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

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)

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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.

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