CBL

PERSONAL DETAILS
• Muhd Fateh Aqil /2 y.o/ Malay /Gombak KL
• Born FTSVD 9 (weeks) @ HRPZ 2 KB
• Birth weight = 3.84kg, Current weight = 12.20 kg
• Antenatal= Mum has GDM and was on diet control
• Postnatal = NNJ admitted for 3 days, developed hypoglycaemia and
has shoulder dystocia during labour however no neurological
complication.
• Immunization up to age.
CHIEF COMPLAINT
• Easy fatigue x24/52 ago followed by non- healing right knee
cut associated with prolonged fever for 3/52 prior to first
medical contact 11/52 ago.
• Patient has no known medical illness and normal
developmental milestones.
HOPI
• Patient was well until he was 1 and half years, where his dad notices his son looks pale, less active
and often get tired easily comparable to his elder brother.
• In (end August 2019),12/52 ago father had noticed that his son was not walking normally, and his
right leg seems to be affected. Son was complaining of right knee pain. Concurrent with this,
patient often developed spike of temperature only during night at least 2-3 days in a week for
about 3 weeks. However, father never seek for any medical treatment at that time. In early
September 2019, 11/52 ago , Fateh suddenly fell on a tar road while he was playing with his elder
brother aged, 5 years old. After the fall, patient sustained minor cut at his right knee. Father
claimed the cut was about 2-3 cm in width. The minor cut was not healing even after 2-3 days.
Father decided to bring his child to a private clinic A and was given oral antibiotics for a course of
10 days. However even after completing the antibiotic, patient cut was not healing in fact become
more worst where father claimed he became bigger. After the fall, father notices patient abdomen
looks distended and he felt small nodules at the back of the ears, head and neck while he was
bathing his child. About 2-3 days later, father then brought patient to a private clinic B where he
then was referred to Columbia Hospital KL in mid-September 2019 , 9/52 ago
• A blood investigation was conducted in Columbia Hospital where the
father was informed there was high number of white blood cells from
the blood investigation and was referred to PPUM at the end
September 2019 , 7/52 ago. During this time, father was informed by
the treating doctor there are multiple bruises over the lower limb of
his son. Multiple palpable nodes were also noted at the axilla and
inguinal region . At PPUM, a bone marrow aspiration was done, and
patient was referred to HUSM for further management.
• Otherwise, father denies of squint, gum bleeding, nose bleeding,
shortness of breath, cough, sore throat, night sweats, jaw lesion, poor
oral intake, weight loss, headache, vomiting, seizures, haematuria,
testicular swelling and skin lesion.
PAST MEDICAL & SURGICAL HISTORY
• Nil
PAEDIATRIC HISTORY
Birth history  
• Born FTSVD @ HRPZ2 with birth weight of 3.84kg
• Antenatal= Mum has GDM and was on diet control
• Postnatal = NNJ admitted for 3 days, developed hypoglycaemia and
has shoulder dystocia during labour however no neurological
complication.
• Immunization up to age.
PAEDIATRIC HISTORY
Developmental Milestone
• Fine motor - Can use a spoon and feed himself
• Gross - Can walk, run, climb up the stairs, tower of 10.
• Social - Actively plays with another patient. Smile and call his dad.
• Speech - Can speak 2 words.
FAMILY HISTORY

• Paternal side has aunty age 55 having breast cancer.

SOCIAL HISTORY
• Initially 4 family members stay together in a town house in Gombak, KL but
since diagnosis, family moved to father’s parents’ house in Gelang Mas, Pasir
Mas
• (45 minute drive from HUSM)
• - Father works as Technical Assistant at Telekom Malaysia KL, salary
RM3000/month, however on two months of unpaid leave since early October
to take care of patient.
• -Mum works as Occupational Therapist at Private centre, salary RM
3000/month, however now has resigned in view that she was pregnant at
time of diagnosis and patient condition.
• - Previously in Gombak, patient was taken care by babysitter.
• Currently, patient being taken care by his father at hospital as mum is
in her puerperium period. Mother delivered to a healthy baby girl
@HUSM on 16/10/19.
• Siblings are taken care by grandmother.
• Father is a smoker.
• Elder brother is not going to pre-school currently.
• Father claimed he uses his savings for time being for the treatment
costs.
SUMMARY
• Patient a 2 year Malay boy from Gombak KL, no known medical illness and
normal developmental milestones presented with a chief complaint of easy
fatigue x24/52 followed by non- healing right knee cut associated with
prolonged fever for 3/52 prior to first medical contact 11/52 ago.
• Has the first medical contact at a private clinic A for non–healing right knee
cut 11/52 before seeking treatment at private clinic B due to worsening of the
healing process of the cut despite a 10 day course of antibiotic.
• Private clinic B referred patient to Columbia Hospital KL 9/52 ago. A blood
investigation was done and revealed high number of white blood cells.Patient
was diagnosed to have acute leukaemia and then referred to PPUM 7/52 for
further management before transferred here due to logistics issues.
PHYSICAL EXAMINATION
• Patient was lying comfortably in ____su__ position in ______ . He was
conscious and alert. He seemed comfortable, not in pain and does not
appear to be in respiratory distress. His nutritional and hydrational
status seemed adequate/not. However, patient look pale and less
active. Chemo port was inserted at his right upper chest. There was
no abnormal movement and no gross deformity seen. There was a
branula on his _____ dorsal hand.
• Vitals - BP; _____ mmHg, RR; ____min, PR; ____T; ____, SpO2____
ANTHROPOMETRIC
MEASUREMENTS
• Weight : 12.2 kg (between 10th to 50th percentile)
• Length : 85.5 cm (between 10th to 50th percentile)
• Palms were warm, dry and pale. Capillary refill time was less than 2
seconds. No palmar erythema, no clubbing. Bruises ? , no scratch
marks. No flapping tremor and no muscle wasting
• Conjunctiva is pale, no discolouration of sclera
• The tongue is coated. There was a whitish ulcer on his tongue. Tonsils
was unable to visualised. No visible gum bleeding or gum hypertrophy.
• Hair at the anterior head look slightly sparse compare to the one at the
posterior.
• No lymphadenopathy
• Bruises can be seen on distal lower limb. Healed scar at the right knee
• Bruises can be seen at sacral region , and patient cry when father
touches the area. No pitting edema.
Abdominal examination
• On inspection, the abdomen moved symmetrical with respiration. The
umbilicus was centrally located and inverted. Abdomen was slightly
distended. There was no surgical scar, no skin discolouration, no
rashes, no visible pulsations and no dilated vein.
• On superficial and deep palpation, abdomen was soft and non-tender.
There is hepatomegaly (liver palpable 4 finger breadth below costal
margin). Spleen was palpable.
• On percussion, abdomen was resonant.
• On auscultation, the bowel sound was heard with regular intervals
and normal intensity.
Respiratory
• Equal breath sounds bilaterally.
• Normal vesicular sounds.

Cardiovascular
• -S1 and S2 heard.
• -No murmur.
Differential diagnosis
• ALL
• Lymphoma
• Gaucher disease
• Neuroblastoma-lymphadenopathy, fever, no weight loss, ataxia