PATIENT’S NAME

Nor Atikah Syahirah (RN:16192427)

DATE OF ADMISSION
11/4/2018
DIAGNOSIS
UTI with mild dehydration
SUMMARY HISTORY OF THE PATIENTS CONDITION

Fatin, a 17 years old Malay girl with underlying spastic diplegic cerebral palsy, presented
with 1 day history of vomiting associated with 2 days of poor oral intake prior to admission.
This happened in the background of 2 weeks of fever.

She was in her usual state of health until 2 weeks ago when her mother started to notice
that she had fever after coming back from her hometown in Pulau Langkawi. She was warm
to touch at that time but there was no documented temperature. The fever was persistent
throughout the day. No chills and rigors were noted. Her mother said she could still attend
school and interact with her friends. She was also eating well and didn’t appear to be
lethargic. No rashes but mother couldn’t tell whether there was any joint pain, retrorbital pain
or headache. No recent fogging at home. No sick contact. No shortness of breath. No chest
pain. No diarrhea and stomachache. No discharge from both ears. No episode of fitting. No
pain upon urination and no blood or discharge were seen at the genitals and anorectal
region. No wounds were seen as well. On day 2 of illness, the mother brought her to GP
because the fever did not get better. Mother could not remember the temperature at that
time. She was prescribed syrup PCM and was told to drink more water. After taking the
medication, the fever resolved for a few hours before setting in again. 1 week after taking
the medication, the fever did not get better and she visited the same GP again. This time,
she was prescribed oral cephalexin and was told to continue to take the syrup PCM. The
fever persisted.

On day 13 of illness, she also started to have nausea. Her mother said she was not eating
as much as usual. Usually, she could finish a small plate of rice, vegetables and meats cut
into small pieces. However, this time she could only eat 2 or 3 spoons of porridge. She also
didn’t want to drink much water as compared to usual. On day 14 of illness, at 3am, she
started to vomit. She vomited about 4 to 5 times prior to admission. The content of the
vomitus was food particles and clear fluid. No blood, no coffee ground vomitus and no bile
were seen. No projectile vomiting. The quantity was described as mild (not too much, not
too little) for each time she vomited. She then quickly bring her to the emergency
department here as the mother said she had never been this sick before.

In the emergency department, she was noted to have mild dehydration. A CBD was
inserted there and the urine was noted to be cloudy by ED team. UFEME biochemistry
showed presence of leucocyte (2+), nitrate and protein (2+). The microscopy showed high
erythrocyte and leucocyte count (erythrocyte: 30, leu: 100). Albumin were also noted to be
low (12) in liver function test. Further blood investigations such as urine culture and
sensitivity, blood culture and sensitivity and CRP were done. IV normal saline and IV
augmentin were given before she was transferred into 5PB.

This is her 2nd hospital admission in her life. Her 1st admission was in 17/4/2017. At that
time, she was having the same symptoms as the present admission for 10 days but with
addition of mild cough and runny nose. After not getting well despite medication from GP,
she was then admitted into PPUM as she had poor oral intake also at that time. Diagnosis of
acute pharyngitis were made and was treated with syrup EES (erythromycin ethysuccinate),
cefuroxime tablet and IV normal saline. Her conditions improved gradually and was
discharged 3 days later with cefuroxime tablet for 1 week. Since then, she was well until this
recent admission.

(To clerk further)Her mother was unsure of the term “Cerebral Palsy” and when her
daughter was diagnosed with it. Instead, she was told that her daughter (9 months old that
time) would be an OKU and have problem with her “akal”. This was said when her mother
brought Atikah to PPUM because she had slower development compared to her siblings.
The mother first noticed such delay was when she had poor eye contact and poor
responsiveness at 5 months old. She then brought her to PPUM and was referred to
ophthalmology. She was told that she had “short-sightedness” and would need to wear
spectacles. Her eye contact improved after that. At 6 months old, she could not turn from
supine to prone and was still floppy. At 1 year old, she started to sit up without support and
was able to stand a little while with support. At 4 years old, she could say “Mama” and
“abah” but mother was unsure whether it carried any meaning. At 15 years old, her period
started (details: ). Her mother also brought her to paediatrics rehabilitation clinic in PPUM
every ?.

Currently, GFMCS V, she is fully dependent on her mother for her activity of daily living
such as bathing, brushing teeth, combing hair, dressing and change pad for her menses.
She couldn’t talk and could only make incomprehensible voice. However she could indicate
discomfort by pointing using her finger. She also has urinary and bowel incontinence and is
using adult diapers. Her mother would usually change it 5 times a day. She is mobilizing on
a standard wheelchair at home with her mother help, a DAF(detachable foot rest
wheelchair) wheelchair with PSD(postural support device) at school. She is studying in a
spastic school near her apartment. She has many friends in her school and her mother said
she enjoys spending time with them. They have physio and OT session there. Can tolerate
1 hour using standing frame. She also had poor postural support and would slouch when
placed on a chair. She has thoracic scoliosis and contracture on her right hamstring. Botox
A injection was given in February 2015 but no improvement. Otherwise, no swallowing
difficulties, no seizures.

Antenatal history was unremarkable. Mother didn’t have gestational diabetes, hepatitis c,
hepatitis B, HIV and hypertension at time of pregnancy. Fetal movements were normal.
However, ultrasound finding suggested that the foetus was small in size. Her mother blood
group ?

Intra-partum history. She was born preterm at (?) week via emergency lower segment c
sec because her mother had difficulty in delivering her via SVD. Her birthweight was (?). Her
mother couldn’t remember anything after that but she could hear nurse shouted
“oxygen!oxygen!”. She denied any complications from the delivery.

The baby was subsequently warded for 1 month. Mother had forgotten where and for what.
Unable to see her baby. (?)

Postpartum. Unsure.

Diet history: Breastfed exclusively for 2 months. Stopped because mum couldn’t produce
enough milk. Change to formula milk, unsure of details. No episodes of prolonged feeding.
Started complementary feeding at 8 months old with porridge. Started adult diet at?

Immunisation was up to date. No additional vaccine were given.

Family history:
 No family members with CP.
Father passed away at the age of 52 y/o due to heart attack.
Mother is 58 years old with underlying health issues????
Eldest son is 42 years old, married, staying with wife in “kampung”, no health issues
Second daughter is 35 years old, clerk, married, no health issues
Third son is 33 years old, driver, married, no health issues
Atikah is 17 years old
Pregnancy was unplanned.

Grandmother and grandfather from both paternal and maternal side have DM and HPT.

Drug hx:
Not on any long term medication. No allergy towards any food or drugs.

Social hx:
Father was the breadwinner, working as (?), passed away
Mother is the primary caregiver, taking care of her daughter full time, not working
Athikah and her mother live together at the ground floor of an apartment. Her other siblings
stayed outside.
They are financially supported by PERKESO, JKM and donations of equipment from other
people.
How she cope?
Difficulties?
Travel?
Who look after her if she is gone?
EXAMINATION OF ALL SYSTEMS

Estimated bodyweight of 35kg

Height was not measured (contracture, unable to stand)
Segmental length can be used to estimate height?? (Segmental length growth
chart/calculations)
HC:

RR: 19 rpm
HR: 98 bpm
Temp:36 degree celcius
BP:112/75 mmHg
SpO2:99%
Pain: 0

General inspection:

She is lying prop up at 45 degree on the bed with both lower limbs slightly elevated with
pillows. She is alert and not in respiratory distress. She appeared to be thin and short for her
age. There is splint with branula on the patient’s left arm. There is windswept deformity
noted with the right hip adducted and internally rotated, the left hip abducted and rotated
externally. Equinovarus deformity was also seen. No dysmorphic features were noted.
Patient is not pale, jaundice, cyanosed but appear to have facial oedema. A wheelchair was
noted at the side of bed.

There was no finger clubbing, no peripheral cyanosis and no palmar crease pallor. The
hands were cold to touch(aircond?). No peripheral stigmata of infective endocarditis. Cap
refil was less than 2 seconds. Hand was moist. Pulse volume is good, regular rhythm with
rate of 96bpm. No sclera jaundice and no conjunctival pallor. Mouth.

Inspection:
No scars, no muscle wasting, no involuntary movement, no fasciculations and no tremor
were noted on all 4 limbs.

RUL:
Tone- clasp knife spasticity, no tight fisting of hand
Power-3/5 shoulder, others cannot be examined.
Reflex: Brisk in bicep, tricep and supinator reflex

LUL:
Cannot be examined

RLL:
Tone: hypertonia, contracture over the right hip and knee
Power:
Reflex: Knee reflex and ankle reflex were brisk

LLL:
Tone: hypertonia,
Power: 3/5 on hip flexion,
Reflex: Knee reflex and ankle reflex were brisk

Clonus were absent on both LL

Babinski sign was upgoing
Pitting oedema

Heart:
Not remarkable
Dual heart sound with no murmurs
Apex beat?(might displaced because of scoliosis?)

Lung:
Thoracic scoliosis
Chest expansion normal
Resonant on percussion
Equal, vesicular breath sounds on both lung fields with no added breath sound.

Abdomen:
No hepatomegaly
No splenomegaly
No ascites
RELEVANT INVESTIGATION(S)

Blood culture –ve

Urine culture –ve
Progress:
Admitted
Potassium Chloride injection (5/4 – 0.5g IV infusion single dose stat, 10/4- 10% 2 g for 1
week)
Continue IV augmentin for 1 week (3 times a day)
Human albumin 20 percent infusion (7.5 mL per hour for 1 week)