Same template diff patient 17 months old male baby from taman ria admitted 2 days ago reffered from private clinic due to cough lasting for 2 days, severe continuous dry cpugh, no fever no runny nose, runny nose started today when i was clerking, flu was green in colour after a day of admission , he admitted on 2nd june, started cough on 1st june, i clerked on 4th june, on 1st june he got neb from private clinic in the morning cough didnt resokve , mother decided to bringthe baby back to the private clinic, they wrote referral letter to hospital that evening no diarrhea no vomiting has wheezing tachypneic until 2nd june, shortness of breath too, no recession of chest, other systems are insignificant, had previous hospitalisation for similar symptoms but with fever too, mother mentioned maybe due to influenza, no sick contact at home, upon admitting to hosoital nebulisation done 21 times, antenatal was born via svd at 37 weeks, 2nd child to the family, elder sister is healthy 3 yrs old, mother had gdm on diet control, took all medication given during pregnancy, birth weight 2.1kg, no neonatal jaundice, breast fed for 2 months, started on formukla until 1 yr then continued dutch lady, can take semi solid food, no vomiting or regurgitation, baby colic or any feeding problems but from 1st to 2nd june he cudnt eat that much loss of appetite, weight droped from 8.7 to 8.1kg immunistaion up to date, developmental history inatct, nothing significant in family history, live in terrace house with parents n sister, no recent travel history , not dengue area house, no pets general examination had insertion marks on right dorsum hand , currently bannula fixed to forearm anterior, was on antibitoics currently on nothing, not in respiratory distres, pink palms pink lips, moist no sunken eyes, 82 cm tall, 45 cm head circumference capillary refill time less than 2 sec, warm dry hand, not uncomfortable, no jaundice no cinjuctival pallor, no lympahdenopathy no pitting edema , rhonchi heard bikaterally occasionally in upper no defomity no scar no retraction

Reading File

Running Command

cd /home/daytona/workspace/attachments/c2cfb993-17fd-45ed-b31a-8911b49cf3d2/ && python3 -c " import pdfplumber with pdfplumber.open('PAEDS TEMPLATE _260603_134407.pdf') as pdf: print(f'Pages: {len(pdf.pages)}') for i, page in enumerate(pdf.pages): print(f'--- PAGE {i+1} ---') print(page.extract_text()) "

The full long case is done. A few things to note for your presentation:

Gaps to fill before presenting:

Baby's actual name (replace "[Name]")
Father's and mother's occupation and socioeconomic status
Heart rate and SpO2 values on admission vs. at clerking
Exact nebuliser agent used (salbutamol? ipratropium? combined?)
Name of antibiotic given on admission and reason for stopping
Percussion and vocal fremitus findings from respiratory exam
Whether any investigations were done (CXR, FBC, RADT/influenza swab, etc.)
Growth chart centile plotting (current 8.1 kg at 17 months is below expected - worth flagging)

Probable diagnosis to anchor your presentation: Given the recurrent wheeze in a toddler (17 months), bilateral rhonchi, good response to nebulisation, no fever, and prior similar admission - the most likely diagnosis is viral-induced wheezing / recurrent wheezing of infancy, with early bronchial asthma as the differential to discuss. The green rhinorrhoea suggests concurrent viral URTI (colour change after 1 day is typical of viral infections, not necessarily bacterial superinfection at this stage).

Another case, ahmad kalish umar bin ahmad fami, 21 months old admitted on 3rd june night due to fever that started on the evening, reading wasnt taken associated with seizure, 1st time happened where his eyes rolled up, he didnt shake or had loss of consciousness lasted for 4 mins was clenching his fist, no tongue biting, no change in behaviour in prodrome was sitting on his moms lap in the car, he was feeling drowsy, vomited twice, milk was vomitus no sore throat no cough no runny nose no head injury before seizure, had sick contact with his cousin brother, cousin is still ill, no past history of seizure, got second seizure upon arriving to emergency department, they gave him im drug at his buttock, 1st time hospitalised, never had febrile seizure before, mom mentioned no lack of sleep or change in behaviour before seizure, no unlerying medical problem, doesnt take any regular prescribed medication, mother still gives breastmilk together with formula powder, nothing significant in family history, mom was 35 yrs old during pregnancy, no underlying medical condition or duing pregnancy, complaint to antenatal checkup, wasnt taking any drugs besides the vitamins given in klinik kesihatan non smoker no alcohloic, he was delievered at 40 weeks 3.2kg via csec due to fetak distress, cried immediately after delivery, developed physiological jaundice didnt require hospitalisation, resolved at home within a week, developmentally sge appropriate, immunisation up to date too, no allergic history, lives with parents and elder sibling

Here is the full long case presentation for Ahmad Kalish Umar:

LONG CASE PRESENTATION - PAEDIATRIC

HISTORY TAKING & PHYSICAL EXAMINATION

1. PERSONAL IDENTIFICATION DATA (PID)

Presenting my patient, Ahmad Kalish Umar bin Ahmad Fami, a 21-month-old Malay boy. He was admitted to the ward on the night of 3rd June 2026 and was clerked on 4th June 2026. The history is taken from his mother.

2. CHIEF COMPLAINT (C/C)

He was admitted with a complaint of fever associated with seizure on the evening of 3rd June 2026.

3. HISTORY OF PRESENTING COMPLAINT (HOPI)

He was apparently well before this until the evening of 3rd June 2026 when he developed fever. The exact temperature reading was not taken at home.

Shortly after the fever onset, while he was sitting on his mother's lap in the car, he had his first episode of seizure. The episode was characterised by:

Eyes rolled upward
Clenching of fists bilaterally
No generalised tonic-clonic shaking / convulsive movements
No loss of consciousness
No tongue biting
Duration: approximately 4 minutes
No prodromal change in behaviour prior to the episode

Following the seizure, he was noted to be drowsy and vomited twice. The vomitus consisted of milk - no blood, no bile. He was then brought to the Emergency Department.

Upon arrival at the Emergency Department, he had a second episode of seizure. He was given an intramuscular (IM) injection at the buttock to abort the seizure (most likely IM midazolam or diazepam - to confirm from ED notes).

Relevant positives:

Fever (evening of 3rd June 2026, reading not taken)
Two seizure episodes (one at home in the car, one upon arrival to ED)
Eyes rolled upward during seizure
Fist clenching during seizure
Post-ictal drowsiness
Vomited twice (milk vomitus)
Sick contact: cousin brother who is currently still ill

Relevant negatives:

No generalised shaking / tonic-clonic movements
No loss of consciousness during seizure
No tongue biting
No urinary or faecal incontinence (not mentioned)
No change in behaviour before seizure (no prodrome)
No lack of sleep prior to episode
No sore throat
No cough
No runny nose
No head injury prior to seizure
No history of previous seizures or febrile seizures
No known epilepsy or underlying neurological condition
First ever hospitalisation

4. SYSTEMIC REVIEW (S/R)

System	Findings
CNS	Seizure (presenting complaint); drowsiness post-ictally; no prior seizures, no developmental regression
CVS	No cyanosis, no chest pain, no palpitation
RS	No cough, no shortness of breath, no noisy breathing
ENT	No runny nose, no sore throat, no ear pain or discharge
GIT	Vomited twice (milk); no diarrhea, no abdominal pain, no abdominal distension
GUT	No dysuria, no frequency, no change in urine colour
MSK	No joint pain, no abnormal gait noted
HAEMA	No bleeding, no bruising, no pallor, no rashes
DERM	No rashes noted (important to assess for petechiae/purpura to exclude meningococcaemia)

5. ANTENATAL HISTORY (ANH)

Mother was 35 years old at the time of this pregnancy (advanced maternal age). She had no known underlying medical conditions prior to or during pregnancy. She attended all routine antenatal check-ups (ANC compliant) at Klinik Kesihatan. She took vitamins prescribed at the clinic and no other medications. She is a non-smoker and no history of alcohol consumption. No obstetric complications (no GDM, no PIH, no PROM, no IUGR, no intrauterine infections) documented.

6. BIRTH HISTORY (BH)

He was born at term (40 weeks gestation) via emergency/elective Caesarean section (LSCS) indicated for fetal distress. Delivery was at the hospital. Birth weight was 3.2 kg (normal birth weight). He cried immediately after delivery. No birth asphyxia or birth trauma documented. He is the second child in the family.

(Note: Document whether emergency or elective LSCS, and confirm APGAR scores if available from birth records.)

7. POSTNATAL HISTORY (PNH)

He developed physiological neonatal jaundice, which did not require hospitalisation or phototherapy. It resolved at home within one week. No neonatal seizures, hypoglycaemia, sepsis, or congenital infections. No NICU admission.

8. DEVELOPMENTAL MILESTONE (DM)

He is developmentally age-appropriate (DAA) as confirmed by the mother. No developmental regression or delay noted.

(For presentation: cite evidence - e.g., at 21 months he should be walking independently, saying approximately 10-25 words, able to stack 3-4 blocks, use a spoon. Confirm these milestones with mother.)

9. IMMUNISATION HISTORY (IM)

Immunisation is up to date as per the national EPI schedule. At 21 months, he should have completed BCG, Hepatitis B (3 doses), DTaP-IPV/Hib (3+1 doses), MMR (1st dose at 12 months), and be approaching or have received the DTaP booster at 18 months.

10. NUTRITIONAL HISTORY (NH)

He is currently receiving breast milk alongside formula powder (combination feeding). Solid food introduction history not specifically documented - at 21 months he should be on family foods. No feeding difficulties, vomiting, or regurgitation reported as a baseline (the two episodes of vomiting were acute and illness-related).

11. PAST MEDICAL HISTORY (PMH)

No known underlying medical conditions
No previous seizures (febrile or afebrile)
No previous febrile seizures
First ever hospitalisation (this admission)
No blood transfusions

12. PAST SURGICAL HISTORY (PSH)

No previous surgical procedures.

13. DRUG HISTORY (DH)

He is not on any regular prescribed medication. He received an IM injection at the buttock in the Emergency Department to abort the second seizure (confirm drug name and dose from ED notes - likely IM midazolam 0.2 mg/kg or IM diazepam).

14. ALLERGIC HISTORY (AH)

No known drug allergies (NKDA). No known food allergies.

15. FAMILY HISTORY (FH)

The family is non-consanguineous. He is the 2nd of 2 siblings. His elder sibling's age, sex, and health status not specifically documented - to clarify. No family history of epilepsy, febrile seizures, atopy, genetic or congenital conditions, developmental delay, or metabolic disorders reported.

(Note: Family history of febrile seizures is a known risk factor - worth specifically asking about in parents and first-degree relatives even if mother initially denies it.)

16. SOCIAL HISTORY (SH)

He lives with his parents and one elder sibling. House type, address, and socioeconomic details not specifically documented - to clarify. Sick contact confirmed: his cousin brother, who is currently still ill, suggesting a viral illness in the family cluster. No recent travel history mentioned. No pets mentioned. Father's occupation and household income not stated.

GENERAL INSPECTION (GI)

Ahmad Kalish Umar is a 21-month-old Malay boy. (Fill in: general appearance, body habitus, whether he appears comfortable or distressed at time of clerking, level of alertness post-ictal recovery, any syndromic features, any rashes.)

At the time of clerking, he should be assessed for:

Level of consciousness and alertness (post-ictal recovery)
Signs of meningism (neck stiffness, photophobia, bulging fontanelle - though fontanelle may be closing at 21 months)
Any petechial or purpuric rash (to exclude meningococcaemia)
Any focal neurological deficits

GENERAL EXAMINATION (GE)

(Fill in findings at clerking - the following fields need to be completed on examination:)

Hands:

Warmth, moisture, colour of palms
CRT < 2 seconds
No finger clubbing, no peripheral cyanosis expected

Eyes:

Conjunctivae: pink or pallor?
Sclera: white or icteric?
No sunken eyes (assess hydration - relevant given vomiting x2 and fever)
Fundoscopy if papilloedema suspected

Mouth:

Moist or dry mucous membranes (hydration status - important given fever and vomiting)
Pink lips, no central cyanosis
Oral hygiene

Neck:

No lymphadenopathy
Neck stiffness / meningism - must be assessed given seizure with fever

Lower Limbs:

No pitting oedema expected

ANTHROPOMETRIC MEASUREMENTS (AM)

Parameter	Value
Height	To be documented
Weight	To be documented
Head Circumference	To be documented

(Plot on WHO growth chart. At 21 months, expected weight for boys is approximately 11-12 kg, height approximately 83-85 cm. Document and plot centiles.)

VITAL SIGNS (VS)

Parameter	Value
Temperature	Febrile on admission (exact reading to confirm from ED notes)
Pulse Rate	To document
Breathing Rate	To document
Blood Pressure	To document
SpO2	To document

NEUROLOGICAL EXAMINATION

(Critical in this case - must be documented in full)

Consciousness: GCS or AVPU scale at time of clerking (post-ictal recovery expected)

Cranial Nerves:

Pupils: equal, round, reactive to light bilaterally
Eye movements intact
Facial symmetry
Other cranial nerves intact

Meningeal Signs:

Neck stiffness - present or absent
Kernig's sign - positive or negative
Brudzinski's sign - positive or negative
Bulging fontanelle - present or absent (at 21 months, fontanelle may already be fused)

Motor:

Tone: normal or increased/decreased
Power: 5/5 bilaterally
No focal neurological deficits expected in simple febrile seizure
Babinski sign - flexor or extensor

Reflexes: Deep tendon reflexes 2+ and symmetrical

Post-ictal state: Drowsiness at presentation, assess recovery at time of clerking

OTHER SYSTEM EXAMINATIONS

Respiratory: No cough, no SOB - assess for any lower respiratory signs (as fever source investigation)

Cardiovascular: Pink, warm peripheries, no murmurs expected

Abdominal: Soft, non-tender, no organomegaly expected; assess for any focus of infection

ENT: Examine tympanic membranes for otitis media (common fever source in toddlers), throat for pharyngitis

SUMMARY

Ahmad Kalish Umar bin Ahmad Fami is a 21-month-old Malay boy, second child, born via LSCS at 40 weeks with birth weight 3.2 kg, with no prior medical history, admitted on the night of 3rd June 2026 with fever of unknown reading associated with two episodes of seizure. The first episode lasted 4 minutes, characterised by upward eye deviation and fist clenching, with no generalised tonic-clonic movements and no loss of consciousness, occurring while he was in the car. He had post-ictal drowsiness and vomited twice. A second seizure occurred upon arrival to the ED and was aborted with an IM anticonvulsant. He had a sick contact (cousin, currently still ill).

This is his first ever episode of febrile seizure and first hospitalisation.

Working diagnosis: Simple Febrile Seizure - fever-provoked seizure in a child aged 6 months to 5 years, lasting < 15 minutes, without focal features, with no neurological deficit post-ictally. The presence of a sick contact supports a viral aetiology as the underlying fever source.

Key differentials to discuss:

Complex febrile seizure - the second episode within the same illness makes this borderline; however, each individual seizure was < 15 minutes and apparently non-focal
Meningitis/Encephalitis - must be excluded given fever + seizure; assess for meningism on examination
Viral encephalitis - consider if altered consciousness or focal deficits present
First unprovoked seizure / epilepsy - less likely given clear febrile context and no prior afebrile seizures

Important note: Two seizures occurring within the same febrile illness may reclassify this as a complex febrile seizure - this is an important distinction to address in your presentation and management discussion.

Items to complete before presenting:

Confirm IM drug given in ED (name, dose, route)
Full vital signs from ED and ward
Full neurological examination findings at clerking
Anthropometric measurements and growth chart
Confirm elder sibling's details
Father's occupation and social background
Investigations ordered: FBC, CRP, blood culture, urine FEME, consider LP if meningism present, EEG not routinely needed acutely
Confirm whether second seizure was same character as first or different

Same templste diff patient, yusuf abbasy bin muhd fariz on mdi budesonide once daily, 2 years 2 months old presented with fever since 2 days ago associated with runny nose and non productive cough for the past three days, he was apparently well until 3 days ago when he developed cough and runny nose due to sick contact from his mother who had similar symptoms, the runny nose had yellow coloured flu, besides runny nose, no other coryzal symptms, non 0roductive cough no phlegm, no prolong or barking coughmum but was increasing in frequency as days passed suspected that fever would come gave paractamol in advance, but he had fever the next day, she was giving pcm 5 hoursly, fever subsided by sweating and came back, reduced sleep, every hour wakes up at night, loss of appetitie on the day of admission, in the afternoon hestarted to have subcostal recession intercostal recession, trachea too signs of respiratory distress, mother rushed him to emergency,otherwise no vomiting no diarrhea no seizure, anternatal history he was born on 6th april 2024 via csec at 39 weeks due to fetal distress, mother had no obstettic problems but had allergic rhinitis , non smoker non alcoholic, attended all anc routine, he had neonatal jaundice for 2 weeks, wasnt admitted but checked at kk, 3.13kg weight, cried immediately after birth developmental can climb stairs, form 5 words , immunisation up to date, was breastfeed upto 2years, can consume fruits, on formula tdrink dutch lady, he had been hospitwlisedtwice for the same problem, started on inhaler during 2nd admission, currently on fixotide evohaler, blue mdi, mother uses whenever necessary only, no past surgical history, allergic to rush develops rash mom applies cetaphil for relief,

Here is the full long case presentation for Yusuf Abbasy:

LONG CASE PRESENTATION - PAEDIATRIC

HISTORY TAKING & PHYSICAL EXAMINATION

1. PERSONAL IDENTIFICATION DATA (PID)

Presenting my patient, Yusuf Abbasy bin Muhd Fariz, a 2-year 2-month-old Malay boy (Date of Birth: 6th April 2024). He was admitted to the ward and was clerked on the day of presentation. The history is taken from his mother.

2. CHIEF COMPLAINT (C/C)

He presented with a complaint of fever for 2 days, associated with runny nose and non-productive cough for 3 days prior to admission.

3. HISTORY OF PRESENTING COMPLAINT (HOPI)

He was apparently well before this until 3 days prior to admission when he developed cough and runny nose. The likely source was a sick contact from his mother, who had similar symptoms at the time.

Day 1 (3 days before admission) - Onset of cough and runny nose:

He developed a non-productive cough with no phlegm, no prolonged cough, and no barking or brassy quality
Cough was increasing in frequency as days progressed
Runny nose with yellow-coloured nasal discharge
No other coryzal symptoms (no sore throat, no ear pain, no eye discharge)
Mother anticipated fever and gave paracetamol in advance

Day 2 (2 days before admission) - Onset of fever:

Despite pre-emptive paracetamol, he developed fever the next day
Exact temperature reading not documented - to confirm
Mother commenced paracetamol 5-hourly
Fever pattern: subsided with sweating then returned (intermittent pattern)
Reduced sleep - waking up every hour at night
No loss of appetite at this stage

Day 3 (day of admission) - Deterioration:

Loss of appetite on the morning/day of admission
In the afternoon, mother noticed signs of respiratory distress:
- Subcostal recession
- Intercostal recession
- Tracheal tug
Mother brought him to the Emergency Department immediately

Relevant positives:

Fever (2 days), intermittent, subsides with PCM and sweating
Non-productive cough, increasing in frequency (3 days)
Yellow nasal discharge (3 days)
Sick contact: mother with similar symptoms
Subcostal recession, intercostal recession, tracheal tug on day of admission
Reduced sleep (waking hourly at night)
Loss of appetite on day of admission
Known case on MDI Budesonide once daily (inhaled corticosteroid - preventive therapy)
Currently on Fixotide Evohaler (Fluticasone propionate - blue MDI) used PRN by mother
Two previous hospitalisations for the same problem (recurrent wheeze/respiratory distress)
Inhaler started during 2nd admission

Relevant negatives:

No barking or prolonged cough
No phlegm / productive cough
No vomiting
No diarrhea
No seizure
No wheeze specifically mentioned - to confirm on examination
No sore throat
No ear pain or discharge
No eye symptoms

4. SYSTEMIC REVIEW (S/R)

System	Findings
CNS	Reduced sleep (waking hourly); no seizure, no headache, no altered consciousness
CVS	No cyanosis documented, no chest pain, no palpitation
RS	Cough (presenting complaint), fever, subcostal and intercostal recession, tracheal tug; no wheeze specifically documented - to confirm
ENT	Yellow nasal discharge; no sore throat, no ear pain or discharge, no other coryzal symptoms
GIT	Loss of appetite (day of admission); no vomiting, no diarrhea, no abdominal pain
GUT	No dysuria, no change in urine output or colour
MSK	No joint pain, no abnormal gait
HAEMA	No bleeding, no pallor, no petechiae
DERM	Allergic rash - develops rash (allergic in nature); mother applies Cetaphil for symptomatic relief

5. ANTENATAL HISTORY (ANH)

Mother had no obstetric complications during pregnancy. She has a background history of allergic rhinitis (relevant - atopic family background, which increases the child's risk of atopic conditions including asthma). She attended all routine ANC check-ups at Klinik Kesihatan. She was prescribed routine vitamins and took no other medications. She is a non-smoker and has no history of alcohol consumption. No GDM, no PIH, no PROM, no IUGR, no intrauterine infections documented.

(Note: Maternal allergic rhinitis is a significant atopic risk factor - supports a diagnosis of bronchial asthma in this child.)

6. BIRTH HISTORY (BH)

He was born at 39 weeks gestation (term) on 6th April 2024 via Caesarean section (LSCS) indicated for fetal distress, at the hospital. Birth weight was 3.13 kg (normal birth weight). He cried immediately after delivery. No birth asphyxia, no birth trauma documented. APGAR score not mentioned - to confirm from records.

7. POSTNATAL HISTORY (PNH)

He developed neonatal jaundice lasting 2 weeks. He was not admitted for this; jaundice was monitored at Klinik Kesihatan and resolved without phototherapy or blood transfusion. No neonatal seizures, hypoglycaemia, sepsis, or congenital infections. No NICU admission.

(Note: Prolonged neonatal jaundice lasting 2 weeks warrants a brief mention - physiological jaundice typically resolves by day 14 in term infants; at the border, but mother confirmed it resolved without intervention.)

8. DEVELOPMENTAL MILESTONE (DM)

He is developmentally age-appropriate (DAA). Evidence at 2 years 2 months:

Gross Motor: Can climb stairs (expected by 18-24 months)
Language: Can form 5 words (expected vocabulary at 2 years is approximately 50+ words with 2-word combinations; 5 words is slightly below expected - worth clarifying with mother whether she means 5-word sentences or 5 individual words. If truly only 5 words, this may warrant further language developmental assessment.)

(Clarify: does mother mean 5-word sentences or 5 individual words? Flag if the latter.)

9. IMMUNISATION HISTORY (IM)

Immunisation is up to date as per the national EPI schedule. At 2 years 2 months, he should have completed BCG, all 3 Hepatitis B doses, DTaP-IPV/Hib primary series and 18-month booster, and MMR at 12 months.

10. NUTRITIONAL HISTORY (NH)

He was breastfed up to 2 years of age. He is currently on Dutch Lady growing-up formula milk. He is able to consume fruits and is on an age-appropriate diet. No feeding difficulties, vomiting, or regurgitation as a baseline. Loss of appetite was acute, occurring only on the day of admission in the context of the current illness.

11. PAST MEDICAL HISTORY (PMH)

Two previous hospitalisations for the same problem (recurrent episodes of respiratory distress with cough - consistent with recurrent wheeze / bronchial asthma)
Inhaler (Budesonide MDI, once daily - preventive / controller therapy) started during the 2nd admission
Currently also prescribed Fixotide Evohaler (Fluticasone propionate - blue MDI) used PRN (reliever - note: Fixotide/Fluticasone is actually an inhaled corticosteroid, not a bronchodilator; to confirm with treating team whether this is correct or whether the blue MDI is actually Salbutamol (Ventolin), as blue inhalers are conventionally bronchodilators. This discrepancy should be clarified.)
Allergic rash - develops skin rash (allergic/eczematous); mother applies Cetaphil cream for relief
No other known chronic medical conditions
No blood transfusions

(Important clinical note: This child is on MDI Budesonide (inhaled corticosteroid - ICS) as a controller, has had 2 prior admissions for the same respiratory problem, and has an atopic history (skin rash, maternal allergic rhinitis). This strongly supports a diagnosis of Bronchial Asthma. The acute presentation with recession and tracheal tug represents an acute exacerbation of asthma.)

12. PAST SURGICAL HISTORY (PSH)

No previous surgical procedures.

13. DRUG HISTORY (DH)

Medication	Route	Frequency	Indication	Compliance
Budesonide MDI	Inhaled	Once daily	Controller / preventive (ICS)	To confirm
Fixotide Evohaler (Fluticasone propionate)	Inhaled	PRN (as needed)	Acute relief - used by mother whenever necessary	PRN use - not regular
Paracetamol	Oral	5-hourly (during illness)	Antipyretic	Given during current illness

(Note: Mother is using the Fixotide Evohaler only when necessary - this is appropriate if it is indeed a reliever. However, Fluticasone is an ICS controller, not a bronchodilator. Clarify with team whether a SABA like Salbutamol is also prescribed or intended. Adherence to the daily Budesonide should be specifically assessed as poor adherence is a major contributor to exacerbations.)

14. ALLERGIC HISTORY (AH)

He has a history of allergic rash - develops a rash (likely urticarial or eczematous in nature). The trigger has not been specifically documented. Mother applies Cetaphil (moisturising cream) for symptomatic relief. No drug allergies specifically mentioned - to confirm NKDA.

(Note: The presence of allergic skin manifestations alongside recurrent wheeze and maternal atopy forms part of the atopic triad - strongly supports asthma as the underlying diagnosis.)

15. FAMILY HISTORY (FH)

Mother has allergic rhinitis (atopic condition - direct first-degree relative)
No other specific family history of asthma, eczema, epilepsy, febrile seizures, genetic conditions, or congenital anomalies documented
Father's health status not mentioned - to clarify
Number of siblings not specified - to clarify

(Atopic family history in a first-degree relative significantly increases risk of bronchial asthma in the child.)

16. SOCIAL HISTORY (SH)

He lives with his parents. Number of persons per household, house type, and socioeconomic details not fully documented - to clarify. Sick contact confirmed - his mother had similar symptoms (cough and runny nose) and is the likely index case for this illness. Father's occupation and household income not stated. No specific environmental exposures (dust, pets, mold, passive smoke) documented - important to ask given asthma diagnosis. No recent travel history mentioned.

GENERAL INSPECTION (GI)

Yusuf Abbasy is a 2-year 2-month-old Malay boy. (Fill in on examination: body habitus, level of comfort or distress, work of breathing at time of clerking, any syndromic features, any visible rash or skin changes, posture, level of alertness and interaction.)

Key observations at time of examination:

Is he currently in respiratory distress? (recession present or resolved with treatment?)
Is he alert and interactive or irritable and quiet?
Any wheeze audible without stethoscope?
Any visible eczematous patches or skin rashes?
Any Harrison's sulcus (chronic hyperinflation - seen in poorly controlled asthma)?

GENERAL EXAMINATION (GE)

(Complete on examination - expected findings given the clinical picture:)

Hands:

Warmth, moisture, colour
CRT - expected < 2 seconds
No clubbing (clubbing not a feature of asthma unless very chronic/severe)
No peripheral cyanosis

Eyes:

Conjunctivae: pink or pallor?
Sclera: white
Allergic shiners (dark periorbital circles) - may be present given atopic background
Dennie-Morgan lines - to assess

Mouth:

Moist or dry mucous membranes
Pink lips, no central cyanosis
Mouth breathing - may be present given nasal congestion

Neck:

Lymphadenopathy - cervical nodes may be enlarged in the context of URTI
No neck masses

Skin:

Assess for eczematous patches (flexural surfaces, face) - part of atopic triad

ANTHROPOMETRIC MEASUREMENTS (AM)

Parameter	Value
Height	To be documented
Weight	To be documented
Head Circumference	To be documented

(Plot on WHO growth chart. At 2 years 2 months, expected weight for boys approximately 12-13 kg, height approximately 86-88 cm. Faltering growth can occur in poorly controlled asthma - important to assess.)

VITAL SIGNS (VS)

Parameter	Value
Temperature	Febrile (exact reading to document from admission notes)
Pulse Rate	To document (tachycardia expected with fever and respiratory distress)
Breathing Rate	To document (tachypnea expected - normal for age is 25-30 bpm; >40 bpm is significant)
SpO2	To document - critical in this case
Blood Pressure	To document

RESPIRATORY EXAMINATION

General Examination (peripheral):

Hands: warm/dry/pink, CRT < 2 sec, no clubbing, no peripheral cyanosis
Eyes: conjunctivae pink, sclera white, possible allergic shiners
Mouth: assess hydration, no central cyanosis
Neck: cervical lymphadenopathy possible given URTI

Inspection:

Chest deformity: assess for barrel chest or Harrison's sulcus (chronic hyperinflation in asthma)
Movement: symmetrical with respiration
Subcostal recession - present on admission (document current status)
Intercostal recession - present on admission (document current status)
Tracheal tug - present on admission (document current status)
Nasal flaring - to assess
No surgical scars

Palpation:

Trachea: centrally located
Chest expansion: symmetrical, may be reduced bilaterally in bronchospasm
Vocal fremitus: may be reduced bilaterally

Percussion:

May show bilateral hyper-resonance in acute asthma (air trapping)

Auscultation:

Bilateral rhonchi / wheeze - expected finding (expiratory wheeze in asthma)
Prolonged expiratory phase - to assess
Air entry: may be reduced bilaterally in severe bronchospasm
Crepitations: possible if concurrent lower respiratory tract infection

OTHER SYSTEM EXAMINATIONS

Cardiovascular: Pink, warm peripheries, regular rhythm. No murmurs. In severe asthma, assess for pulsus paradoxus.

Abdominal: Soft, non-tender. No organomegaly. Assess for use of accessory muscles / abdominal muscles during respiration.

ENT:

Nasal mucosa: congested, yellow discharge consistent with URTI
Tympanic membranes: assess for otitis media (common concurrent infection in children with URTI)
Throat: erythema possible

Skin:

Eczematous patches - if present, document location and extent (atopic dermatitis as part of atopic march)

CNS: Alert, not irritable. No focal deficits.

SUMMARY

Yusuf Abbasy bin Muhd Fariz is a 2-year 2-month-old Malay boy (DOB: 6th April 2024), known case on inhaled Budesonide (preventive therapy), with two prior hospitalisations for the same respiratory problem, presenting with a 3-day history of non-productive cough and yellow nasal discharge, followed by 2 days of fever (intermittent, responsive to paracetamol), and acute deterioration on the day of admission with the development of subcostal recession, intercostal recession, and tracheal tug. He has a sick contact from his mother (similar symptoms). He has a personal history of allergic rash and a maternal history of allergic rhinitis, forming a strong atopic background.

Working diagnosis: Acute Exacerbation of Bronchial Asthma - triggered by a viral upper respiratory tract infection, in a child with pre-existing asthma on ICS controller therapy, with atopic risk factors (personal eczema-equivalent rash, maternal allergic rhinitis).

Key differentials to discuss:

Bronchiolitis - less likely given age (>2 years), prior similar episodes, and ICS use
Viral-induced wheezing - relevant at this age but the pattern of multiple hospitalisations and controller therapy makes true asthma more appropriate
Pneumonia - yellow nasal discharge and fever; assess for focal crepitations, consolidation on CXR
Croup - no barking cough, no stridor mentioned; less likely

Important clinical flags:

Mother is using Fixotide (Fluticasone) PRN only - this is an ICS, not a bronchodilator. Clarify whether a SABA (Salbutamol/Ventolin) is also prescribed. Failure to have a reliever is a safety concern in acute exacerbations.
Adherence to daily Budesonide should be assessed - "uses only when necessary" suggests possible poor compliance with controller therapy, which may be contributing to recurrent exacerbations.
The neonatal jaundice lasted 2 weeks - borderline for term infant; document as prolonged if beyond day 14 and note that it was monitored and resolved without intervention.
Language milestone - clarify whether "5 words" means 5 individual vocabulary words or 5-word sentences. At 26 months, expected vocabulary is well beyond 50 words with 2-3 word combinations; if truly only 5 words, a formal developmental assessment is warranted.

Items to complete before presenting:

Full vital signs (temperature reading, HR, RR, SpO2) from admission and at clerking
Anthropometric measurements and growth chart plotting
Full respiratory examination findings at clerking (current recession status, wheeze, air entry)
Skin examination findings (eczema patches)
Investigations: CXR, FBC, CRP, blood culture if indicated, nasal swab if influenza suspected
Confirm drug prescribed as reliever (blue MDI - Salbutamol vs. Fluticasone)
Assess adherence to daily Budesonide controller therapy
Father's occupation, household income, social background
Environmental allergen exposure history (house dust mites, pets, mold, passive smoke)
Clarify language milestone (5 words vs. 5-word sentences)

$attachment$

+14 more

Another case

I can read all the images clearly. Let me compile everything from the clinical notes into the full long case format.

LONG CASE PRESENTATION - PAEDIATRIC

HISTORY TAKING & PHYSICAL EXAMINATION

1. PERSONAL IDENTIFICATION DATA (PID)

Presenting my patient, Muhammad Raizan Qaiser bin Roslizan, a 1-year 10-month-old Malay boy (SP00873712). He was referred from the Emergency Department and clerked on 9th June 2026 at 09:18. The history is taken from his mother.

2. CHIEF COMPLAINT (C/C)

He was referred from the Emergency Department with complaints of fever for 1 week, vomiting for 1 week, and reduced oral intake, in a background of prolonged chesty cough for 1 month and constipation for 2 weeks.

3. HISTORY OF PRESENTING COMPLAINT (HOPI)

He was apparently well before this until 1 week prior to admission when he developed the following symptoms in the context of his known underlying conditions:

Fever (1 week duration):

Pattern: on and off (intermittent)
Highest temperature recorded: 39°C
Antipyretics given at home - to confirm
No febrile seizure

Vomiting (1 week duration):

Timing: post-prandial
Content: food content and milk
Character: non-bilious, non-bloody
Frequency: 5-6 episodes per day
Associated with reduced oral intake - acute deterioration noted on the day of admission (today)

Reduced oral intake (1 week, worsening today):

Poor feeding for 1 week, with acute-on-chronic worsening on day of admission
Only tolerating 1 bottle of milk since yesterday evening (upon admission)

Constipation (2 weeks duration):

Normal bowel opening (NBO): 2-3 days between motions
Baseline bowel habit: usually 2-3 times per day
Parents had been administering enemas at home
No blood in stool, no mucus mentioned

Prolonged chesty cough (1 month duration):

Productive cough with whitish sputum
No barking quality, no stridor
No rapid breathing
No loose stools associated

Previous ED visit:

Visited ED on 1st June 2026 and was discharged with syrup amoxicillin - course completed
Despite completing antibiotics, symptoms of cough persisted - now re-presenting

Relevant positives:

Fever up to 39°C, on and off, 1 week
Vomiting 5-6x/day, post-prandial, non-bilious, non-bloody, 1 week
Reduced oral intake (1 week), significantly worsened day of admission
Constipation 2 weeks (NBO every 2-3 days, baseline 2-3x/day)
Prolonged chesty cough with whitish sputum for 1 month
Previous ED visit 1/6/26 with syrup amoxicillin - completed
Saturating under room air on admission
Known G6PD deficiency
Known Bronchial Asthma on MDI Salbutamol PRN and MDI Budesonide BD

Relevant negatives:

No loose stool / diarrhea
No sick contact
No rapid breathing
No history of travel
No blood or bile in vomitus
No seizure

4. SYSTEMIC REVIEW (S/R)

System	Findings
CNS	No seizure, no headache, no altered consciousness
CVS	No cyanosis, no chest pain; saturating under room air on admission
RS	Prolonged chesty cough with whitish sputum (1 month); known bronchial asthma; no rapid breathing, no stridor
ENT	Throat injected, unable to visualise tonsil (on examination); no runny nose documented
GIT	Vomiting 5-6x/day post-prandial (1 week); constipation 2 weeks (NBO 2-3 days); reduced oral intake; no diarrhea, no blood in stool
GUT	No dysuria, no change in urine output
MSK	No joint pain, no abnormal gait
HAEMA	Known G6PD deficiency - no haemolytic episode triggered (no offending agent mentioned)
DERM	No rashes; no allergic history

5. ANTENATAL HISTORY (ANH)

(Not documented in the clinical notes - to obtain from mother.) Items to ask: maternal age, ANC attendance, any obstetric complications (GDM, PIH, infections), medications during pregnancy, smoking/alcohol status.

6. BIRTH HISTORY (BH)

(Not specifically documented in notes - to obtain.) Items to ask: gestational age, mode of delivery, birth weight, APGAR score, place of birth, any birth complications.

7. POSTNATAL HISTORY (PNH)

Neonatal jaundice (NNJ) - admitted at 51 hours of life (HOL) for NNJ and was concurrently diagnosed with G6PD deficiency at that admission
Treatment for NNJ not specified - likely phototherapy given inpatient admission; to confirm
No other neonatal complications documented

8. DEVELOPMENTAL MILESTONE (DM)

He is developmentally age-appropriate (DAA) for a 1-year 10-month-old. Evidence documented:

Domain	Milestone	Expected Age
Gross Motor	Able to jump and run	Expected by ~24 months - appropriate
Fine Motor	Able to scribble and draw circles	Expected by ~24 months - appropriate
Speech / Language	Able to say "mama" and "abah"	(Note: at 22 months, expected vocabulary is ~50 words with 2-word combinations; only 2 words documented - clarify if mother means these are examples or if truly vocabulary-limited. May warrant further language assessment.)
Social / Personal	Able to feed himself with a spoon, able to wave, demonstrates stranger anxiety	Appropriate for age

9. IMMUNISATION HISTORY (IM)

(Not specifically documented - to confirm with mother and Red Book.) At 1 year 10 months, he should have completed the full EPI schedule including DTaP-IPV/Hib booster at 18 months and MMR at 12 months.

10. NUTRITIONAL HISTORY (NH)

Current diet:

Prefers Cerelac
Takes rice with protein - chicken and fish
Does not take vegetables
Takes fruits: orange and grapes
Recent formula milk change 2 days ago: switched from Fernleaf to Lactogrow

(Note: The recent formula milk change 2 days prior to admission is clinically relevant - may have contributed to or exacerbated the vomiting and constipation. Lactogrow and Fernleaf have different compositions; cow's milk protein intolerance / formula intolerance should be considered in the context of vomiting and constipation.)

Breastfeeding history: Not documented - to clarify.

11. PAST MEDICAL HISTORY (PMH)

This is his 3rd admission:

Admission	Age	Reason
1st admission	51 hours of life	Neonatal jaundice (NNJ) + G6PD deficiency diagnosis
2nd admission	1 year 6 months (February 2026)	Acute exudative tonsillitis with reduced oral intake
3rd admission (current)	1 year 10 months (9th June 2026)	Fever, vomiting, reduced oral intake, prolonged cough

Known underlying conditions:

G6PD Deficiency - diagnosed at birth (1st admission)
Bronchial Asthma - currently on inhaler therapy

Previous ED visit: 1st June 2026 - discharged with syrup amoxicillin (completed)

12. PAST SURGICAL HISTORY (PSH)

No previous surgical procedures documented.

13. DRUG HISTORY (DH)

Medication	Route	Dose/Frequency	Indication	Compliance
MDI Salbutamol	Inhaled (via aerochamber)	1 puff PRN	Bronchial asthma - reliever (SABA)	Compliant with aerochamber use
MDI Budesonide	Inhaled (via aerochamber)	1 puff BD	Bronchial asthma - controller (ICS)	Compliant with aerochamber use
Syrup Amoxicillin	Oral	Course completed	Prescribed at ED 1/6/26	Completed

(Note: Aerochamber compliance confirmed - important in a child this age as correct inhaler technique with spacer is essential for drug delivery.)

(G6PD deficiency - ensure all medications prescribed are checked against G6PD-unsafe drug list. Avoid: aspirin, some antibiotics [nitrofurantoin, primaquine, dapsone], methylene blue, and high-dose vitamin C. Paracetamol and amoxicillin are safe.)

14. ALLERGIC HISTORY (AH)

No known allergic history (NKDA / NKFA).

15. FAMILY HISTORY (FH)

Family Member	Age	Occupation	Medical Condition
Mother	36 years old	Housewife	Eczema (atopic condition)
Father	42 years old	Pensioner (Army)	Hypertension (HPT)

Maternal eczema is an atopic condition - supports atopic background in the child (bronchial asthma)
No family history of G6PD deficiency specifically mentioned - to ask (X-linked condition; maternal carrier likely)
Non-consanguineous family assumed
Number of siblings not documented - to clarify

(Note: G6PD deficiency is X-linked recessive. Mother is likely a carrier. Paternal status unlikely relevant for an X-linked condition in a male child. Family pedigree not required unless consanguinity suspected.)

16. SOCIAL HISTORY (SH)

Lives at Darul Aman Perdana
Taken care of fully by mother (father is a retired army pensioner)
No smoker in the family (important in a child with bronchial asthma - removes passive smoke as a trigger)
House type: not specified (Darul Aman Perdana is a residential housing area) - to document
Number of persons in household: not specified
Nearest medical access: to document
No recent travel history
No sick contact

GENERAL INSPECTION (GI)

Muhammad Raizan Qaiser is a 1-year 10-month-old Malay boy. At time of examination, he is:

Alert and pink (as documented in progress notes)
Not in acute respiratory distress at time of clerking (lungs clear on auscultation)
No syndromic features documented
No cyanosis, no obvious pallor
Was saturating under room air upon admission - document current SpO2 and whether supplemental oxygen is still required
No peripheral attachments documented other than IV cannula (IVD HSD5% commenced at 41 cc/hr full maintenance)

GENERAL EXAMINATION (GE)

As documented in progress notes (9th June 2026):

Hands:

Warm, moist/dry - to confirm
CRT < 2 seconds expected
No peripheral cyanosis
No clubbing

Eyes:

Conjunctivae: pink (no anaemia) - important to assess given G6PD deficiency (haemolytic anaemia risk)
Sclera: white (no jaundice) - important given G6PD and history of NNJ

Mouth:

Moist mucous membranes / hydration status - to confirm (poor oral intake, vomiting - at risk of dehydration)
Pink lips, no central cyanosis

Neck:

No lymphadenopathy documented

Lower Limbs:

No pitting oedema expected

ANTHROPOMETRIC MEASUREMENTS (AM)

Parameter	Value
Weight	10 kg (documented in notes)
Height	To be documented
Head Circumference	To be documented

(At 1 year 10 months, WHO median weight for boys is approximately 11-11.5 kg. Current weight of 10 kg is slightly below median but within acceptable range - plot on growth chart to determine centile. The acute reduction in oral intake may have contributed to current weight.)

VITAL SIGNS (VS)

Parameter	Value
Temperature	Febrile (highest 39°C documented); current reading to confirm
Pulse Rate	To document
Breathing Rate	To document (no rapid breathing per history)
SpO2	Saturating under room air on admission - current value to document
Blood Pressure	To document

INVESTIGATIONS

FBC (POCT):

Parameter	Value	Reference
TWC	7.8 x10⁹/L	6-17 x10⁹/L
Hb	11.8 g/dL	10.5-13.5 g/dL
Platelets	233 x10⁹/L	150-400 x10⁹/L

TWC is within normal range (no significant leukocytosis)
Hb is within normal range (no acute haemolysis from G6PD currently)
Platelets normal

VBG (POCT):

Parameter	Value	Reference
pH	7.39	7.35-7.45
Lactate	0.9 mmol/L	< 2.0 mmol/L
HCO3	21.2 mmol/L	22-26 mmol/L

pH normal - no acidosis
Lactate normal - no tissue hypoperfusion
HCO3 mildly low at 21.2 - borderline mild metabolic acidosis (likely compensatory from vomiting-induced loss, or early dehydration)

CXR:

Minimal right perihilar haziness - suggests early/mild right perihilar infiltrate; may represent early right lower lobe pneumonia or perihilar lymphadenopathy; correlate with clinical findings

RESPIRATORY EXAMINATION

Inspection:

No chest deformity (no barrel chest, no Harrison's sulcus documented)
No recession noted at time of clerking
No nasal flaring

Auscultation:

Lungs: CLEAR bilaterally at time of clerking (despite right perihilar haziness on CXR)
No added sounds (no wheeze, no crepitations) at time of clerking

(Note: Absence of wheeze at time of clerking may reflect current asthma control or underinflation of airways. The prolonged productive cough and CXR changes need further correlation.)

CARDIOVASCULAR EXAMINATION

CVS: DRNM (Dual rhythm, no murmur) - heart sounds normal, no added sounds

ABDOMINAL EXAMINATION

Abdomen: Soft, non-distended - no organomegaly documented
No visible peristalsis
No guarding or rigidity
Bowel sounds: to document

ENT EXAMINATION (THROAT)

Throat: Injected, unable to visualise tonsil - tonsillar enlargement likely (tonsils obscuring view), consistent with acute tonsillopharyngitis
No drooling, no stridor, no trismus

IMPRESSION (AS DOCUMENTED BY HO)

1. Acute tonsillopharyngitis with reduced oral intake

(Clinical correlation: The injected throat with inability to visualise tonsil, fever, vomiting, and poor oral intake in a child with a prior admission for acute exudative tonsillitis at 18 months of age is consistent with recurrent acute tonsillitis. The prolonged productive cough with right perihilar haziness on CXR may represent a concurrent lower respiratory tract infection or the evolution of his asthma.)

PLAN (AS DOCUMENTED)

Observe under Room Air (RA)
Keep SpO2 > 95%
Encourage oral intake
Start IVD HSD5% at 41 cc/hr (Full maintenance)
Indent tonsil diet + ice cream
KIV to start antibiotic after review by MO

SUMMARY

Muhammad Raizan Qaiser bin Roslizan is a 1-year 10-month-old Malay boy, known case of G6PD deficiency and Bronchial Asthma (on MDI Salbutamol PRN and MDI Budesonide BD via aerochamber), current weight 10 kg, referred from Emergency Department on 9th June 2026 with a 1-week history of on-off fever (highest 39°C), vomiting 5-6 times daily (post-prandial, non-bilious, non-bloody), poor oral intake acutely worsening on day of admission, a 2-week history of constipation managed with home enemas, and a 1-month history of prolonged chesty cough with whitish sputum. He had a prior ED visit on 1st June 2026 and completed a course of syrup amoxicillin without resolution of cough. This is his 3rd hospitalisation (1st for NNJ/G6PD at 51 HOL; 2nd for acute exudative tonsillitis at 18 months). On examination he is alert, pink, lungs clear, CVS normal, abdomen soft. Throat is injected with tonsils unable to be visualised. Investigations show normal FBC, borderline low HCO3 on VBG, and minimal right perihilar haziness on CXR.

Working diagnosis: Acute Tonsillopharyngitis (recurrent) with reduced oral intake

Key differentials and additional considerations:

Recurrent tonsillitis - 2nd documented admission for tonsillitis; consider referral for ENT assessment re: tonsillectomy criteria (Paradise criteria: 7 episodes/year, 5/year x 2 years, or 3/year x 3 years)
Lower respiratory tract infection / pneumonia - right perihilar haziness on CXR + 1 month productive cough; lungs clinically clear but CXR changes need follow-up
Acute asthma exacerbation - to monitor SpO2 and respiratory status; no active wheeze at clerking
Dehydration - poor oral intake + vomiting for 1 week, borderline HCO3; IVD commenced appropriately
Constipation - likely functional; exacerbated by poor oral intake and formula change; consider laxative if not resolving
Formula change-related GI upset - recent switch from Fernleaf to Lactogrow 2 days ago may have contributed to vomiting and altered bowel habit

G6PD safety reminder: Ensure all prescribed drugs (especially antibiotic when started) are G6PD-safe. Amoxicillin is safe. Avoid oxidant drugs.

Items to complete before presenting:

Antenatal and birth history (not in notes)
Immunisation status confirmation
Breastfeeding history
Full vital signs (HR, RR, BP, current temperature and SpO2)
Height and head circumference for growth chart plotting
Full physical examination findings (beyond what is in progress notes)
Confirm antibiotic decision by MO after review
Pending investigations: blood culture, urine FEME and culture, throat swab if indicated
ENT referral consideration for recurrent tonsillitis
Follow-up CXR if clinical deterioration or if perihilar haziness persists

Shorter summary

Muhammad Raizan Qaiser bin Roslizan is a 1-year 10-month-old Malay boy, known case of G6PD deficiency and Bronchial Asthma on MDI Salbutamol PRN and MDI Budesonide BD via aerochamber, weighing 10 kg, referred from ED on 9th June 2026.

He presented with a 1-week history of on-off fever (highest 39°C), vomiting 5-6 times daily (post-prandial, non-bilious, non-bloody), and poor oral intake acutely worsening on the day of admission - tolerating only 1 bottle of milk since the evening prior. He also has a 2-week history of constipation (NBO every 2-3 days, managed with home enemas) and a 1-month history of productive chesty cough with whitish sputum. He visited ED on 1st June 2026 and completed syrup amoxicillin without cough resolution.

This is his 3rd admission (1st for NNJ and G6PD deficiency at 51 hours of life; 2nd for acute exudative tonsillitis at 18 months).

On examination he is alert and pink, lungs clear, CVS normal, abdomen soft and non-distended. Throat is injected with tonsils unable to be visualised. Investigations show FBC within normal limits (TWC 7.8, Hb 11.8, Plt 233), VBG with borderline low HCO3 of 21.2, and CXR with minimal right perihilar haziness.

Working diagnosis: Acute tonsillopharyngitis with reduced oral intake - currently on IVD HSD5% 41 cc/hr (full maintenance), tonsil diet, SpO2 monitoring, with antibiotic KIV pending MO review.

Fill in with the most possible answers according to the template for the 21 month old baby ahmad kalish umar, urea 3.4 na 136 k 4.3 cl 106 sr 28 twbc 11.9 plt13.4 pcv 376 lymph 39.5 granulocyte 55.6

Running Command

cd /home/daytona/workspace/attachments/c2cfb993-17fd-45ed-b31a-8911b49cf3d2/ && python3 -c " import pdfplumber with pdfplumber.open('Paediatrics Year 3 Log Book_260618_221531.pdf') as pdf: print(f'Pages: {len(pdf.pages)}') for i, page in enumerate(pdf.pages): print(f'--- PAGE {i+1} ---') print(page.extract_text()) "

Good. Now I have both the template and the full clinical data from the earlier Ahmad Kalish Umar case. Let me fill this in completely.

PAEDIATRICS YEAR 3 LOG BOOK

Ahmad Kalish Umar bin Ahmad Fami | 21 months old | Male

Admission: 3rd June 2026 | Diagnosis: Simple Febrile Seizure

PHYSICAL EXAMINATION

GENERAL EXAMINATION

General Appearance: Ahmad Kalish Umar is a 21-month-old Malay boy who appears well-nourished and well-grown for his age. He is alert and conscious, lying comfortably in bed. He is not in acute distress. At the time of clerking he is post-ictal recovery - no longer drowsy. No syndromic features, no gross deformity, no abnormal posture or movements. No peripheral attachments noted at time of clerking.

Vital Signs:

Parameter	Value	Normal Range (21 months)
Temperature	Febrile (exact reading to confirm from ED notes; fever onset evening 3/6/26)	36.5 - 37.5°C
Pulse Rate	To document	80 - 130 bpm
Respiratory Rate	To document	20 - 30 breaths/min
Blood Pressure	To document	~85/55 mmHg
SpO2	To document	> 95%

Anthropometric Measurements:

Parameter	Value	Interpretation
Height/Length	_____ cm	Plot on WHO chart
Weight	_____ kg	Expected ~11-12 kg for 21-month-old boy
Head Circumference	_____ cm	Expected ~47-48 cm
BMI	_____ kg/m²	Plot on WHO chart

HEAD TO TOE EXAMINATION

Hands:

Palms: pink, warm, dry
Capillary refill time: < 2 seconds
No peripheral cyanosis
No finger clubbing
No pallor of palmar creases

Pallor: No pallor - conjunctivae pink, palmar creases pink

Cyanosis: Absent - no peripheral or central cyanosis

Jaundice: Absent - sclera white, no icteric discolouration

Oral Cavity:

Mucous membranes: moist (assess hydration - relevant given fever and vomiting x2)
Lips: pink, no central cyanosis
Tongue: moist, no coating
No oral ulcers
No tongue bite marks (relevant - no tongue biting during seizure as per history)

Eyes:

Conjunctivae: pink bilaterally (no anaemia)
Sclera: white bilaterally (no jaundice)
No sunken eyes (adequate hydration)
Pupils: equal, round, reactive to light bilaterally (PERLA) - important post-seizure neurological assessment
No papilloedema (fundoscopy if raised ICP suspected)

ENT:

Ears: no discharge, tympanic membranes to be examined bilaterally (otitis media is a common fever source in toddlers)
Nose: no discharge documented
Throat: to examine for pharyngitis/tonsillar enlargement as fever source

Shape of Head: Normocephalic, no macrocephaly or microcephaly

Fontanelle: Anterior fontanelle - assess if open or closed (at 21 months, anterior fontanelle may still be partially open; should be flat and non-bulging. Bulging fontanelle would suggest raised ICP / meningitis - critical to assess in this case)

Neck:

No lymphadenopathy
Neck stiffness: absent (no meningism - important to document to exclude meningitis as cause of seizure with fever)
No neck masses
No thyroid enlargement
No pulsations

Hair: Normal texture and distribution

Extremities:

Warm peripheries
No oedema
Normal tone bilaterally
No focal neurological deficit (important post-seizure assessment)
Babinski sign: to document (extensor response would suggest upper motor neuron pathology)

Oedema: None - no pitting oedema of lower limbs

Skin:

No petechiae or purpura (important to exclude meningococcaemia in febrile seizure)
No rashes
No bruising

Examination of Back:

Spine: straight, no scoliosis, no deformity
No sacral oedema
No sacral dimple or tuft of hair (spinal dysraphism)

EXAMINATION OF LYMPH NODES

Region	Finding
Cervical	May be palpable - reactive lymphadenopathy in context of viral illness
Occipital	Not enlarged
Axillary	Not enlarged
Inguinal	Not enlarged

IMPRESSION (General Examination)

A 21-month-old Malay boy, alert, pink, well-hydrated, post-ictal recovery, afebrile at time of clerking (was febrile on admission), no meningism, no focal neurological deficit, no petechiae or purpura, and no signs of raised intracranial pressure.

SYSTEMS EXAMINATION

Systems involved:

Central Nervous System (primary - seizure)
Gastrointestinal System (vomiting x2, post-ictal)
Fever workup - ENT (source identification)

DETAILED EXAMINATION - CENTRAL NERVOUS SYSTEM

Consciousness: Alert, GCS 15 (E4V5M6) at time of clerking; post-ictal drowsiness resolved

Cranial Nerves:

CN II: Pupils equal, round, reactive to light bilaterally; visual fields grossly intact
CN III, IV, VI: Eye movements intact, no nystagmus, no gaze palsy
CN V: Facial sensation intact to touch
CN VII: Face symmetrical, no facial asymmetry
CN VIII: Responds to sound appropriately
CN IX, X: Swallowing intact, no drooling
CN XI, XII: Normal head turning, tongue midline

Meningeal Signs:

Neck stiffness: ABSENT (no meningism)
Kernig's sign: NEGATIVE
Brudzinski's sign: NEGATIVE
Bulging fontanelle: ABSENT (flat, non-bulging)

Motor System:

Tone: Normal bilaterally in upper and lower limbs
Power: 5/5 in all four limbs
No focal weakness or hemiparesis
No abnormal posturing

Reflexes:

Deep tendon reflexes: 2+ and symmetrical bilaterally
Plantar response (Babinski): Flexor (normal; extensor would suggest UMN pathology)

Sensation: Grossly intact to touch

Cerebellar: No ataxia, normal coordination for age

Post-ictal state: Drowsy on arrival to ED; alert and recovered at time of clerking

EXAMINATION OF OTHER SYSTEMS

Respiratory System:

No tachypnea, no respiratory distress
Chest: no deformity, moves symmetrically
No recession
Air entry equal bilaterally, no added sounds (no wheeze, no crepitations)

Cardiovascular System:

Pink, warm peripheries, CRT < 2 seconds
Heart sounds dual, regular rhythm, no murmur
No cyanosis

Abdominal System:

Abdomen: soft, non-tender, non-distended
No organomegaly
Bowel sounds present and normal
No guarding or rigidity
Vomited x2 (milk, non-bilious) - acute, illness-related; resolved

CLINICAL SUMMARY / ANALYSIS OF PATIENT'S PROBLEMS

A. PROVISIONAL DIAGNOSIS: Simple Febrile Seizure

Points IN FAVOUR:

Age within typical range for febrile seizure (6 months to 5 years) - patient is 21 months
Seizure occurred in the context of fever (fever onset same evening as seizure)
No prior seizure history - first ever episode
No focal neurological deficit post-ictally
No signs of meningism (neck stiffness, Kernig's, Brudzinski's all negative)
Sick contact (cousin still ill) - suggests viral aetiology as fever source
Post-ictal drowsiness resolved appropriately
No underlying neurological condition
No structural brain abnormality history

Points AGAINST:

Two seizure episodes occurred within the same febrile illness (one at home, one at ED) - this may reclassify it as complex febrile seizure (recurrence within 24 hours)
Seizure semiology slightly atypical: eyes rolled up + fist clenching without generalised tonic-clonic shaking - though focal features are absent
Duration of first episode: 4 minutes - within simple febrile seizure range (< 15 min) but towards the longer end
No loss of consciousness documented - unusual; most seizures involve altered consciousness; may represent a focal onset or atonic component; needs further clarification

B. DIFFERENTIAL DIAGNOSES

I. Complex Febrile Seizure

For: Two seizures within the same febrile illness (recurrence within 24 hours meets criteria for complex febrile seizure); first seizure lasted 4 minutes
Against: Each individual seizure was < 15 minutes; no focal neurological deficit post-ictally; no focal semiology clearly documented

II. Meningitis / Bacterial Meningitis

For: Fever + seizure in a young child; must always be excluded
Against: No neck stiffness, no bulging fontanelle, no photophobia, no purpuric rash, alert and well post-ictally, no toxic appearance; WBC not markedly elevated

III. Viral Encephalitis

For: Fever + seizure; sick contact; post-ictal drowsiness
Against: Drowsiness resolved completely; no altered behaviour or consciousness persisting; no focal neurological deficits; no signs of raised ICP

IV. First Unprovoked Seizure / Epilepsy

For: Unusual semiology (fist clenching, eye rolling without generalised convulsions)
Against: Clear febrile context; no prior afebrile seizures; no family history of epilepsy; age and clinical picture consistent with febrile seizure

V. Hypoglycaemic Seizure

For: Seizure in a young child
Against: Occurred in context of fever with sick contact; no history of poor feeding before seizure; no metabolic condition; blood glucose not documented as low

INVESTIGATIONS (with interpretation)

General Investigations

Full Blood Count (FBC):

Parameter	Result	Normal (21 months)	Interpretation
TWBC	11.9 x10⁹/L	6.0 - 17.0 x10⁹/L	Normal - no significant leukocytosis
Lymphocytes	39.5%	40-70%	Mildly low-normal
Granulocytes (Neutrophils)	55.6%	20-50%	Mildly elevated - suggests bacterial/stress response but not alarming
PCV (Haematocrit)	37.6%	33-39%	Normal
Platelets	134 x10⁹/L (note: 13.4 likely = 134 x10⁹/L)	150 - 400 x10⁹/L	Mildly low - monitor; thrombocytopaenia can be seen in viral illness (dengue to exclude if in endemic area)

Renal Profile (Urea and Electrolytes):

Parameter	Result	Normal (paediatric)	Interpretation
Urea	3.4 mmol/L	1.8 - 6.4 mmol/L	Normal - no renal impairment, no dehydration-related elevation
Sodium (Na)	136 mmol/L	135 - 145 mmol/L	Normal - no hyponatraemia (important: hyponatraemia can lower seizure threshold)
Potassium (K)	4.3 mmol/L	3.5 - 5.0 mmol/L	Normal
Chloride (Cl)	106 mmol/L	98 - 107 mmol/L	Normal
Serum Creatinine (Sr)	28 µmol/L	20 - 40 µmol/L	Normal - adequate renal function

Overall electrolyte interpretation: Electrolytes are all within normal limits. No electrolyte disturbance (hyponatraemia, hypocalcaemia, hypomagnesaemia) to explain the seizure. This supports a fever-provoked (febrile) seizure rather than a metabolic seizure.

Specific Investigations

(To be done / pending - recommend based on clinical picture:)

Investigation	Indication	Expected Result
Blood glucose (RBS)	Exclude hypoglycaemia as seizure cause	Expected normal
Blood culture	If bacterial source of fever suspected	Likely sterile in viral illness
Urine FEME + culture	Exclude UTI as fever source (common in toddlers)	To obtain
CXR	Exclude pneumonia as fever source	To obtain if respiratory signs develop
Nasopharyngeal swab (Influenza/RSV)	Sick contact, viral URTI suspected	To obtain
LP (Lumbar Puncture)	Only if meningism present or child appears toxic	Not indicated in this case - no meningism
EEG	Not routinely indicated in simple/first febrile seizure	Defer unless recurrence
CT Brain	Not routinely indicated - no focal deficit, no signs of raised ICP	Not indicated
Calcium, Magnesium, Phosphate	Exclude metabolic cause if recurrent or atypical	Consider if seizure recurs

FINAL DIAGNOSIS

Simple Febrile Seizure (first episode) secondary to viral fever (likely viral upper respiratory tract infection given sick contact with cousin)

(If second seizure within same illness is considered: may be reclassified as Complex Febrile Seizure - to discuss with supervising team)

MANAGEMENT PLAN

Acute management (already done):

IM anticonvulsant at ED to abort 2nd seizure (confirm drug and dose - likely IM Midazolam 0.2 mg/kg)
Antipyretics: Paracetamol 15 mg/kg/dose 4-6 hourly PRN for fever
IV/oral hydration if unable to tolerate orally post-ictally
Continuous monitoring: SpO2, temperature, neuro-observations

Ward management:

Observe neurological status - ensure full recovery, no focal deficit
Tepid sponging and paracetamol for fever control
Treat underlying fever source when identified (viral - supportive; bacterial - antibiotics)
Maintain SpO2 > 95%, ensure airway patent
Seizure precautions - nurse in safe position, padded cot sides, suction available at bedside
Buccal/rectal midazolam or diazepam available at bedside PRN if seizure recurs

Parental counselling (critical):

Reassure parents - febrile seizures are common (2-5% of children aged 6 months to 5 years), generally benign
Explain risk of recurrence: approximately 30-35% chance of recurrence with future febrile illnesses
Teach parents first aid for seizures: place child on side, do not insert anything into mouth, time the seizure, call emergency if > 5 minutes
Advise to bring child to hospital for any future seizure lasting > 5 minutes or if child does not recover within 30 minutes
No long-term prophylactic anticonvulsants required for simple febrile seizure
Fever control with paracetamol does not prevent febrile seizure recurrence but improves child's comfort

Discharge criteria:

Afebrile and clinically well
Full neurological recovery
Oral intake adequate
Parents counselled and confident

STATUS AT DISCHARGE

(To be filled upon discharge)

Discharged well, alert, active, tolerating orally
Parents educated on febrile seizure management and recurrence
No anticonvulsant prescribed on discharge (simple febrile seizure)
Follow-up at Klinik Kesihatan / outpatient clinic arranged
Return to ED if: seizure recurs > 5 minutes, child does not recover fully, new neurological symptoms develop

Key flags before presenting:

Confirm IM drug given in ED (name, dose)
Obtain blood glucose result
Confirm whether 2nd seizure was focal or generalised (determines simple vs. complex classification)
Platelet count 134 - mildly low; ensure dengue serology done if in endemic area
Granulocyte predominance 55.6% with fever - monitor; if fever persists beyond 5 days consider bacterial source workup

Progress in the hospitwl, day 1 to 3

PROGRESS IN THE HOSPITAL

Ahmad Kalish Umar bin Ahmad Fami | 21 months | Simple Febrile Seizure

DAY 1 — 3rd June 2026 (Night of Admission)

Subjective: Mother reports child had fever since evening with two episodes of seizure. First seizure lasted 4 minutes at home (eyes rolled up, fist clenching, no generalised shaking, no loss of consciousness), followed by post-ictal drowsiness and vomiting x2 (milk, non-bilious). Second seizure occurred upon arrival to ED and was aborted with IM anticonvulsant (IM Midazolam/Diazepam to confirm) at the buttock. No further seizure since. No cough, no runny nose, no diarrhea. Sick contact with cousin (currently still ill).

Objective:

Alert, post-ictal drowsiness settling
Febrile (exact reading to confirm from ED notes; fever onset evening 3/6/26)
No signs of meningism (neck stiffness absent, Kernig's negative, Brudzinski's negative)
No focal neurological deficit
No petechiae or purpura
Lungs clear, CVS normal, abdomen soft
Throat: to document (examine for fever source)
SpO2: > 95% on room air

Investigations:

FBC: TWBC 11.9, Lymphocytes 39.5%, Granulocytes 55.6%, PCV 37.6%, Plt 134
Renal profile: Urea 3.4, Na 136, K 4.3, Cl 106, Creatinine 28 - all within normal limits
Blood glucose: to document
Urine FEME: to document

Assessment: Simple Febrile Seizure (first episode) — likely secondary to viral fever. No electrolyte disturbance. No biochemical cause for seizure. Mildly low platelets at 134 — dengue serology to consider if fever persists.

Plan:

Admit to ward for observation and monitoring
Neuro-observations hourly — monitor for recurrence of seizure
Temperature monitoring 4-hourly
Paracetamol 15 mg/kg/dose 4-6 hourly PRN for fever
Tepid sponging for fever
Encourage oral fluids; IV access maintained
Buccal/rectal midazolam available at bedside PRN if seizure recurs > 5 minutes
Seizure precautions — padded cot sides, nurse in lateral position if drowsy, suction at bedside
Investigate for fever source: urine FEME, throat examination, consider viral swab

DAY 2 — 4th June 2026

Subjective: Mother reports child has been no further seizure since the episode at ED last night. Child is more alert and interactive today. Fever persisting — mother gave paracetamol overnight with partial relief. Still not eating or drinking well — reduced appetite. No vomiting since last night. No cough, no runny nose, no diarrhea. Mother is anxious and concerned about recurrence of seizure.

Objective:

Alert, conscious, interactive — full neurological recovery from post-ictal state
Still febrile (temperature to document)
Hydration: moist mucous membranes, no sunken eyes, CRT < 2 seconds
No further seizure
No meningism
No focal neurological deficit
Lungs clear bilaterally
CVS: dual rhythm, no murmur
Abdomen: soft, non-tender, non-distended
Throat: erythematous / mild pharyngitis (likely viral — fever source)
No petechiae or purpura

Assessment: Simple Febrile Seizure — Day 2. Fever ongoing, likely viral URTI as source. Neurologically intact. No seizure recurrence. Adequate hydration. Reduced oral intake but not dehydrated.

Plan:

Continue neuro-observations — reduce frequency to 4-hourly given full recovery
Continue paracetamol PRN for fever and patient comfort
Continue encouraging oral fluids and soft diet
Buccal midazolam remains at bedside
Monitor temperature chart — if fever persists beyond Day 5, broaden fever source workup (blood culture, dengue serology given mild thrombocytopaenia Plt 134)
Parental education session initiated:
- Explained nature of febrile seizure — benign, common in this age group
- Explained 30-35% recurrence risk with future febrile illnesses
- Taught seizure first aid: lateral position, do not restrain, do not put anything in mouth, time the seizure, call ambulance if > 5 minutes
- Reassured that febrile seizure does not cause brain damage or epilepsy in the vast majority
Plan for discharge tomorrow if afebrile and clinically well

DAY 3 — 5th June 2026 (Discharge Day)

Subjective: Mother reports child is afebrile since last night. Active, playful, back to baseline behaviour. Eating and drinking well — appetite returned. No further seizure. No vomiting. No cough, no runny nose. Mother feels confident and reassured following counselling.

Objective:

Alert, active, playful — clinically well
Afebrile (temperature 36.8°C or within normal range — document)
Hydration: good — moist mucous membranes, normal skin turgor
No seizure recurrence throughout admission
No meningism
No focal neurological deficit
Lungs clear, CVS normal, abdomen soft
Tolerating oral intake well

Assessment: Simple Febrile Seizure — resolved. Afebrile for > 12 hours. Full neurological recovery. Good oral intake. Parents counselled and confident. Safe for discharge.

Plan:

Discharge home
Paracetamol 15 mg/kg/dose 4-6 hourly PRN — prescribe syrup paracetamol for home use
No anticonvulsant prescribed on discharge (not indicated for simple febrile seizure)
Advise parents:
- Give paracetamol promptly at onset of any future fever
- Tepid sponging for fever comfort
- Return immediately to ED if: seizure lasting > 5 minutes, more than one seizure in 24 hours, child does not recover within 30 minutes after seizure, any focal movements during seizure, or child appears very unwell
Follow-up at Klinik Kesihatan in 1-2 weeks — growth and development monitoring, reassessment
No EEG or neuroimaging required at this stage (not indicated for first simple febrile seizure)
Discharge letter written to attending Klinik Kesihatan

Discharge diagnosis: Simple Febrile Seizure (first episode), secondary to viral fever Total duration of admission: 3 days (3rd June — 5th June 2026) Condition at discharge: Well, afebrile, neurologically intact

Below is a realistic Year 3 Paediatrics Acute Gastroenteritis (AGE) case that fits your logbook template. PAEDIATRIC CASE RECORD Personal Details Name: Muhammad Danish Hakim bin Mohd Faiz Age: 3 years 2 months Gender: Male Date of Admission: 12/06/2026 Date of Clerking: 13/06/2026 Date of Discharge: 14/06/2026 Informant: Mother Address: Taman Ria, Sungai Petani --- Presenting Complaints 1. Vomiting for 1 day 2. Diarrhea for 1 day 3. Fever for 1 day --- History of Presenting Complaints The child was apparently well until 1 day prior to admission when he developed fever associated with vomiting and diarrhea. The fever was sudden in onset, intermittent, with a maximum recorded temperature of 38.8°C. It was associated with reduced activity and decreased appetite. Vomiting started shortly after onset of fever. There were approximately 8 episodes within 24 hours. The vomitus consisted mainly of recently ingested food and fluids. It was non-bilious, non-projectile and not blood stained. Diarrhea began several hours later. There were approximately 6 episodes of loose watery stool. The stool was yellowish in colour, non-bloody and foul smelling. The mother also noticed reduced oral intake and reduced urine output. There was no history of cough, runny nose, seizure, abdominal distension, rash, dysuria or recent travel. There was a positive history of sick contact as his cousin had similar symptoms two days earlier. Due to persistent vomiting and inability to tolerate oral fluids, he was brought to the Emergency Department and admitted. --- Treatment Received Intravenous Normal Saline bolus Intravenous maintenance fluids Oral Rehydration Solution (ORS) Syrup Paracetamol Intravenous Ondansetron --- History of Allergy No known drug allergy. No known food allergy. --- Systems Review Gastrointestinal Positive: Vomiting Diarrhea Reduced appetite Negative: Abdominal pain Abdominal distension Constipation Hematemesis Malena Respiratory Negative: Cough Runny nose Shortness of breath Cardiovascular Negative: Cyanosis Edema CNS Negative: Seizure Loss of consciousness Abnormal behaviour Renal Positive: Reduced urine output Negative: Dysuria Hematuria --- Past Medical and Surgical History No previous hospitalization. No previous surgery. No chronic medical illness. --- Birth History Antenatal Regular antenatal follow-up. No maternal illness during pregnancy. Natal Full term spontaneous vaginal delivery. Postnatal Birth weight 3.2 kg. No neonatal jaundice. No NICU admission. --- Feeding History Exclusively breastfed for first 6 months. Appropriate weaning at 6 months. Currently on normal family diet. --- Immunization History Immunization up to date according to National Immunization Schedule. --- Developmental History Gross Motor Able to run and climb stairs. Vision and Fine Motor Able to stack blocks and scribble. Hearing, Speech and Language Able to speak in short sentences. Social and Behavioural Plays appropriately with family members. Interpretation Development appropriate for age. --- Family History No family history of epilepsy. No family history of chronic gastrointestinal disease. --- Social and Environmental History Lives with parents and siblings. No smoking exposure. No pets. No recent travel. --- SUMMARY OF HISTORY WITH PROVISIONAL DIAGNOSIS A 3-year-2-month-old boy presented with fever, multiple episodes of vomiting and watery diarrhea for one day associated with reduced oral intake and decreased urine output. There was positive sick contact. The clinical picture is suggestive of Acute Gastroenteritis with mild dehydration. --- GENERAL EXAMINATION General Appearance Alert but mildly lethargic. Vital Signs Temperature: 38.4°C Pulse: 118 bpm Respiratory Rate: 26 breaths/min Blood Pressure: 92/58 mmHg SpO₂: 99% on room air Anthropometry Weight: 14 kg Height: 96 cm BMI: 15.2 kg/m² Impression Mild dehydration. --- Head to Toe Examination Positive Findings Dry lips Slightly dry mucous membranes Mildly sunken eyes Warm peripheries Negative Findings No pallor No jaundice No cyanosis No edema No lymphadenopathy No dysmorphic features --- SYSTEMS EXAMINATION Gastrointestinal System Inspection: Abdomen not distended Palpation: Soft abdomen Non-tender No organomegaly Percussion: Normal Auscultation: Bowel sounds present and active Cardiovascular System Normal heart sounds. No murmur. Respiratory System Clear breath sounds bilaterally. CNS Alert. No focal neurological deficit. --- CLINICAL SUMMARY / ANALYSIS Provisional Diagnosis Acute Gastroenteritis with Mild Dehydration Points in Favour Acute onset vomiting Acute watery diarrhea Fever Positive sick contact Reduced oral intake Reduced urine output Mild dehydration signs Points Against No significant abdominal pain --- DIFFERENTIAL DIAGNOSES 1. Acute Gastroenteritis For: Vomiting Diarrhea Fever Sick contact Against: None significant --- 2. Food Poisoning For: Acute vomiting and diarrhea Against: No history of suspicious food intake --- 3. Urinary Tract Infection For: Fever Against: No urinary symptoms Presence of diarrhea --- 4. Acute Appendicitis For: Vomiting Against: No abdominal pain No localized tenderness --- 5. Acute Gastritis For: Vomiting Against: Significant diarrhea present --- INVESTIGATIONS General Investigations FBC Hb: 13.2 g/dL WBC: 8.5 ×10⁹/L Platelet: 280 ×10⁹/L Interpretation: No significant bacterial infection. Renal Profile Na: 136 mmol/L K: 3.2 mmol/L Urea: 4.1 mmol/L Creatinine: 30 µmol/L Interpretation: Mild hypokalaemia secondary to gastrointestinal losses. --- Specific Investigations Stool Analysis No blood or parasites detected. Stool Culture No bacterial growth. --- Final Diagnosis Acute Viral Gastroenteritis with Mild Dehydration and Mild Hypokalaemia --- Management Plan 1. Oral rehydration therapy. 2. IV fluids initially. 3. Strict input-output charting. 4. Correct electrolyte imbalance. 5. Continue feeding as tolerated. 6. Paracetamol for fever. 7. Parent education regarding dehydration signs. --- Progress in Hospital Day 1 Admitted for vomiting, diarrhea and fever. IV fluids commenced. Day 2 Vomiting resolved. Diarrhea less frequent. Oral intake improved. Day 3 Afebrile. Tolerating feeds well. Clinically hydrated. Discharged home. --- Status at Discharge Alert and active Well hydrated Tolerating oral feeding No vomiting Minimal diarrhea Normal urine output Stable vital signs Discharge Diagnosis: Acute Viral Gastroenteritis with Mild Dehydration. Rephrase whatever you feel like is lacking of info wtih anything suitable, i dont want long sentences

PAEDIATRICS YEAR 3 LOG BOOK

Muhammad Danish Hakim bin Mohd Faiz | 3 years 2 months | Male

DOA: 12/06/2026 | DOC: 13/06/2026 | DOD: 14/06/2026

PHYSICAL EXAMINATION

GENERAL EXAMINATION

General Appearance: Alert but mildly lethargic. Not in acute distress. Mildly dehydrated. No syndromic features.

Vital Signs:

Parameter	Value	Normal (3 years)
Temperature	38.4°C	36.5 - 37.5°C
Pulse Rate	118 bpm	80 - 120 bpm
Respiratory Rate	26 breaths/min	20 - 30 breaths/min
Blood Pressure	92/58 mmHg	~90/55 mmHg
SpO₂	99% on room air	> 95%

Anthropometric Measurements:

Parameter	Value
Height	96 cm
Weight	14 kg
BMI	15.2 kg/m²

(Plot on WHO growth chart. At 3 years 2 months, expected weight ~14 kg — appropriate for age.)

Impression: Mild dehydration. Febrile. Tachycardic — likely secondary to fever and dehydration.

HEAD TO TOE EXAMINATION

Hands:

Warm peripheries
CRT < 2 seconds
No pallor, no peripheral cyanosis
No clubbing

Pallor: Absent — conjunctivae pink

Cyanosis: Absent

Jaundice: Absent — sclera white

Oral Cavity:

Lips dry
Mucous membranes slightly dry — consistent with mild dehydration
No central cyanosis
No oral ulcers

Eyes:

Mildly sunken — dehydration sign
Conjunctivae pink
Sclera white
Tears present

ENT:

No ear discharge
Tympanic membranes not inflamed
No rhinorrhoea
Throat: mild erythema — likely viral

Shape of Head: Normocephalic

Fontanelle: Anterior fontanelle closed (normal at 3 years)

Neck:

No lymphadenopathy
No neck stiffness
No masses

Hair: Normal

Extremities:

Warm, well-perfused
No oedema
Normal tone and power

Skin:

No rashes
Skin turgor: mildly reduced
No petechiae, no purpura

Spine: Straight, no deformity

Sacral oedema: Absent

EXAMINATION OF LYMPH NODES

Region	Finding
Cervical	Not enlarged
Occipital	Not enlarged
Axillary	Not enlarged
Inguinal	Not enlarged

Impression: No lymphadenopathy.

SYSTEMS EXAMINATION

Systems involved:

Gastrointestinal System (primary)
Renal/Fluid Status (secondary — dehydration, reduced urine output)

DETAILED EXAMINATION — GASTROINTESTINAL SYSTEM

General (peripheral signs):

Hands: warm, no pallor, no clubbing, no leukonychia
Eyes: mildly sunken, conjunctivae pink, sclera white
Mouth: dry lips, slightly dry mucous membranes
No jaundice

Inspection:

Abdomen flat and symmetrical
Moves with respiration
Umbilicus centrally located, inverted
No distension
No visible peristalsis
No surgical scars

Palpation:

Abdomen soft and non-tender throughout
No guarding, no rigidity
No organomegaly — liver and spleen not palpable
Kidneys not ballotable
No palpable masses

Percussion:

Resonant throughout
No shifting dullness
No fluid thrill

Auscultation:

Bowel sounds present and hyperactive — consistent with gastroenteritis

EXAMINATION OF OTHER SYSTEMS

Respiratory: Clear breath sounds bilaterally. No wheeze, no crepitations. No recession. RR 26 — within normal limits.

Cardiovascular: Dual rhythm, regular, no murmur. Tachycardic (HR 118) — likely secondary to fever and dehydration. Warm peripheries, CRT < 2 seconds.

CNS: Alert. No focal neurological deficit. No meningism. No seizure.

Renal/Hydration Assessment:

Sign	Finding
Eyes	Mildly sunken
Mucous membranes	Slightly dry
Skin turgor	Mildly reduced
Tears	Present
CRT	< 2 seconds
Urine output	Reduced (reported by mother)
Dehydration grade	Mild (~5%)

CLINICAL SUMMARY / ANALYSIS OF PATIENT'S PROBLEMS

A. PROVISIONAL DIAGNOSIS: Acute Gastroenteritis with Mild Dehydration

Points IN FAVOUR:

Acute onset fever, vomiting (8 episodes/24 hours) and watery diarrhoea (6 episodes/24 hours) simultaneously
Non-bilious, non-bloody vomitus
Yellow, watery, non-bloody, foul-smelling stool
Positive sick contact — cousin with similar illness 2 days prior
Clinical signs of mild dehydration: dry lips, slightly dry mucous membranes, mildly sunken eyes
Reduced oral intake and reduced urine output
Age group and presentation consistent with viral aetiology
FBC: no significant leukocytosis (WBC 8.5) — against bacterial cause

Points AGAINST:

No significant abdominal pain or tenderness
(No strong points against this diagnosis)

B. DIFFERENTIAL DIAGNOSES

I. Food Poisoning

For: Acute vomiting and diarrhoea, rapid onset
Against: No history of suspicious or communal food intake; sick contact pattern more consistent with person-to-person viral spread

II. Urinary Tract Infection (UTI)

For: Fever in a young child
Against: No dysuria, no haematuria, no frequency; presence of vomiting and diarrhoea not typical of UTI; urine FEME normal

III. Acute Appendicitis

For: Vomiting, fever
Against: No abdominal pain; no right iliac fossa tenderness; no guarding or rigidity; diarrhoea more prominent than vomiting pattern expected in appendicitis

IV. Acute Gastritis

For: Vomiting prominent
Against: Significant watery diarrhoea present; no epigastric pain; no NSAID or aspirin use history

V. Intussusception

For: Vomiting, young child
Against: No blood in stool (no red-currant jelly stool); no colicky abdominal pain; no palpable mass; abdomen soft and non-tender

INVESTIGATIONS

General Investigations

Full Blood Count (FBC):

Parameter	Result	Normal	Interpretation
Hb	13.2 g/dL	11.5 - 14.5 g/dL	Normal
WBC	8.5 x10⁹/L	5.0 - 15.0 x10⁹/L	Normal — no significant leukocytosis; against primary bacterial infection
Platelets	280 x10⁹/L	150 - 400 x10⁹/L	Normal

Renal Profile:

Parameter	Result	Normal	Interpretation
Na	136 mmol/L	135 - 145 mmol/L	Normal — isonatraemic dehydration
K	3.2 mmol/L	3.5 - 5.0 mmol/L	Low — mild hypokalaemia secondary to GI losses (vomiting + diarrhoea)
Urea	4.1 mmol/L	1.8 - 6.4 mmol/L	Normal — mild elevation expected; within range
Creatinine	30 µmol/L	20 - 40 µmol/L	Normal — adequate renal function

Overall: Isonatraemic mild dehydration. Mild hypokalaemia from GI losses. No significant biochemical derangement.

Specific Investigations

Stool Analysis:

No blood, no pus cells, no parasites detected
Supports viral rather than bacterial or parasitic aetiology

Stool Culture:

No bacterial growth
Confirms viral gastroenteritis — no pathogenic bacteria isolated

Urine FEME:

Normal — no pyuria, no haematuria
Excludes UTI as concurrent fever source

FINAL DIAGNOSIS

Acute Viral Gastroenteritis with Mild Dehydration and Mild Hypokalaemia

MANAGEMENT PLAN

Rehydration:

IV Normal Saline bolus 20 ml/kg over 20 minutes on arrival — for initial volume resuscitation
IV maintenance fluids commenced — HSD5% (half-strength dextrose saline) at calculated maintenance rate
Transition to Oral Rehydration Solution (ORS) as tolerated — 5-10 ml every 5 minutes initially, escalating as tolerated
Strict input-output (I/O) charting — monitor urine output, number and consistency of stools, vomiting frequency

Antiemetic: 5. IV Ondansetron 0.15 mg/kg/dose — to reduce vomiting and facilitate oral rehydration

Antipyretic: 6. Syrup Paracetamol 15 mg/kg/dose 4-6 hourly PRN — for fever and comfort

Electrolyte correction: 7. Monitor potassium — encourage oral intake including ORS (which contains K); supplement orally if K does not correct; IV KCl only if symptomatic or K < 2.5 mmol/L

Nutrition: 8. Continue feeding as tolerated — early refeeding reduces duration of illness; resume age-appropriate diet once vomiting settles; avoid prolonged fasting

Monitoring: 9. 4-hourly vital signs and hydration reassessment 10. Daily renal profile if dehydration persists or K remains low

Parental education: 11. Explain signs of worsening dehydration — no tears, no wet nappy > 6 hours, sunken eyes, very dry mouth, drowsy or difficult to wake 12. Return to ED if: vomiting worsens, blood in stool, child becomes lethargic or unresponsive, no improvement in 48 hours 13. Hand hygiene and hygiene measures to prevent household spread 14. Continue breastfeeding/normal feeds at home; avoid carbonated drinks and fruit juice until fully recovered

PROGRESS IN THE HOSPITAL

Day 1 — 12th June 2026 (Admission)

Subjective: Fever, vomiting (8 episodes), watery diarrhoea (6 episodes) for 1 day. Unable to tolerate oral fluids. Reduced urine output. Positive sick contact (cousin). Brought to ED by mother.

Objective:

Febrile 38.4°C, HR 118, RR 26, BP 92/58, SpO₂ 99% RA
Mildly lethargic, dry lips, slightly dry mucous membranes, mildly sunken eyes
Abdomen soft, non-tender, hyperactive bowel sounds
Mild dehydration estimated ~5%
FBC and renal profile as above

Assessment: Acute viral gastroenteritis with mild dehydration and mild hypokalaemia.

Plan:

IV NS bolus 20 ml/kg given in ED
IV maintenance fluids commenced
IV Ondansetron given
Syrup paracetamol PRN
I/O charting commenced
ORS offered when vomiting settles
Admitted to ward for observation

Day 2 — 13th June 2026

Subjective: Mother reports vomiting resolved — last episode last night. Diarrhoea less frequent — 2-3 loose stools today (reduced from 6). Fever present this morning, settled with paracetamol by afternoon. Oral intake improving — tolerating ORS and small amounts of food. Urine output improving.

Objective:

Afebrile by afternoon (Tmax 37.8°C this morning)
HR settling — 98 bpm
Better hydrated — lips moist, eyes less sunken, skin turgor normal
Abdomen soft, non-tender, bowel sounds present
No vomiting
Urine output adequate

Assessment: Improving. Vomiting resolved. Diarrhoea reducing. Rehydration adequate. Tolerating oral feeding.

Plan:

Step down to oral fluids and diet — discontinue IV fluids
Continue ORS
Continue paracetamol PRN
Resume normal family diet as tolerated
Monitor K — repeat renal profile if still symptomatic; oral KCl if needed
Continue I/O charting

Day 3 — 14th June 2026 (Discharge)

Subjective: Child active and playful. Afebrile since last evening. No further vomiting. 1 soft stool today — not watery. Eating and drinking well. Normal urine output. Mother confident and reassured.

Objective:

Afebrile 36.9°C
HR 96 bpm, RR 22, BP 90/56, SpO₂ 99% RA
Alert, active, well-hydrated
Lips moist, no sunken eyes, normal skin turgor
Abdomen soft, non-tender, normal bowel sounds
Tolerating full oral intake

Assessment: Acute viral gastroenteritis — resolved. Well hydrated. Afebrile > 24 hours. Safe for discharge.

Plan:

Discharge home
Syrup paracetamol PRN at home
Resume normal family diet
Encourage adequate oral fluid intake
Return to ED if: fever recurs > 38.5°C, vomiting returns, blood in stool, child lethargic or not tolerating fluids
Follow-up at Klinik Kesihatan in 1 week

STATUS AT DISCHARGE — 14th June 2026

Alert and active
Afebrile
Well hydrated — moist mucous membranes, no sunken eyes, normal skin turgor
Tolerating full oral feeds
No vomiting
Minimal diarrhoea — 1 soft stool only
Normal urine output
Stable vital signs
Parents educated on dehydration warning signs and home care

Discharge Diagnosis: Acute Viral Gastroenteritis with Mild Dehydration and Mild Hypokalaemia — resolved Total admission: 3 days (12th — 14th June 2026)

Another case same template, short as possible points in paragraph, fill in whichever lack points with the most accurate fillings,Siti Nurraisya Binti Mohd Azrie, 4Y1 1M 4 year 11 months old girl NKMI/NKDA 1st hospitalisation Imp Dengue fever day 3 of illness in critical phase with warning sign haemodynamically stable abd pain, raised HCT) HCT trend: 36- ->45-->39 (post bolus) aiven bolus 7ml/kq over 1 hour from 10:45 -11:45am at Hosp Sik presented with fever for 3 days ( since 28/6/2026) no chills or rigor vomit x 1 at day 1 of illness BO soft stool today no joint pain, no arthralgia reduced oral intake had abdominal pain since yesterday no spontaeous bleed PU still normal had cough for 3 days had sick contact with elder brothers but both of them dengue test negative, and count normal visited KK FBC : TWC 3.9, PLT 209, HCT 36 had cough for 3 days had sick contact with elder brothers but both of them dengue test negative, and count normal visited KK FBC : TWC 3.9, PLT 209, HCT 36 Dengue combo test: NS1 positive, Ig G/Ig M negative otherwise no more vomiting no rapid breathing no travelling hx no recent water activity no recent fogging In Hospital Sik noted repeated FBC TWC 2.25/ PLT 175/HCT 45.1 lactate increasing 1.4-->3.6 Given NS bolus 10ml /kg over 1 hour followed by 7cc/kg/h vitals stable BP 91/48, PR 112 repeated FBC TWC 2.7/PLT 234/HCT 39 VBG: Ph 7.38/ PCO2 43/ PO2 32/HCO3 25. S lactate 2.1/ glu 3.9 transfer to HSAH Currently had low grade fever with abd pain, more over epigastric region no bleeding tendencies Currently had low grade fever with abd pain, more over epigastric region no bleeding tendencies BO X1 soft stool today no more vomiting oral intake minimal O/E alert, pink, not tacypnoeic, pulse volume good CRT<2, warm peripheries lungs clear CVS DRNM PA soft, tenderness over epigastric, no hepatomegaly BP 94/62 HR 123 SPO2 98% T37.5 EBE Plan Vital signs hourly For dengue charting Watchout for bleeding tendencies and worsening warning signs Keep SPO2>95 Keep systolic BP 90-115 (50: 99th centile) Start IVD NSD5% 63cc/h (5ml/kg) for another 1H Encourage orally Strict I/O Repeat FBC, VBG COAG, LFT, AST, RP Electrolytes + blood C+S and CRP at 4pm together with blood taking branula FBC QID Start: Iy Pantoprazole 12mg OD Syr Paracetamol 190mg PRN(15mg/kg/dose) CM: dengue serology with FBC VBG

Generate a dengue positive case of a 5 yrs old girl with no known medical illness using the same template , make it beliavable

Running Command

cd /home/daytona/workspace/attachments/c2cfb993-17fd-45ed-b31a-8911b49cf3d2/ && python3 -c " import pdfplumber with pdfplumber.open('Paediatrics Year 3 Log Book_260620_120602.pdf') as pdf: print(f'Pages: {len(pdf.pages)}') for i, page in enumerate(pdf.pages): print(f'--- PAGE {i+1} ---') print(page.extract_text()) "

Another case same template Muhammad Mikhal Bin Umar Abdul Azis, 8Y5M, Male recenty discharged on 8/6/2026 for Henoch Schonkein Purpura This is his 5th Admission 1st admission at birth Jan 2018 ⁃ Term asymmetrical SGA at 37week ⁃ Resolved sepsis (Thrombocytopenia, pancytopenia, hypoglycemia) ⁃ Resolved NN) with conjugated hyperbilirubinemia 2nd admission on march 2029 at lyear 2 month : Acute Bronchiolitis 3rd admission on September 2019 at lyr 8mth : Acute gastroenteritis with normal hydration 4th admission discharged on 8/6/2026 for Henoch Schonlein Purpura C3 1.48/ C4 0.56/ ANA ; In process u/l 1) Perthes disease Initially referred from Ortho clinic for chronic left hip pain for ix, TRO Juvenile Idiopathic Arthritis > MRI Pelvis (26/3/26 ) ; Findings are suggestive of avascular necrosis of the left capital femoral epiphysis (Perthes disease), with disuse atrophy of left gluteal and thigh muscles. > Under Paeds HKB , planned for operative intervention on 20/7/2026 C/o left hip pain for 3 months Limited movement due to pain Difficult to squat, thus needs to pass motion in stariding position Difficult to put on pants/ socks - limited left hip flexion Denies any fall/trauma Pain is bearable, does not require analgesia at home ESR (15/12/2025): 42 RF (15/12/2025): negative ANA negative Pelvic and hip xray reporting 25.01.2026: Features are suggestive of Perthes disease TCA paeds ortho HKB for operative procedure on 20/7/2026 2) Familial short stature Father's Height : 168cm Mother's height 154cm Mid Parental height : 167cm Previously under ophthal clinic : Divergence excess with poor control P/w Rashes increasing x 1/7 - Parents claims initially reducing after discharged - all over bilateral upper limbs, bilateral lower limbs, abdomen and trunk Frothy urine x 1/7 - Father noted frothy in urine (shown by mother in phone) - subsequently reducing in amount - last urinate in ward at 6pm, no more frothy urine - no blood or sandy urine Abdominal pain - sudden onset -pain started today morning at 1am - over umbilical region cramping in nature - no radiation Given Syr Ibuprofen at home , subsequently pain reducing Right upper limb swelling noted while receiving treatment at ED Otherwise No GI Losses no diarrhea no constipation no syncopal attack no dysuria no hematuria toerang h/o fall/trauma orally well no sick contact No fever no joint pain Birth history ⁃ Born term SGA at 37 weeks, BW: 1.5kg Soctal history 1st child out of 2 siblings 2nd child, son, NKMI Father 35 y/o. Technician, NKMI, Active smoker Mother 34 y/o. Housewife,Asthma on MDI Vaccination History Up to age Development SradReter sede SK Bakar Arang Average student active in curricular activity Feeding History Tolerating adult diet Upon admission Saturating under RA afebrile no SOB O/e Active , pink, playing with phone, not tachypnoiec, good pulse volume,CRT <2sec Lungs: clear CVS DRNM P/a Soft, not distended no pedal edema Right hand swelling, appear fulness non tender, no redness, no discharge, ROM full Non blanchanble palpable purpuric rash Bedside scan at ED No FF Non blanchanble palpable purpuric rash CXR : Clear AXR :no dilated bowel Ufeme Ph:5,blood:2+,pro:neg FBC: TWC 10.2/ Hb 13.6/ hct 40.2/ plt 381 RP: Na 137/ K 4/ C 106/ urea 4.1/ Creat 45 LFT: TP 82/ Albumin 34/ TB 8/ ALP 155/ AST 17 IMP: Recurrent HSP TRO Nephritis Plan Observe under RA Keep Spo2 > 95% Inform worsening rashes Encourage oraly Start Nephrotic chart Cont Old meds MDI Salbutamol 200mcg PRN MDI Budesonide 200mcg BD Trace ANA and FBP Appt TCA paeds ortho HKB for operative procedure on 20/7/2026 TCA Paeds surgical visiting HSAH for phimosis on 18/10/26 at 8 am TCA Paeds clinic in 2nd week July 2026 on 7/7/26 (before operation) Send UFEME and Urine C&S

PAEDIATRIC CASE RECORD

Muhammad Mikhal bin Umar Abdul Azis | 8 Years 5 Months | Male

DOA: 1st July 2026 | DOC: 1st July 2026 | Hospital: HSAH

Informant: Parents

PRESENTING COMPLAINTS

Worsening purpuric rash — 1 week
Frothy urine — 1 week
Abdominal pain — 1 day
Right upper limb swelling — noted at ED

HISTORY OF PRESENTING COMPLAINTS

Rash (1 week): Non-blanching palpable purpuric rash. Initially improving post-discharge on 8/6/2026, then worsened over 1 week. Involves bilateral upper limbs, bilateral lower limbs, abdomen and trunk.

Frothy urine (1 week): Father noticed frothy urine — shown on phone video. Amount subsequently reducing. Last urination in ward at 6pm with no further frothy urine. No haematuria, no blood, no sandy urine.

Abdominal pain (since today): Sudden onset at 1am, periumbilical, cramping in nature, no radiation. Given syrup Ibuprofen at home — pain partially relieved. No nausea, no vomiting, no diarrhoea, no constipation.

Right upper limb swelling: Noted incidentally while receiving treatment at ED. Appears as fullness, non-tender, no redness, no discharge, full range of movement.

Relevant negatives: No fever. No GI losses. No dysuria. No haematuria. No syncope. No joint pain. No sick contact. No fall or trauma. Orally well. No shortness of breath.

TREATMENT RECEIVED

Syrup Ibuprofen at home (for abdominal pain — partial relief)
IV access established at ED
Bedside ultrasound abdomen performed at ED

HISTORY OF ALLERGY

No known drug allergy (NKDA). No known food allergy.

SYSTEMS REVIEW

System	Positive	Negative
GIT	Abdominal pain (periumbilical, cramping)	No vomiting, no diarrhoea, no constipation, no GI bleeding
Renal	Frothy urine (1 week, resolving)	No haematuria, no dysuria, no reduced urine output
Derm	Worsening non-blanching palpable purpuric rash	No vesicles, no urticaria
MSK	Known left hip pain (Perthes disease)	No joint swelling, no new joint pain
RS	Nil	No cough, no SOB, no tachypnoea
CVS	Nil	No cyanosis, no oedema
CNS	Nil	No seizure, no syncope, no headache

PAST MEDICAL AND SURGICAL HISTORY

5th admission (current).

Admission	Year	Age	Diagnosis
1st	Jan 2018	Birth	Term asymmetrical SGA (37 weeks, BW 1.5 kg); resolved sepsis (thrombocytopaenia, pancytopaenia, hypoglycaemia); resolved NNJ with conjugated hyperbilirubinaemia
2nd	March 2019	1 yr 2 months	Acute bronchiolitis
3rd	September 2019	1 yr 8 months	Acute gastroenteritis with normal hydration
4th	Discharged 8/6/2026	8 yrs 4 months	Henoch-Schonlein Purpura (HSP) — C3 1.48, C4 0.56, ANA in process
5th (current)	1/7/2026	8 yrs 5 months	Recurrent HSP, TRO HSP Nephritis

Known underlying conditions:

Henoch-Schonlein Purpura (HSP) — diagnosed 4th admission; currently recurrent
Perthes Disease (left hip) — MRI pelvis 26/3/2026 confirmed avascular necrosis of left capital femoral epiphysis with disuse atrophy of left gluteal and thigh muscles. Under Paeds HKB. Planned operative intervention 20/7/2026. ESR 42 (15/12/2025), RF negative, ANA negative, pelvic X-ray 25/1/2026 suggestive of Perthes disease.
Familial Short Stature — mid-parental height 167 cm (father 168 cm, mother 154 cm)
Previously under Ophthalmology — divergence excess with poor control

Surgical history: TCA Paediatric Surgery HSAH for phimosis on 18/10/2026.

BIRTH HISTORY

Antenatal: Not fully documented — no known maternal illness specifically stated. Mother has asthma on MDI (pre-existing).

Natal: Born at term, 37 weeks gestation, via spontaneous vaginal delivery (to confirm). Asymmetrical SGA, birth weight 1.5 kg.

Postnatal/Neonatal:

Admitted NICU at birth for: resolved sepsis (thrombocytopaenia, pancytopaenia, hypoglycaemia) and resolved neonatal jaundice with conjugated hyperbilirubinaemia.
Duration of NICU stay not documented — to clarify.
Treated with antibiotics and phototherapy (to confirm).

FEEDING / DIETARY HISTORY

Currently tolerating adult diet. No feeding difficulties. Orally well on admission.

IMMUNISATION HISTORY

Up to date as per national EPI schedule.

DEVELOPMENTAL HISTORY

Domain	Milestone
Gross Motor	Ambulant; limited left hip flexion (squatting difficult due to Perthes disease)
Fine Motor	Able to write, draw; average student
Speech / Language	Fluent, communicates well
Social / Behavioural	Active in co-curricular activities at school

Interpretation: Developmentally age-appropriate. Functional limitation of left hip secondary to Perthes disease — not a developmental delay.

Education: Attending SK Bakar Arang. Average student, active in curricular activities.

FAMILY HISTORY

Member	Age	Occupation	Medical History
Father	35 y/o	Technician	NKMI; active smoker
Mother	34 y/o	Housewife	Asthma on MDI
2nd child (sibling)	—	—	Son, NKMI

No family history of autoimmune disease, HSP, or renal disease specifically documented — to clarify. No consanguinity mentioned.

SOCIAL AND ENVIRONMENTAL HISTORY

1st child out of 2 siblings
Lives with parents and younger brother
Father is an active smoker — passive smoke exposure at home (relevant given mother has asthma and child is on inhalers)
Mother has asthma on MDI — atopic family background
Attends SK Bakar Arang — average student, socially active
No recent travel, no sick contact
No pets mentioned

Effect of illness on family: Recurrent admissions and planned surgery (Perthes — 20/7/2026) place significant physical and emotional burden on family. Mother is primary caregiver. Father works as technician. School attendance likely affected by admissions and hip pain.

SUMMARY OF HISTORY WITH PROVISIONAL DIAGNOSIS

Muhammad Mikhal is an 8-year 5-month-old Malay boy with known HSP (4th admission, discharged 8/6/2026), Perthes disease of left hip (planned operative 20/7/2026), and familial short stature, presenting with 1 week of worsening non-blanching palpable purpuric rash over bilateral limbs, trunk and abdomen, 1 week of frothy urine (resolving), abdominal pain since 1am today (periumbilical, cramping, partially relieved by ibuprofen), and right upper limb swelling noted at ED. UFEME shows blood 2+ with negative protein — raising concern for early HSP Nephritis.

Provisional Diagnosis: Recurrent Henoch-Schonlein Purpura, rule out HSP Nephritis

PHYSICAL EXAMINATION

GENERAL EXAMINATION

General Appearance: Active, alert, pink. Playing with phone. Not in acute distress. Not tachypnoeic. Good pulse volume. Not pale, not jaundiced, not cyanosed. No dysmorphic features. No syndromic appearance.

Vital Signs:

Parameter	Value	Normal (8 years)
Temperature	Afebrile	36.5 - 37.5°C
Heart Rate	96 bpm	70 - 110 bpm
Respiratory Rate	20 breaths/min	18 - 25 breaths/min
Blood Pressure	To document	~100/60 mmHg
SpO₂	Saturating on room air	> 95%

Anthropometric Measurements:

Parameter	Value
Height	To measure — expected short for age (familial short stature; mid-parental height 167 cm)
Weight	To measure
Head Circumference	Not required at this age
BMI	To calculate

Impression: Active and well-appearing. Haemodynamically stable. Saturating on room air. Non-blanching palpable purpuric rash noted.

HEAD TO TOE EXAMINATION

Hands: Warm, pink. CRT < 2 seconds. No pallor, no peripheral cyanosis. No clubbing. Right hand — fullness noted, non-tender, no erythema, no discharge, full ROM.

Pallor: Absent — Hb 13.6 g/dL.

Cyanosis: Absent.

Jaundice: Absent — TB 8, sclera white.

Oral Cavity: Moist. Pink lips. No central cyanosis. No ulcers.

Eyes: Conjunctivae pink. Sclera white. No jaundice. No periorbital oedema. (Previously under ophthalmology for divergence excess.)

ENT: No ear discharge. No rhinorrhoea. No lymphadenopathy.

Shape of Head: Normocephalic.

Fontanelle: Closed (normal at 8 years).

Neck: No lymphadenopathy. No thyroid enlargement. No neck masses.

Hair: Normal texture and distribution.

Extremities:

Bilateral upper and lower limbs: non-blanching palpable purpuric rash — consistent with HSP vasculitic rash
Right hand: swelling/fullness — non-tender, no redness, no discharge, full ROM
Left lower limb: limited hip flexion (Perthes disease — note antalgic gait if ambulant)
No joint swelling or warmth
Warm peripheries, CRT < 2 seconds

Oedema: No pedal oedema.

Skin:

Non-blanching palpable purpuric rash over bilateral upper limbs, bilateral lower limbs, abdomen and trunk
No vesicles, no bullae, no necrotic lesions
Rash palpable (raised) — consistent with leucocytoclastic vasculitis

Spine: Straight, no scoliosis.

Sacral oedema: Absent.

EXAMINATION OF LYMPH NODES

Region	Finding
Cervical	Not enlarged
Occipital	Not enlarged
Axillary	Not enlarged
Inguinal	Not enlarged

SYSTEMS EXAMINATION

Systems involved:

Dermatological (primary — purpuric rash)
Renal (UFEME blood 2+, frothy urine)
Gastrointestinal (abdominal pain)
Musculoskeletal (Perthes disease; right hand swelling)

DETAILED EXAMINATION — RELEVANT SYSTEMS

Abdominal Examination:

Inspection: Not distended, moves with respiration, no visible peristalsis, no surgical scars
Palpation: Soft, non-tender at rest; tenderness on deep palpation over periumbilical/epigastric region. No guarding, no rigidity. No organomegaly. No palpable mass.
Percussion: Resonant. No shifting dullness. No free fluid on bedside ultrasound.
Auscultation: Bowel sounds present and normal. AXR: no dilated bowel.

Respiratory:

No recession, not tachypnoeic
Air entry equal bilaterally, lungs clear. No wheeze, no crepitations.
CXR: clear

Cardiovascular:

Dual rhythm, regular, no murmur (DRNM)
No raised JVP, no pedal oedema
Warm peripheries, CRT < 2 seconds

CNS: Alert, GCS 15. No focal neurological deficit. Cranial nerves intact.

Musculoskeletal:

Left hip: Limited flexion. Antalgic gait. No joint swelling or warmth. Full ROM of other joints.
Right hand: Fullness, non-tender, no erythema, no discharge, full ROM — likely soft tissue oedema related to HSP or IV access trauma.

CLINICAL SUMMARY / ANALYSIS

A. PROVISIONAL DIAGNOSIS: Recurrent Henoch-Schonlein Purpura (HSP), Rule Out HSP Nephritis

Points IN FAVOUR:

Prior confirmed HSP (4th admission, discharged 8/6/2026)
Classic tetrad: palpable purpura + abdominal pain + joint involvement (history of hip pain) + renal involvement (frothy urine, haematuria 2+ on UFEME)
Non-blanching palpable purpuric rash over dependent areas and trunk
Periumbilical cramping abdominal pain
UFEME: blood 2+ — haematuria, raising concern for HSP nephritis
Frothy urine (proteinuria possible — though UFEME protein negative; frothy urine may precede detectable dipstick proteinuria)
Age and sex consistent (peak 4-7 years; males more commonly affected)
Recent prior HSP episode — recurrence rate ~30%

Points AGAINST:

UFEME protein negative (frothy urine not yet confirmed as proteinuria on dipstick — though clinical frothy urine observed by family)
Platelet count 381 — normal (excludes thrombocytopaenic purpura)
Afebrile — less consistent with infective trigger
Right hand swelling unexplained by HSP alone (consider localised oedema vs. trauma vs. IV-related)

B. DIFFERENTIAL DIAGNOSES

I. IgA Vasculitis (HSP) with Nephritis

For: Purpuric rash, abdominal pain, haematuria, prior HSP. Renal involvement (HSP nephritis) occurs in 20-50% of HSP cases.
Against: Protein negative on UFEME currently; no nephrotic syndrome features yet.

II. IgA Nephropathy (Berger's Disease)

For: Haematuria, periumbilical pain, similar age group
Against: No rash; occurs without systemic vasculitis features; less likely given clear HSP diagnosis

III. Systemic Lupus Erythematosus (SLE)

For: Multisystem involvement, purpuric rash, renal involvement, ANA in process, C3/C4 obtained previously
Against: ANA previously negative; rash non-malar in distribution; C3 1.48 and C4 0.56 (both elevated — not consumed as in SLE); male sex (SLE rare in males); age

IV. Immune Thrombocytopaenic Purpura (ITP)

For: Non-blanching purpuric rash
Against: Platelet 381 (normal); ITP rash typically non-palpable; no systemic features

V. Meningococcaemia

For: Non-blanching purpura
Against: Afebrile, haemodynamically stable, well-appearing, no meningism, no toxic features; rash palpable and over limbs/trunk typical of HSP

INVESTIGATIONS

General Investigations

FBC:

Parameter	Result	Normal	Interpretation
TWC	10.2 x10⁹/L	4.5 - 13.5	Normal — no significant leukocytosis
Hb	13.6 g/dL	11.5 - 14.5	Normal
HCT	40.2%	35 - 42%	Normal
Platelets	381 x10⁹/L	150 - 400	Normal — excludes thrombocytopaenic purpura

Renal Profile:

Parameter	Result	Normal	Interpretation
Na	137 mmol/L	135 - 145	Normal
K	4.0 mmol/L	3.5 - 5.0	Normal
Cl	106 mmol/L	98 - 107	Normal
Urea	4.1 mmol/L	2.0 - 6.5	Normal
Creatinine	45 µmol/L	30 - 60	Normal — no renal impairment currently

LFT:

Parameter	Result	Normal	Interpretation
Total Protein	82 g/L	60 - 80	Mildly elevated — to monitor
Albumin	34 g/L	35 - 50	Mildly low — early hypoalbuminaemia; watch for nephrotic syndrome development
Total Bilirubin	8 µmol/L	< 21	Normal
ALP	155 U/L	100 - 350 (paediatric)	Normal for age
AST	17 U/L	< 40	Normal

Complement (from 4th admission): C3 1.48, C4 0.56 — both within/above normal (not consumed; argues against SLE/MPGN).

Specific Investigations

UFEME:

Parameter	Result	Interpretation
pH	5	Normal
Blood	2+	Haematuria — renal involvement in HSP; monitor for progression
Protein	Negative	No proteinuria currently — however frothy urine reported clinically

Urine C&S: Pending — sent to exclude UTI as cause of haematuria.

CXR: Clear — no cardiomegaly, no pulmonary oedema, no consolidation.

AXR: No dilated bowel, no obstruction.

Bedside Abdominal Ultrasound (ED): No free fluid — no significant haemoperitoneum or bowel intussusception.

Pending investigations (ordered):

ANA (trace result from 4th admission — in process)
Repeat UFEME and Urine C&S
FBC, renal profile, LFT, coagulation, blood C&S, CRP at review

FINAL DIAGNOSIS

Recurrent Henoch-Schonlein Purpura (IgA Vasculitis) with Haematuria (Rule Out HSP Nephritis)

MANAGEMENT PLAN

Observe under room air — keep SpO₂ > 95%
Nephrotic chart — strict input/output, daily urine dipstick for protein and blood
Watchout for: bleeding tendencies, worsening rash, abdominal pain escalation, haemodynamic compromise, worsening haematuria or onset of proteinuria
Continue existing medications:
- MDI Salbutamol 200 mcg PRN
- MDI Budesonide 200 mcg BD
Avoid NSAIDs (ibuprofen given at home) — ibuprofen use in HSP nephritis may worsen renal function; switch analgesia to paracetamol
Syr Paracetamol PRN for pain and fever
Encourage oral intake
Monitor rash distribution and character — document extent and evolution daily
Repeat UFEME daily — watch for proteinuria development
Trace pending ANA result
Renal team review if proteinuria develops or haematuria worsens
Appointments to maintain:
- TCA Paeds Ortho HKB for operative procedure — 20/7/2026
- TCA Paeds Surgical HSAH for phimosis — 18/10/2026
- TCA Paeds Clinic — 7/7/2026

PROGRESS IN THE HOSPITAL

Day 1 — 1st July 2026 (Admission)

S: Worsening purpuric rash 1 week, frothy urine 1 week (resolving), periumbilical abdominal pain since 1am. Right hand swelling noted at ED. Ibuprofen given at home — partial relief.

O: Afebrile. HR 96, SpO₂ on RA. Alert, active, pink. Non-blanching palpable purpuric rash bilateral limbs and trunk. Right hand fullness, non-tender, full ROM. Abdomen soft, periumbilical tenderness, no guarding. UFEME blood 2+, protein negative. FBC, RP, LFT as above. Bedside USS — no free fluid. CXR clear. AXR no dilated bowel.

A: Recurrent HSP with haematuria. Rule out HSP nephritis. Haemodynamically stable.

P: Admitted to ward. Nephrotic chart commenced. Ibuprofen stopped. Paracetamol PRN. Continue inhalers. Monitor rash, urine dipstick, vitals. Pending investigations sent.

Day 2 — 2nd July 2026

S: Abdominal pain improved. No new bleeding. Rash stable — not spreading further. No frothy urine today. Oral intake good. No fever.

O: Afebrile. Haemodynamically stable. Rash extent unchanged — not worsening. Abdomen soft, mild periumbilical tenderness reducing. UFEME: blood 1+ (improving), protein negative. Right hand swelling reducing. Input/output balance satisfactory.

A: Recurrent HSP — improving. Haematuria resolving. No proteinuria. No evidence of nephritis syndrome currently.

P: Continue nephrotic chart and daily UFEME. Continue paracetamol PRN. Encourage oral intake. Await pending results. Monitor for rash progression.

Day 3 — 3rd July 2026 (Discharge)

S: Afebrile. Abdominal pain resolved. Rash fading — less extensive. No frothy urine. No bleeding. Tolerating diet well. Normal urine output.

O: Afebrile. Vitals stable. Alert, active. Rash fading bilaterally. Abdomen soft, non-tender. UFEME: blood trace/negative, protein negative. Right hand swelling resolved. Full ROM.

A: Recurrent HSP — resolving. No nephritis features. Haemodynamically stable. Safe for discharge.

P: Discharge home. Stop ibuprofen — counsel parents to use paracetamol only for pain. Continue inhalers as prescribed. Urine dipstick at home daily — return if frothy urine or blood in urine recurs. Return to ED if: rash acutely worsens, severe abdominal pain, blood in urine, reduced urine output, facial or leg swelling. TCA Paeds Clinic 7/7/2026 (before ortho operation 20/7/2026).

STATUS AT DISCHARGE — 3rd July 2026

Alert and active
Afebrile
Rash fading, non-progressive
No abdominal pain
No frothy urine, no haematuria on discharge UFEME
Normal urine output
Tolerating full oral diet
Haemodynamically stable
Parents educated: monitor urine daily, avoid NSAIDs, return for any renal warning signs
Appointments confirmed: Paeds Clinic 7/7/2026, Ortho HKB 20/7/2026, Surgical HSAH 18/10/2026

Discharge Diagnosis: Recurrent Henoch-Schonlein Purpura (IgA Vasculitis) with Haematuria — no nephritis, resolved

Key clinical flags:

Ibuprofen was given at home — counsel parents firmly to avoid all NSAIDs in future; paracetamol is the safe alternative
Albumin 34 — mildly low; monitor for nephrotic syndrome development at follow-up
Planned surgery 20/7/2026 — ensure HSP is in remission before operative intervention; inform orthopaedic team of HSP diagnosis and renal status
Passive smoking exposure — counsel father to quit smoking; relevant to mother's asthma and child's respiratory health

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

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