Name : Adam bin Zakaria

Age : 4 years old

DOA : 19.01.201 7
DOC : 21.1.2017

Chief Complain
History was taken from the parents of a 4 year old Malay boy that was brought to
the hospital due to generalized weakness and loss of appetite.
History of Presenting Illness
Generalized weakness started 3 days prior to admission along with fever, post-
tussive vomiting and loss of appetite. The content of the vomitus was food and
triggered by repetitive coughing. The cough started a week prior to admission
and was chesty, productive with copious clear sputum. Boy was given Ventolin as
needed two days prior to admission for the severe cough. These symptoms are
all preceded by an acute onset of fever. The temperature was not recorded, only
briefly subsided when given syrup paracetamol but recurred despite
interventions. Patient also complained of headache and periumbilical stomach
ache. The headache was diffuse, not radiating to the back of the neck and not
exacerbated by his movements. The periumbilical stomach ache is not improved
by eating, defaecation nor vomiting. Adam experienced lower limbs muscle
cramp a day prior to admission. Otherwise, urination and defaecation are normal
for this child.
There was no symptom of runny nose, noisy breathing, wheeze, or dyspnea.
Historian denied history of child having sore throat, difficulty swallowing, drooling
of saliva and trismus.
No urinary signs & symptoms such as dysuria, incontinence, hematuria, increase
in frequency abdominal distension or suprapubic pain.
The was no complaints of neck stiffness (demonstrated as pain when eliciting
motions of the neck), loss of consciousness, seizure, irritability.
Historian denied giving readily prepared food from stalls or restaurants to chill
lately. No other person living with the boy had gastrointestinal symptoms such as
diarrhoea and vomiting. No history of allergies to food or beverages except for
lactose. Denies giving the child lactose-containing beverages.
Patient does not live in a dengue prone area and no fogging activities are noted
by the parent. No recent outdoor activities (jungle tracking) or bleeding
tendencies in this child. No chills and rigors or sweating noted.

Past Neonatal/Medical/Surgical History

Adam is lactose intolerant Diagnosed 6 month old when he was given formula
milk. Developed rashes. Parents were counselled and educated on Adams
condition. They are aware and alert on Adams condition which has not had any
complications since diagnosis was made.
Diagnosed with asthma at 3 years of age. Currently well-controlled requiring
Ventolin not more than once every 6 months.
Evaluation of asthma :
No daytime symptoms, nocturnal symptoms, activity limitations, not needing
reliever treatment more than twice in a weak except during exacerbations in this
past one week prior to admission. Adam has cold-induced asthma. Strong family
history of asthma and atopy is noted. No dusty carpets or pets at home nor does
he live near factories or construction sites.
Allergic rhinitis Daily symptoms of runny nose and watery eyes in early
mornings that subsides as the day comes along.
Hand, food & mouth disease He was diagnosed at UMMC a year ago when
father brought him in when noticing ulcers of the mouth and palms. Treatment
was done and he recovered without further complications.
Drug History
Ventolin PRN
Allergies
Lactose-based beverages.
Antenatal and Birth History
No antenatal complications, normotensive, normaglycaemic.
Mum had spontaneous vaginal delivery requiring 22 stitches at UMMC. Baby was
born term at 37 weeks weighing 3.3kg.
Family Hx
*Draw
Developmental History
Gross Motor : Walks at 1 year old
Fine Motor : Able to scribble and draws at 3 years of age
Hearing and Speech : Says mama at 9 months
Social : Put on own shows at 2 years old, knows name at 2, interact with other
child well at 3
Immunisation :
Copies table
Nutritional History
Adam is breast fed until 1 year old and started to wean at 8 months old, first with
cows milk then changed to soy-based milk because of his lactose intolerance.
Current diet is protein from chicken and beef and carbohydrate from mainly rice.
Dislikes vegetables and fruits. Not taking vitamins.
Social History
Dad is Mr Zakaria who is a self-employed businessman, divorced from the
mother, Ms Liyana who works as an English teacher at a private sector. They
share custody. Adam lives with his dad and grandparents in a double storey
house with 7 people in the house in total. The primary caretaker is the paternal
grandparents. Adam is in his second year of kindergarten.
PHYSICAL EXAMINATION (copy from notes)
INVESTIGATIONS

Unit Ref Range

Urine FEME
Biochemistry
Specific gravity

Copy from phone and A4 paper

CXR copy paper
Final Dx
Atypical pneumonia
Tx see notes
Discussion
Etiology
Epidemiology
Clinical Manifestations
Lab and Imaging
Diagnosis
The patient presented with fever, cough, post-tussive vomiting, lethargy with
reduced oral intake. These are all non-specific symptoms that could belong to
any one of the differential diagnosis. Due to strong physical examination findings
which is crepitations on auscultations and the result of sputum culture to confirm
mycoplasma pneumonia as causative agent, the diagnosis of atypical pneumonia
is the obvious choice. Lack of some signs & symptoms to support other
differential diagnosis such as lack of urinary symptoms to diagnose UTI, lack of
clear decompensation and critical phases such as in dengue fever and normal
haematocrit level make the diagnosis of dengue highly unlikely. Although, if
Adams fever prolongs and worsens with further changes of haematocrit and
platelet could be detected, with his overall symptoms, theres a high index of
suspicion for dengue. Adams blood pressure and capillary refill time was normal.
That rules out any haemodynamic instability. To suspect upper respiratory tract
infection complicated with lower respiratory tract infection is possible although
there is no evidence of runny nose, inflammation of upper respiratory tract
during throat examination that could rule out pharyngitis, no enlarged or injected
tonsils which rules out tonsillitis or possible tonsillar abcess. In addition to that,
his pre-existing asthma is well controlled and there is no history of recent
exposure (cold, water) that could trigger AEBA. There were no gastrointestinal
symptoms such as changes in stool consistency or frequency, no h/o ingestion of
food that he was allergic to nor did Adam have history of eating possibly
contaminated food abdominal examination did not show any bloating and the
bowel sound is present and normal. Gastroenteritis is rules out based on these
negative findings. Meningitis requires the presentation of meningisism which
wasnt demonstrated during physical examination. Furthermore, Adam did not
experience any loss of consciousness, irritability or altered mental status. He also
did not complain of any pain around the neck and did not appear toxic-looking.
DDx
Treatment
Complications
Prognosis
Prevention