.
Hands: Right hand - two fang marks visible over the dorsum. Localised swelling over the dorsum of the right hand. Warm to touch. No necrotic patch. No blistering. No erythema at this time.
Pallor: Absent
Cyanosis: Absent
Jaundice: Absent
Oral cavity: Moist mucous membranes. No oral bleeding or mucosal haemorrhage.
Eyes: No ptosis, no diplopia, no blurred vision reported. Pupils equal and reactive.
ENT: No epistaxis. No bleeding from gums.
Shape of head: Normocephalic
Neck: No lymphadenopathy. No neck stiffness.
Hair: Normal
Fontanels: Closed (age-appropriate)
Extremities: Right upper limb - see dedicated examination below. Left upper and bilateral lower limbs: no swelling, no injury. Good perfusion bilaterally.
Skin: No petechiae, no purpura, no ecchymoses elsewhere on the body.

Examination of Back:

Spine: No deformity. Normal alignment.
Sacral oedema: Absent

Lymph Nodes:

Cervical: Not enlarged
Occipital: Not enlarged
Axillary (right): Mildly enlarged reactive lymph nodes possible given localised envenomation - to monitor
Inguinal: Not enlarged

Systems Examination

Systems involved:

Musculoskeletal / Right Upper Limb (primary)
Haematological (monitoring for coagulopathy)
Cardiovascular
Neurological

Right Upper Limb - Detailed Examination:

Parameter	Finding
Fang marks	Two fang marks present over right dorsum of hand
Swelling	Present, localised to dorsum of right hand
Warmth	Warm to touch
Erythema	No erythema at present
Necrotic patch	Absent
Blistering	Absent
Range of movement	Full range at elbow, wrist, and all finger joints
Passive stretch test	Negative (no pain on passive finger extension - no compartment syndrome)
Compartment	Soft, not tense
Radial pulse	Palpable
CRT	< 2 seconds
Sensation	Intact over right hand and fingers

Impression of right hand: Localised pit viper envenomation with local tissue effect only (swelling, warmth). No features of compartment syndrome. Intact neurovascular status distally.

Cardiovascular: Heart sounds dual, regular, no murmur. Good pulse volume. No haemodynamic compromise. CRT < 2 seconds centrally and peripherally.

Respiratory: Lungs clear on auscultation. No wheeze, no crepitations. Not tachypnoeic. Stable on room air. No neurotoxic features (no respiratory paralysis, no respiratory distress).

Abdomen: Soft, non-distended. No tenderness. No organomegaly. Bowel sounds present and normal. No signs of abdominal compartment involvement.

Neurological: Alert and conscious. Communicates appropriately. No ptosis, no diplopia, no dysarthria. No focal neurological deficit. No altered sensorium. Sensation intact in right upper limb.

Clinical Summary / Analysis of Patient's Problems

Muhammad Adib Amal is a 5-year-9-month-old previously healthy boy presenting with an alleged bite from a Trimeresurus purpureomaculatus (Mangrove Pit Viper) to the right dorsum of the hand. The snake was witnessed, identified, and brought to hospital. He has localised envenomation characterised by two fang marks, swelling, and warmth over the right dorsum of the hand. There are no features of systemic envenomation (no coagulopathy, no neurotoxicity, no cardiovascular compromise, no respiratory involvement). No compartment syndrome. Distal neurovascular status intact. X-ray shows no foreign body, no gas shadow, no bony changes.

A. Provisional Diagnosis

Localised envenomation - Trimeresurus purpureomaculatus (Mangrove Pit Viper) bite, right hand - no systemic envenomation at presentation

Points in favour:

Witnessed bite with identified snake species (Trimeresurus purpureomaculatus - Mangrove Pit Viper, a haemotoxic pit viper common in riverine and mangrove habitats)
Two clear fang marks on right dorsum of hand
Localised swelling, warmth, and pain at bite site - consistent with local tissue effect of venom
Residential area near river - plausible habitat for Mangrove Pit Viper
No tourniquet or sucking applied - appropriate first aid limiting venom distribution
Haemodynamically stable, no bleeding tendency, no systemic envenomation at time of review

Points against:

Onset of systemic envenomation (coagulopathy, haemorrhage) with Trimeresurus species may be delayed - patient remains at risk and requires close monitoring for at least 24-48 hours
Herbal remedy (daun bisa) applied - may confound local wound assessment

B. Differential Diagnoses

I. Dry bite (no venom injected)

Trimeresurus species can deliver dry bites with fang marks but no envenomation
Two fang marks present with localised swelling - suggests at least local envenomation has occurred
Dry bite remains possible if swelling does not progress and no systemic features develop
Clinical monitoring over 24-48 hours will differentiate

II. Non-venomous snake bite

If the snake identification is incorrect, envenomation risk would be lower
However, snake was brought to hospital and identified as Trimeresurus purpureomaculatus
Two fang marks are consistent with a viperid bite pattern

III. Compartment syndrome of the right hand

A known serious complication of pit viper envenomation due to progressive tissue swelling
Currently excluded: compartment soft, passive stretch test negative, radial pulse palpable, CRT < 2s, sensation intact
Must continue to monitor closely as swelling may progress

IV. Secondary wound infection / cellulitis

Risk of secondary bacterial infection from the wound itself or from application of herbal leaves over the bite site
No signs of infection at present - wound warm but no erythema, no pus, no necrosis
Monitor over 24-48 hours; wound care and tetanus status to be ensured

Investigations (with Interpretation)

General Investigations

Investigation	Result	Interpretation
X-ray Right Hand/Radius-Ulnar	No foreign body, no osteomyelitis changes, no gas shadow	No bony injury, no retained fang fragment, no gas-forming infection
FBC	Pending	To assess for thrombocytopaenia (venom-induced thrombocytopaenia with Trimeresurus species) and haemoconcentration
Coagulation profile (PT, APTT, INR, fibrinogen)	Pending	Key investigation - Trimeresurus purpureomaculatus venom is haemotoxic; defibrination syndrome and coagulopathy are known complications
Blood film	Pending	To assess for microangiopathic changes, fragmented RBCs, thrombocytopaenia
Renal profile (urea, creatinine, electrolytes)	Pending	Myonecrosis and haemoglobinuria can cause acute kidney injury in severe envenomation
LFT	Pending	Baseline; venom-induced hepatotoxicity possible in severe cases
Urinalysis	Pending	To look for haematuria, haemoglobinuria, or myoglobinuria
Blood grouping and crossmatch	To be sent	In anticipation of potential need for fresh frozen plasma or blood products if coagulopathy develops

Specific Investigations / Monitoring:

Serial swelling measurements with demarcation charting of right dorsum of hand
Distal circulation charting: radial pulse, CRT, sensation, capillary filling - hourly initially, then 2-hourly once stable
Repeat coagulation profile at 6 hours and 24 hours post-bite to detect delayed onset of haemotoxic coagulopathy

Final Diagnosis:

Alleged snake bite - Trimeresurus purpureomaculatus (Mangrove Pit Viper) - localised envenomation, right hand dorsum, no compartment syndrome, no systemic envenomation at presentation
Infant of mother with GDM - previous admission (resolved, no ongoing sequelae)

Management Plan

1. Envenomation Management - Local

Right upper limb elevation to reduce swelling and promote lymphatic drainage
Monitor and demarcate swelling margin with a skin marker - reassess every 1-2 hours for progression
Distal circulation charting hourly: radial pulse, CRT, skin temperature, sensation, and capillary refill
Passive stretch test to be repeated with each assessment to detect early compartment syndrome
No tourniquet, no incision, no suction - avoid wound manipulation
Wound care: clean the bite site gently; no herbal applications to continue
Tetanus status confirmed up to date - no additional prophylaxis required

2. Antivenom

No antivenom indicated at this time - no systemic envenomation features present
Criteria for antivenom administration (to be reviewed): evidence of systemic envenomation - coagulopathy (prolonged PT/APTT, low fibrinogen, elevated D-dimer), haemorrhage, progressive severe local swelling, or cardiovascular/neurological compromise
Polyvalent or species-specific antivenom to be on standby; discuss with toxicology or poison centre if systemic features develop
Risk of antifascin reaction and anaphylaxis if antivenom given - ensure resuscitation equipment and adrenaline available at bedside

3. Haematological Monitoring

Serial FBC, coagulation profile (PT, APTT, fibrinogen, D-dimer), and renal profile at:
- Baseline (on admission)
- 6 hours post-bite
- 24 hours post-bite
- If any clinical deterioration - urgent repeat
If coagulopathy detected: consider fresh frozen plasma (FFP), cryoprecipitate, or antivenom depending on severity

4. Pain Management

Paracetamol (15 mg/kg/dose) PRN for pain
Avoid NSAIDs (risk of worsening coagulopathy if haemotoxic envenomation develops)
Avoid intramuscular injections given risk of haematoma if coagulopathy develops

5. Hydration

Encourage oral fluid intake
IV access secured and maintained - IV fluids if oral intake inadequate or clinical deterioration
Monitor urine output - aim > 1 mL/kg/hour; haemoglobinuria or myoglobinuria mandates aggressive IV hydration

6. Observation and Admission

Admit under joint Paediatrics and Orthopaedic teams
Minimum 24-48 hours observation given risk of delayed haemotoxic envenomation with Trimeresurus purpureomaculatus
Nurse in monitored bay with regular vital signs
Stable on room air - observe under RA

7. Parental Counselling

Explain the nature of the snake species and the risk of delayed coagulopathy
Counsel regarding the importance of avoiding traditional remedies (herbal applications) on the wound
Reassure regarding current stability and explain monitoring plan
Advise on environmental precautions at home given proximity to river - keep the area around the water meter clear of stones and debris

Progress in the Hospital

Day 1 (26/06/2026, evening): Muhammad Adib Amal admitted following witnessed Trimeresurus purpureomaculatus bite to the right dorsum of the hand at 15:50H. On review, child alert, conscious, and haemodynamically stable. Right hand: two fang marks with localised swelling and warmth over dorsum, no necrotic patch, no compartment syndrome features, radial pulse palpable, CRT < 2s, sensation intact. X-ray right hand: no foreign body, no gas shadow, no bony injury. No antivenom given. Right upper limb elevated. Distal circulation charting commenced hourly. Swelling margin demarcated. Bloods sent including FBC, coagulation profile, renal profile, and urinalysis. Under joint Paediatrics and Orthopaedics teams. Parents counselled. Plan to monitor closely for 24-48 hours for systemic envenomation.

Status of Patient at Time of Discharge

(To be completed at discharge)

Discharge criteria:

Minimum 24-48 hours observation completed
Serial coagulation profiles normal at 6 hours and 24 hours post-bite
No signs of systemic envenomation (no coagulopathy, no haemorrhage, no renal impairment)
Swelling stable or regressing, no compartment syndrome
Intact distal neurovascular status of right upper limb
Tolerating full oral intake
Wound reviewed - no signs of secondary infection
Parents educated on wound care, signs of late envenomation to watch for (bruising, bleeding, progressive swelling), and when to return to hospital
Environmental safety counselling given regarding residential area near river

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