I now have the logbook template and sufficient clinical information. Let me compose the full case presentation following the logbook template exactly.
PAEDIATRIC CASE RECORD
DEMOGRAPHIC DATA
| |
|---|
| Name | Mhd Aqil Hanif bin Mohamad Idris |
| Age | 44 days old |
| Sex | Male |
| Date of Admission | 28 June 2026 |
| Date of Clerking | 29 June 2026 (afternoon) |
| Informant | Mother (reliable) |
| Date of Birth | 17 May 2026 |
| Admission No. | 3rd admission |
PRESENTING COMPLAINTS
- Noisy breathing since birth, worsening for 2 days (since 26/6/2026)
- Productive cough for 1 week (since 21/6/2026)
HISTORY OF PRESENTING COMPLAINTS
Noisy breathing:
- Present since birth; mother reports an intermittent inspiratory noise
- Acutely worsened on 26/6/2026; most severe episode on 28/6/2026 at 3-7 AM
- During that episode: rapid breathing noted, suprasternal recession observed by mother
- No cyanosis/bluish discolouration of lips or body
- No apnoeic episodes, no fitting
- In ED: SpO2 92%, HR 158 bpm - placed on NPO2; lungs clear on auscultation
- On ward at 11 PM 28/6: SpO2 improved to 98% on NPO2, not tachypnoeic, no fever
Cough:
- Productive cough, on and off, onset 21/6/2026 (1 week duration)
- Sick contact: mother had URTI symptoms
Pertinent negatives: No fever, no bluish discolouration, no runny nose, no vomiting, no diarrhoea, tolerating feeds as usual (3 oz/3-hourly)
PAST MEDICAL AND SURGICAL HISTORY
1st Admission (at birth - NNJ):
- Term LGA (37+4 weeks), BW 4.02 kg
- Neonatal jaundice (NNJ), G6PD deficient
2nd Admission (D7 of life, 23/5 - 24/5/2026):
- Term LGA (BW 4.02 kg; weight at admission 3.76 kg - weight loss 6.46%)
- G6PD deficient
- Rebound NNJ with neurotoxic risk factors:
- SBR at D7: 269 umol/L (above PT level; PT level at >120 HOL: 255/294)
- SBR at D8: 210 umol/L (below PT level, decreasing trend)
- Infant of mother with DM (on treatment)
- Infant of mother with beta-thalassaemia trait
- Hypospadias (noted, surgical follow-up pending)
BIRTH HISTORY
Antenatal:
- Mother 36 years old, known DM on treatment, beta-thalassaemia trait
- No documented antenatal complications beyond above
Natal:
- Delivered via Emergency LSCS (EMLSeS) for:
- Large for gestational age (LGA)
- 1 previous LSCS
- Gestation: 37 weeks + 4 days (term)
- Birth weight: 4.02 kg
Postnatal/Neonatal:
- HCt (head circumference) at birth: 30 cm
- Length at birth: 54.5 cm
- G6PD: Deficient
- cTSH: 4.54 (within normal range - no overt hypothyroidism)
- Mother blood group: AB positive
- History of NNJ, managed as above
FEEDING / DIETARY HISTORY
- Currently: Breast milk + Dutch Baby formula, 3 oz every 3 hours
- Feeding well, tolerating feeds as usual, no change in feeding during current illness
- No weaning (44 days old)
IMMUNISATION HISTORY
- Age 44 days - expected immunisations: BCG, Hepatitis B (birth dose), and possibly first dose of Hep B/DTP/Hib/IPV at 2 months (not yet due)
- (Not explicitly stated; to be confirmed)
DEVELOPMENTAL HISTORY
(At 44 days - expected developmental milestones for ~6 weeks)
| Domain | Finding |
|---|
| Gross Motor | Still has head lag (present; expected at this age) |
| Fine Motor | Fixates on object (appropriate) |
| Speech/Language | Quietens to sound (appropriate) |
| Social | Social smile present (slightly early - expected ~6 weeks) |
Interpretation: Development appears age-appropriate. Head lag is expected at 44 days.
FAMILY HISTORY
| |
|---|
| Mother | 36 years old, DM, beta-thalassaemia trait, URTI (recent), housewife |
| Father | 41 years old, NKMI, security guard |
| 1st child | 5-year-old daughter, unilateral developmental delay |
| This patient | 2nd child |
SOCIAL & ENVIRONMENTAL HISTORY
- Lives in own house with adequate water supply and electricity
- Household: 5 members including an adopted child
- No smoking history documented
- Mother as primary caregiver
SUMMARY OF HISTORY WITH PROVISIONAL DIAGNOSIS
A 44-day-old male infant, previously known G6PD deficient, term LGA, born via EMLSCS, presenting with worsening noisy inspiratory breathing since birth (acute worsening over 2 days) and productive cough for 1 week in the context of sick contact (mother with URTI). In ED, SpO2 was 92% improving to 98% on NPO2. Clinically, he has mild suprasternal recession, occasional inspiratory stridor, and mild tachypnoea.
Provisional Diagnosis: Mild Laryngomalacia with superimposed Acute Bronchiolitis
PHYSICAL EXAMINATION
General Examination
- GCS: 15/15 - Alert, responsive
- Appearance: Pink, not pale, not jaundiced, not dysmorphic
- Respiratory: Mild subcostal recession (SCR), mild tachypnoea, occasional inspiratory stridor
- Hydration: Good peripheral pulses, CRT < 2 seconds
Vital Signs
| Parameter | Value |
|---|
| SpO2 | 98% (on NPO2 2 L/min) |
| Heart rate | 158 bpm (on presentation; settled in ward) |
| Temperature | Afebrile |
| RR | Mildly elevated (improved on NPO2) |
Anthropometric Measurements
| |
|---|
| Current Weight | 4.55 kg (BW was 4.02 kg, gaining appropriately) |
| Length at birth | 54.5 cm |
| Head circumference at birth | 30 cm |
Head to Toe Examination
- Head/Neck: Normocephalic, no dysmorphic features
- Eyes: Pink conjunctiva, no jaundice
- ENT: Occasional inspiratory stridor noted
- Oral cavity: Moist mucosa, no thrush
- Skin: Pink, no rash, no jaundice
- Fontanelle: Not documented (to be examined)
- Hands: No clubbing, no cyanosis, CRT < 2 sec
Systems Examination
Respiratory:
- Mild subcostal recession, mild tachypnoea
- Occasional inspiratory stridor
- Breath sounds: Clear bilaterally - no rhonchi, no crepitations
- No use of accessory muscles (beyond mild SCR)
- CXR: Clear lung fields, no consolidation
CVS:
- Dual rhythm, no murmur (DRNM)
- Good pulse volume
Abdomen:
- Soft, non-distended, non-tender
Neurology:
- Alert, GCS 15
- Head lag present (age-appropriate)
- Social smile, fixates on objects
CLINICAL SUMMARY / ANALYSIS
A 44-day-old male, G6PD deficient, term LGA (37+4 weeks via EMLSCS), presented with stridor since birth with acute worsening + productive cough in the setting of sick contact, with SpO2 dip to 92% in ED improving on supplemental O2.
A. PROVISIONAL DIAGNOSIS
1. Mild Laryngomalacia
Points IN FAVOUR:
- Inspiratory stridor present since birth - classic hallmark
- Age: 44 days - peak age for laryngomalacia presentation (typically presents birth to 2 months)
- Intermittent, worse when active/agitated (worsening at 3-7 AM when infant may have been crying/feeding)
- Occasional stridor on exam with otherwise clear lung fields
- ENT referral made for flexible nasendoscopy (scope) - gold standard confirmation
- Lansoprazole prescribed - management of co-existing GORD which exacerbates laryngomalacia
- Mild severity: no apnoea, feeding adequate, no failure to thrive (weight gained from 4.02 to 4.55 kg)
Points AGAINST:
- Acute worsening not typical of isolated laryngomalacia - suggests superimposed cause
- SpO2 92% in ED is more profound than expected in mild laryngomalacia alone
2. Acute Bronchiolitis
Points IN FAVOUR:
- Age < 2 years, peak season
- Productive cough for 1 week, worsening
- Sick contact (mother with URTI - likely RSV or rhinovirus)
- Tachypnoea, subcostal recession, SpO2 92% on presentation
- Improved with supplemental O2 (supportive management - consistent with bronchiolitis)
Points AGAINST:
- Lung fields clear on auscultation (bronchiolitis usually has wheeze/fine crepitations)
- No wheeze documented
- CXR clear (no hyperinflation/consolidation - atypical but possible in early bronchiolitis)
B. DIFFERENTIAL DIAGNOSES
| Dx | For | Against |
|---|
| Subglottic stenosis | Stridor since birth, inspiratory, worsening | No previous intubation, CXR normal, scope pending |
| Tracheomalacia | Stridor/noisy breathing since birth | Stridor is inspiratory (tracheomalacia gives biphasic/expiratory), lungs clear |
| Vocal cord palsy | Congenital stridor | Usually high-pitched, may have feeding difficulty; no birth trauma documented |
| Pneumonia | Cough, tachypnoea, SpO2 dip, sick contact | CXR clear - no consolidation, afebrile |
| RSV bronchiolitis | Age, sick contact, cough, SpO2 dip | No wheeze, lungs clear |
INVESTIGATIONS
| Investigation | Result | Interpretation |
|---|
| SpO2 (ED) | 92% | Hypoxaemia - required supplemental O2 |
| SpO2 (ward, on NPO2) | 98% | Improved with 2 L/min nasal prong O2 |
| CXR | Clear lung fields, no consolidation | No pneumonia, no hyperinflation |
| G6PD | Deficient | Known; important for drug prescribing (avoid oxidant drugs) |
| cTSH | 4.54 | Within normal range; no congenital hypothyroidism |
| SBR (D7 of life) | 269 umol/L | Was above PT level - treated (now resolved) |
| SBR (D8 of life) | 210 umol/L | Below PT level, decreasing trend - resolved NNJ |
| Mother BG | AB positive | Noted; no ABO incompatibility issue (mother AB+) |
| Weight | 4.55 kg (current) vs 4.02 kg (birth) | Adequate weight gain - no failure to thrive |
Pending/Recommended:
- Flexible nasendoscopy (ENT scope) - to confirm laryngomalacia
- NPA for RSV/rhinovirus (if bronchiolitis suspected)
- FBC if clinically indicated
MANAGEMENT PLAN
Immediate
- NPO2 2 L/min - maintain SpO2 >95%
- Monitor for signs of respiratory distress (RR, SpO2, work of breathing)
- Encourage oral feeds as tolerated
Medications
| Drug | Dose | Indication |
|---|
| NS drops | 1 drop each nostril TDS | Nasal decongestion |
| Syrup Paracetamol | 70 mg PRN (15 mg/kg/dose; weight 4.55 kg = 68.25 mg ≈ 70 mg) | Analgesia/antipyretic |
| PO Lansoprazole | 5 mg OD | GORD - exacerbates laryngomalacia |
Specialist Referral
- ENT referral for flexible nasendoscopy (laryngoscopy) to confirm laryngomalacia - done on 29/6/2026
Bronchiolitis (if confirmed)
- Supportive care: O2, adequate hydration, monitor feeding
- No routine bronchodilators, antibiotics, or steroids (not evidence-based in bronchiolitis)
PROGNOSIS
Laryngomalacia: Excellent prognosis. In ~90% of cases, mild laryngomalacia resolves spontaneously by 18-24 months of age as supraglottic structures mature. This infant is already gaining weight well (4.02 → 4.55 kg), feeding adequately - no signs of failure to thrive. No surgical intervention (supraglottoplasty) anticipated at this stage.
Acute Bronchiolitis (if confirmed): Generally self-limiting over 7-10 days. Risk of RSV-related disease is higher in infants < 3 months. Close monitoring of feeding and respiratory status important.
Overall: Good prognosis. Infant is haemodynamically stable, responding to supplemental O2, and growing well.
Note on G6PD deficiency: Avoid oxidant drugs (e.g. aspirin, certain antibiotics - trimethoprim, nitrofurantoin, dapsone). Lansoprazole and paracetamol are safe. No haemolysis triggers currently present.
This case presentation follows the Paediatrics Year 3 Log Book template. Duration is designed to be concise for a student case presentation with other presenters to follow.
