CASE SUMMARY

NAME : MUHAMMAD FADHL DANIAL BIN GUSTI FLORANTE

IC : 160501-12-0899
SEX : MALE
WEIGHT: 4.5KG
AGE : 7 MONTHS OLD

Background history

Antenatal history Mother:

1. History of intrauterine death at term 2012. Investigations done with no
genetic abnormality.
2. History of preterm delivery at 7 months
3. History of ectopic pregnancy in 2013 with left salphingectomy was
done
4. Anaemia in pregnancy
Birth history Full Term, SVD at 37 weeks and 3 days
Birth weight: 2.65kg.
APGAR score was 9 in 1 min

Hospitalisation History 1st Hospitalisation (1/5/16-4/5/16)

Admitted NICU for: Transient tachypnoea of newborn with neonatal
jaundice secondary to polycythemia.
Venesection 1/5/16 for polycythemia
Down syndrome noted at birth with incidental finding of
murmurbedside ECHO: PDA

2nd Hospitalisation (21/10/16-25/10/16)

Acute bronchiolitis

3rd Hospitalisation (15/11/16- 21/11/16)

Viral pneumonia and possible epilepsy

4th Hospitalisation (27/11/16 til today)

Bronchopneumonia
Severe acute gastroenteritis
Acute Bronchiolitis

Problem List 1. Down Syndrome

Young Mother Chromosomal study: Trisomy 21, sporadic down
syndrome, usual age related risk
TFT 18, TSH 5 (4/8/16) Normal.
Hearing:normal
Vision: appt postponed
2. Large PMVSD in failure
Patient developed failure symptoms at 2 months old.
Started on antifailures at 2mths old:

History of current
admission:
Sabahs Women and Child was diagnosed with
Children Hospital from
(27/11/2016-16/12/2016)
Paediatric Cardiology Ward,
Hosp Queen Elizabeth 2
(16/12/16 27/12/16) gain however he developed a nosocomially acquired acute bronchiolitis
Syrup Frusemide 4mg TDS
Syrup Captopril 1.5mg TDS.
Ryles tube feeding since current admission.
IM Palivizumab given x2 (Oct and Dec 2016)
Planned for VSD closure under IJN.
3. Possible epilepsy
Nov 2016, pt developed afebrile seizure. Generalised tonic- clonic seizure
with no residual neurological deficit.
Bedside USG cranium was normal. Not started on entiepileptic. No family
history of seizure.
Was scheduled for EEG on 27/12/26 but postponed due to op in IJN.
Presented with 2 days history of diarrhea, 1 day history of fever, cough,
runny nose and rapid breathing prior to admission.
1. Bronchopneumonia
2. Acute gastroenteritis with severe dehydration, metabolic acidosis and
compensated shock.
Child was intubated for 3 days (27/11-29/11/16). IV Augmentin was given
1/52.Following resolution of infection child was kept in ward for weight
on 9/12/16. No antibiotic was started. Child was active, tolerating feeding
well with weight gaining.
NPA RSV was negative.
Child was transferred over to Paediatric Cardiology Ward on 16/12/16 on
nasal prong 2L/min. In PCW, child was active, no cough, no fever and
tolerating feed via RT and breastfed. Child was able to be weaned off
oxygen.
Hb: 10, TWC 6.6, PLT 573
Na: 138, K 4.4, ur 5.8, cr 43
ESR 13, CRP 1.3