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ID

Name
Age
DOB
DOA
Address
HX taken From

C/O


HOPI


SYSTEMIC
REVIEW

Skin : no rash, no itchiness, pink colour
Head : no injury of the head, no swelling
Eyes : no pain, no discharge
Ears : no hearing problem, no pain
Nose : no nose bleeds, no discharge
Mouth & throat : no ulceration, throat not inflamed
Neck : no neck stiffness, no swelling
Cardiovascular : no cyanosis, not dyspnoeic, chest pain
Respioratory : no cough, noisy breathing
Hemopoeitic : no pallor
Genitourinary : change urine volume, frequency, colour, dysuria
Hepatobiliary : no jaundice
Musculoskeletal : no joint swelling


PMH

1. Any medical illness / same illness before
2. Any hospitalized & treatment
3. Have undergone surgery before.
4. History of trauma or serious injury in the past.
5. No known allergy to food and medication


BIRTH HX

ANTENATAL : uneventful, maternal illness (GDM, PH)
NTRAPARTUM: POG, by SVD/LSCS, birth weight, any Complication
POSTPARTUM : any NCU, NNJ


DEVELOP
MENT HX

Development Milestone was up to his age
1. Hearing Speech : can talk meaningful (2-3 years) / 2-3 words
( 1 year old)
2. Fine Motor & vision : palmar grasp / mature pincer grip / ability to
draw (2-5 years)
3. Gross motor : limb flex (newborn) / crawling (8-9 month) / walks (15
month) / run
4. Social : smiling / stranger anxiety / staring

IMMUNIZATION
HX

completed according to schedule

NUTRITIONAL
HX

1. Breast Feed / Bottle feed : how many times per day
2. When start Weaning
3. Any adult food : porridge, meat, fish

FAMILY HX

1. Anak ke berapa?
2. Berapa siblings?
3. Father and mother work
4. ncome & per capital : Low / moderate SES
5. Does from consanguineous marriage
6. Any same illness run in family
7. Any other disease run in family : asthma , TB, HPT ,
Diabetes, stroke
8. Smoke, Drug, alcohol ?


SOCIAL HX

1. Type of house : terrace
2. How many family member stay together?
3. How many rooms
4. Equip with water & electrical supply?

CASE : AEBA

History of presenting iIIness

Nasrullah bin Shazli, 4 months old ,is a known case of syndromic baby,
presented with cleft palate, webbed neck and central apnea, diagnosed after birth,
currently, cannot tolerate feeding for 2 days duration and had generalized swelling for 1
day prior to admission. He didn't feed a normal volume of milk using the ryle's feeding
tube as usual, and rejects some amounts of milk by crying for 2 days . Mother denied
the child to have fever, vomiting, diarrhea, changing the milk composition.
The patient come with acute generalized swelling over whole body at the same time. He
was not crying or looks irritable during the onset and after. The oedema was non pitting.
The patient looks very pale and lethargic . The mother denied patients to have tea
coloured urine, fever , trauma, insects bite.

Her fever was associated with chesty cough, with whitish sputum, precipitated
at night and cold weather and associated with wheezing and reduced oral intake. No
stridor or whooping sound or post-tussive vomiting noted. No contact to TB patients or
any possible carriers.

She had been taken medication since 4 days ago from a private clinic with no
improvement. However, a day prior to admission, her condition worsen when her mother
claimed she had rapid breathing along with difficulty of breathing that a few times
stopped her from crying before resuming, severe coughing with intercostals recession
and her lips were pale and nails were blue. Her condition did not improve despite giving
her prescribed inhaler. No history of exposure to pets, no carpets or soft toys in house.
Her mother claimed, similar incidences before were milder and resolved with drugs given
by hospital.

She is a known case of asthma since 7 months ago. Her first presentation was
at 6 months of age, she was admitted due to a 1 week course of fever and worsening
cough which was associated with difficulty of breathing, wheezing and pale lips. During
this admission she was 3 times nebulized and was later discharged well with MD
ventolin.

A day after discharged, she was readmitted due to her restless condition and
difficulty of breathing despite treatment. She was later diagnosed with childhood asthma
and given MD inflamide to complement her previous treatment. Until now, she had
occasional mild attacks and resolved with medication. Her asthmatic attacks were mostly
precipitated by cold weather and occurred especially at nights. Her last attack that
requires nebuliser was in September 2006

She also has strong maternal and paternal history of asthma.

Other systemic reviews were not significant. There were no histories of eczema,
urticaria, allergic rhinitis and no conjunctivitis.


CASE AGN

Chief CompIain
Referred case from Hospital Mentakab for
Passing out blood in urine a day prior to admission
facial puffiness with fever and vomiting 2 days prior to admission

History of presenting iIIness
Mohd Alif Aiman, 8 years old Malay boy presented with history of low grade fever for 2
days prior to admission with no association to any rash, chills, rigors, arthalgia, myalgia, fitting
episodes, headaches and of no specific pattern. t is acute in onset with no signs of upper
respiratory tract infections such as cough, sore throat or runny nose. He did take medication in the
form of paracetamol but his fever did not resolved. No other family members had fever and they did
not know of anyone who had dengue in their housing area. His fever is however associated with
lethargy and vomiting.

He vomited 2 to 3 times per day, following food and non-projectile. t was associated with
nausea, loss of appetite and lethargy but not associated with abdominal pain, neck stiffness or
headache or any change in bowel habits. The vomitus contained partially digested food but there
were no blood and not greenish in colour. There were no family members with similar symptoms
and no history of eating outside food. Unlike the fever which persisted until the day of admission,
vomiting lasted only for 2 days prior to admission.

Along with his fever and vomiting, patient came with facial puffiness which was noted by
the mother 2 days ago. She noticed when her son woke up from he suddenly had puffy cheeks.
However, the mother did not notice any abdominal swelling, scrotal swelling or leg swelling. Patient
only noticed his facial swelling when told by his mother but noticed that his legs feel heavy when he
wanted to walk. His mother dismissed the fact in view that he might be lethargic as he was having
fever. He had no history of insect bites, shortness of breath or symptoms of cardiac failure such as
sweating, palpitations, rapid breathing and is able to sleep comfortably while lying flat with one
pillow. He also denied of any incidence of bleeding tendencies such as nose-bleeding, gum-
bleeding or easily bruising and any yellowish discolouration of the skin or the conjunctiva.

One day prior to admission, he noticed that he was passing out blood in his urine. t was painless
and described as coca-cola coloured each time he urinated. He denied of any similar history prior to
this or any trauma to the back and did not notice any foul smelling or any recurrence in bed-wetting
or any changes in his urinary habits. He also did not have any abdominal or colicky loin pain and
was not on any drugs like rifampicin or cyclophosphamide. None of the family members had similar
symptoms. Due to his condition, his parents brought him to Hospital Mentakab and were referred to
Hospital Temerloh.

He also had impetigo occurring since 1 month ago. According to the patient, it was itchy sometimes
and mostly distributed at his legs and hands and forearms. He sought for medication from a private
clinic and was improving with ointment but not yet fully cured. His younger sister also had the same
symptoms developed much later.

There were no significant findings in review of other systems as he denied of having blurring of
vision, drowsiness, fainting episodes, ear or eye discharge, deafness, wheezing, coughing or chest
pain, constipation or diarrhea.


















CASE ACUTE BRONCHOLTS

Chief Complaints:

Running nose & Cough for 6days duration
Fever & shortness of breath on the day of admission.


History Of Presenting llness

This child was previously healthy until 6 days ago when he suddenly develop running
nose. Yellowish discharge continuously being secreted and worsened at night. At the
same time, he develop cough. For the first 5 days, it was hoarse and dry in nature, not
barking or whooping but eventually becomes loud and chesty cough. The sputum was
also yellowish in colour and worsened at night. Baby had difficulty to expectorate the
sputum and this has disturbed his sleep. However, there was no need to prop up his
sleeping position. There was no fever, blood-stained sputum, wheezing or shortness of
breath that accompanies the problems.

On the 5
th
day of illness, his condition worsened and he started to develop fever. t is
sudden, high grade but with no chills or rigors, occurring all day long. Worried about his
condition, the parents brought him to the clinic. He was treated as having Upper
Respiratory Tract nfection (URT) and medication was given. The next day, fever still
persist and the baby suddenly started having difficulty in breathing where the mother
noticed that he opened his mouth wide with increased effort of respiration. He cried and
turned pale but there was no stridor, wheezing or bluish discoloration of the face or
peripheries noted. This is the first time Alif Haikal becoming t was not due to ingestion
of foreign materials as far as the mother concerns since the child was too sick to play. t
was neither precipitated by allergens, cold weather or cold drinks. His parents rushed
him to the Accidents & Emergency Department (A&E).

For the whole duration of sickness, he loss his appetite and cannot tolerate orally. He
will regurgitate each time he was bottle-fed which never happened before since he
stopped breastfeeding at 3 months old. t was non-projectile and the vomitus consist of
milk without blood or bile-stained. Mother had to lessen the amount of milk in order to
reduce amount of vomiting. There was no diarrhea, constipation or history of frequent
vomiting before. As a result, mother claimed slight weight reduction of her baby. He also
become irritable, keep on crying and appeared lethargy. He losses interest with his toys,
refused to play with his sisters and become restlessness. There were no rashes,
redness of the eye or ears, and no similar illness in the family. He had no changes in
urination. He had no history of traveling or contact with sick people. There is no personal
or family history of asthma, eczema or allergic rhinitis. However, he had 3 episodes of
fever, running nose and cough (which the mother could not really remember) but not
worsening into shortness of breath, feeding difficulty and vomiting. During these previous
episodes, it resolved with medication and there was no hospital admission.


CASE : DENGUE HAEMORRHAGIC FEVER

CHIEF COMPLAINT
Fever and headache for 5 days duration

HISTORY OF PRESENTING ILLNESS
Mohd Daneal Faizi was apparently well until 5 days prior to admission when he
developed moderate grade fever. The fever is sudden in onset and continuous through out the day
with no specific pattern. The fever was associated with chills and rigors. He also felt malaise,
lethargy and having generalized weakness following the onset of fever.. The fever was not
responded to paracetamol. Tepid sponging was done but there was only temporary relief before the
fever spike again. The fever was not associated with sore throat, cough, runny nose or nasal and
ear discharge. He also did not experience increase in urine frequency, urgency, painful during
micturition or any abnormal urethral discharge.

He also experienced generalized flush of face, trunk and limb. Upon questioning, his
mother told that she had noticed rashes on the patient abdomen on the second day of the fever but
she thought it was just some mosquito-bite mark. He also had one episode of bleeding from the
nose during nose-picking. t was fresh blood that only stained his finger but not coming out directly
from his nostril. Otherwise, there was no gum bleeding, easy bruising, coughing out blood, blood in
the urine or passing out blood per rectally. He had poor appetite and had been absence from school
from the first day of fever but the patient haven't notice any weight loss.

Along with the fever, he also experienced headache. t was localiz
ed at the frontal area. t was described as mild but persistent. However, the patient was not being
able to describe the pain. Otherwise, there was no nausea and vomiting, no drowsiness, sweating,
myalgia, athralgia, retroorbital pain or back pain. He also denied any blurring of vision, neck
stiffness, recent history of head trauma. He did not experience any fits, numbness, incoordination or
abnormal movements of limbs or trunk. Beside paracetamol, he had not on any drugs.

On further questioning, he told that he also had mild, on and off epigastric pain which is
gradual in onset. The pain is localized and non-radiating. He denied any abdominal distension or
yellowish discolouration of skin. The epigastric pain was not relieved or aggravated by food. He had
normal bowel habit, no diarrhoea or constipation.

He lives in dengue-prone area. The patient told that he did not notice any mosquitoes or
insect bites prior to the fever and he never had dengue before. According to his mother, he will be
playing outside the house from 6 to7 pm every evening. There was no recent history of travelling,
swimming in the lake, pond and sea.

On the second day of the illness, her mother went to the pharmacy and was given syrup
paracetamol and pain killer. Despite all the medication, his condition persist and did not improve.
This brought him for his current hospitalization.


DFFERENTAL DAGNOSS

1. Malaria : TRO not periodic fever, no pallor , not tea color urine
2. Thyphoid fever
3. Scrub Thyphus