LAPORAN UNDER 5 MORTALITY

HOSPITAL JITRA

1. BIODATA(PROFIL) PESAKIT

Nama : Muhammad Afiq Fauzee Bin Abdul Razzaq

Umur : 3 years old

Bangsa : Malay

Alamat: Taman Sinar Harapan Jitra, KM 23.7 Lebuhraya Bkt Kayu Hitam, 0600, Jitra, Kedah

Tarikh rawatan: 18/10/18-23/10/18

2. Kronologi/ rentetan peristiwa
Tarikh dan masa mengikut turutan
18/10/18 at 4 pm
19/101/18
Peristiwa yang berlaku (mengikut rekod
perubatan- termasuk pemeriksaan, siasatan
makmal dan diagnosis)
3 years old, malay, boy presented to OPD
Hospital Jitra with complaints of poor oral
intake and less active 2 weeks. Otherwise no
fever, no vomiting, no diarrhea, no
cough/running nose, no history of fall/ trauma
Child premorbidly ADL dependent.
From medical history, he is a known case of
cerebral palsy.
On examination in ward:
Alert, conscious, not in respiratory distress, not
tachypneic, pupils 2mm bilateral reactive to
light
T: 37⁰C, PR: 80, SPO2- 98% on air, DXT stat:
5.2mmol/L
Lungs: clear, equal air entry
CVS: DRNM
P/A: soft, not distended,
Moving all 4 limbs
Blood investigations:
Full blood count: TWC 13.09/ Hb 8.8/PLT 506
Urea 2.29/ Na 126.6/ K 4.59/ creat 12.05
Impression:
1. Poor oral intake ? cause
2. Hyponatremia secondary to 1.
3. MCHC anemia for investigation
Management:
1. KIV for CXR,AXR if still poor oral intake
2. Start IVD HSD5% 40cc/hr
3. Repeat RP cm along with FBP,iron
studies
8.30am, seen by MO in ward,
Vital signs stable, afebrile
Lungs: clear
CVS: DRNM
P/A: noted? palpable mass over left iliac fossa,
 bowel sound present, not distended
Plan: for chest xray and abdominal xray

12pm:, seen by MO oncall

CXR: bronchopneumonic patches
AXR: ? fecal matter over pelvic area, no dilated
bowel, fecal loaded

RP: urea 2.11/ Na 127/ K 4.06/ creat 14.23

Impression:
1.cover for pneumonia
2.constipation
3.hyponatremia secondary to 1 and 2
Plan:
Ravin enema
Sy lactulose 5ml BD
IV cefuroxime 240mg TDS (25mg/kg/dose)
Keep NBM
Cont IVD
DIL issued

20/10/18 0640am, seen by MO in ward

Noted child had no more vomiting, BO x2
yesterday, afebrile,
Vital signs stable
Lungs: clear
CVS: DRNM
P/A: soft, pelvic mass not felt, bowel sound
present

RP: urea 1.36/ Na 136/ K 4.04

Plan:
For trial of bottle feeding, to off IVD once
tolerating feeding
Continue antibiotic
KIV for ultrasound abdomen and pelvic if still
seeing mass over pelvic region on repeated AXR
on 21/10/18

21/10/12 0810AM, seen by MO in ward

Patient tolerating bottle feeding, no vomiting
Able to BO, afebrile
Vital sign stable
Plan:
 Off IVD, cont bottle feeding, for AXR, cont
antibiotic

0230PM, AXR reviewed: prominent bowel, no

dilated bowel
Patient had 1 temperature spike 38 degree,
noted left hand branula swollen. resolved after
tepid sponging and supp PCM

22/10/18 0800am, review by MO in ward

Had 1 episode of vomiting, fever settling
Vital signs stable
Lungs:clear
CVS:DRNM
P/A:soft, not distended, no mass palpable
Imp: sepsis ? cause possible intrabdominal
sepsis

Plan:
KNBM with IVD full maintance
KIV to escalate to IV rocephine and add IV
metronidazole if persistent temperature spike

23/10/18 0920am, review by MO in ward

Noted patient still had temperature spike, no
vomiting,
Lungs:transmitted sound
CVS: DRNM
P/A:soft, not distended

Vital signs stable,

Septic workout taken

CXR: right perihilar haziness

AXR: fecal loaded, no dilated bowel
TWC: 19.38/ HB 9.0/ PLT 694
NA 124/urea 2.92/ K 3.98/creat 19.79
UFEME: all negative
Blood C+S: result pending

Case d/w paediatrician oncall (Dr. Ooi), send to

HSB for further management.