Name:

Thuruvarasan

A/L

Dilip Nick Name:

There

Kumar
Age:

2 Years 11month old

Date

of 27 July 2013

birth
Gender:

Boy

Race:

Indian

Hosp ID:

HRPB

Address:

Pusing Perak

DOA:

8 July 2015

DOC:

12 July 2015

KK:

Health Clinic (5 min)

Hosp:

Hospital Batu Gajah (15 min)

Transport: Car

GP:
Informant

Mother

Reliability:

Mother has been working at

Singapore and only comes back
once a month to see Thuru. Thus
unreliable.

CHIEF COMPLAINTS:
Periorbital swelling for 3 weeks
Facial puffiness for 3 days
Abdominal distension for 2 days
HISTORY OF PRESENTING ILLNESS:
Thuru was apparently well until 3 weeks ago when he was noted to have a sudden
onset of intermittent swelling around the eyes noted by his grandmother upon waking up. The
swelling was on and off and usually is most noticeable upon waking up in the morning and
gradually subsides throughout the day. The swelling would usually be unnoticeable by
evening and eventually returns the next morning. The swelling was soft with overlying nonerythematous skin, no discolouration of skin and swelling was not tender to touch. The
swelling around the eyes was not associated with any redness of eyes, no eyes discharge, no
pain around the eyes, not itchy and there were no complains of visual disturbance noted.
There was no history of trauma to the eyes and no history of insect bite, food or drug allergy

that would suggest an allergy reaction and no rash or difficulty in breathing. The swelling
around the eyes has been ongoing for 2 weeks with no progression of the swelling noted. The
swelling was said to be limited to the eyes and no associated abdominal, scrotal or leg
swelling noted initially. Grandmother could not appreciate any change in the urine frequency
and amount and did not notice any presence of bubble in the urine as Thuru is well toilet
trained and he goes to urinate on his own at home. However, there were no change in urine
colour, no blood, no foul smelling urine or crying while passing urine noted upon changing
diapers for Thuru at in the morning as he wears diapers once daily every night. Pampers did
not appear heavier upon changing as compared to before. There has no history of recent nose
bleed, abdominal pain, headache, fits, altered consciousness and projectile vomiting. Mother
did not bring Thuru to seek treatment or resort to any form of medication as she assume that
it was due to the childs allergy to dust mite at home. Plus, Thuru condition did not worsen
for the first 2 weeks and otherwise mothers told that Thuru was as active and feeding as usual
and no disturbance in sleeps.
3 days prior to admission, Thuru developed a sudden onset of low grade fever as
Thuru appeared less active that morning and his body felt warmed to touch which was noted
by his mother who was coincidently at home on her one week raya break. The fever was not
associated with any cough, no sore throat, no shortness of breath, no ear discharge, no painful
red eyes with discharge, no neck stiffness, no projectile vomiting, joint pain and no rash. He
has brought to a clinic where his temperature measured was 38 degrees Celsius. He was
prescribed with antibiotic and syrup paracetamol. There took one course of 10 ml
paracetamol and the fever subsides and he did finish the full course of antibiotic for 3 days
once daily after breakfast as told. He had no difficulty taking the medication and no side
effect of medication was noted.
Two days prior to admission, mother notice Thuru swelling around the eyes did not
subside that evening instead notice that Thuru facial puffiness with the cheeks appearing
fuller. Thuru still remains active, eating as usual and was able to sleep well that night. The
next morning, one day prior to admission, Thuru suddenly developed worsening of the
swelling with abdominal distension notice by his grandmother in the morning while bathing
him aside from the facial swelling. There was no change in bowel habit, no loose stop, no
blood or mucus in stool, no abdominal pain, no vomiting, no inconsolable cry, no yellowish
discolouration noted and no fever.

There was taken to Hospital Batu Gajah around 2pm by the mother. There was seen
by the doctor and advice the mother to collect two urine sample from Thuru and bring it back
to be reviewed on the 14 July 2016. No blood was taken and no medication was prescribed to
Thuru. Mother was worried and decided to take Thuru to the previous clinic to be reassured
about Thuru condition. Sample of urine was taken from Thuru at the clinic and tested positive
for protein. His urine was also noted to be bubbly, straw colour and no blood noted on
collection of urine by mother. Hence, Thuru was referred to HRPB for further investigation
and management by the paediatrician.
Mother arrive to casualty around 2pm by car. Th
This was his first hospitalisation and no history of previous episodes of facial
swelling. No history of trauma,

PAST MEDICAL HISTORY: No other past medical history other than stated above

PAST SURGICAL HISTORY: Circumcision at 1 year old

PAST MEDICATIONS HISTORY: No other past medication history other than stated
above

ALLERGY HISTORY: No food and drug allergy.

Prenatal history: Age of parents at conception (father 30 years old, mother 21 years old),
accidental pregnancy, booked into MCH clinic at 8 weeks of gestation, urine pregnancy test
was done, regular check-up. Took iron, folic acid, immunization (tetanus toxoid) during
pregnancy. Ultrasound was done (nothing abnormal), no history of fever with rash, mother
had gestational diabetes and was on insulin during pregnancy, no pregnancy induced
hypertension, no convulsions / ecclampsia, no anemia, no asthma, no swelling of legs, no
proteinuria, no bleeding per vaginum, no heart disease, no ingestion of alcohol, exposed to

smoking (passive, husband is a smoker), no any other illnesses, no exposure to x-rays, no

traditional medicines.
Birth history: Term 39 weeks of gestation, place of birth (KPJ Ipoh), emergency lower
segment caesarean section (because of prolong labour) duration of labour not sure, mother
heard the first cry, APGAR score from baby card 8 in 1 minute 10 in 5 minute, no any
resuscitation, breast-fed immediately after birth, birth weight: 3.6 kg, length: 50 cm, head
circumference: 37 cm. No admission to NICU immediately after birth, duration of stay in
hospital is 2 days, details of treatment given not sure. Vitamin K injection given. Passage of
first meconium (within 24 hours) and transitional stools (Day3). Passage of first urine within
48 hours.
Neonatal history (first 4 weeks of life): no jaundice, no seizure

FEEDING HISTORY: Exclusive breast feeding up until 6 months old, on demand.

Complementary feeds started at 6 months, mother gave porridge and carrot blended together.
Current diet details (breakfast: roti canai, nasi lemak and mineral water, lunch: rice with
chicken or fish and mineral water, tea time snack/drink: nuggets or fish balls and mineral
water, dinner: rice with chicken or fish and vegetables or fruits , supper snack/drink: biscuits),
no specific likes / dislikes.

IMMUNISATION HISTORY: His last vaccine receive was a 5 in 1 combination of DTaP,

IPV and HiB at 2 years old. No side effects or fever develop with vaccines and all were given
on time with no delays.
Age (months)

Vaccine

School years

10

12

24

7y

13y

15y

BCG

Hep B

DTaP

IPV

HiB

Measles

MMR

JE

HPV

DEVELOPMENTAL HISTORY: social smile within 6 weeks, walk at 1 years old.

Currently, Gross motor: Able to play sports such as football, basketball, tennis and riding
bicycle, Vision and fine motor: See and able to focus well in class, can write and count well
Speech, hearing and language: Speak fluently in English, Malay and Tamil, able to tell
stories very well, can sing song Personal and behavioural: Loves going to shool, have few
bestfriends, always mix around with other child, have a good relationship with teachers and
family members. Teachers aware of childs chronic medical problem.

FAMILY HISTORY: Dads name: Saravanan, 43 years old , Moms name: Yogeswary, 34
years old . No consanguinity, no one else in the family is having the same symptoms Shane
which is fever and vomiting. There is family history of diabetes mellitus, Shanes father had
diabetes mellitus since 4 years ago and currently on tablet anti-diabetes, as well as paternal
and maternal granparents also had diabetes mellitus type 2 and hypertension. Other than that,
no family history related to shanes condition. Family dynamics is good. Effect of illness on
family: mother is concerned about childs condition, she is worried if the disease could be
worse.
Saravanan
43 years old

Yogeswary
34 years old

Shiravara
san
5 years

Ghanivarasan
8 years old

Thuruvarasan
2 years 11 months

SOCIOECONOMIC & CULTURAL HISTORY: Dads and moms education is up until

degree, currently Shanes father is working at Telekom Malaysia, and mother is a housewife,
household income is about RM 4K per month. Type of house: double storey terrace house,
number of bed rooms: 5, number of toilets: 3, there are 4 people living in the house.
Electricity, water source supplied by government, no well in the house, sewage disposal also
by government. Not dengue-prone area.

PHYSICAL EXAMINATION
General appearance of the child: Conscious and alert, he is cooperative. Name tag is at left
wrist, branula is attach at left dorsum, not attach to any fluid. Not in respiratory distress.
Level of hygiene: wearing own attire, well-groomed hair, clean nails. No any smell
Extremities:
Hands & feet: palms and soles: pink and warm, no cyanosis of finger and toe nails; no
clubbing of finger nails and toe nails. No koilonychias. No rashes over palms and soles, no
swelling of dorsum of hands and feet, Capillary refill time <2 sec, no pedal oedema.
Head: No dysmorphic features.
Eyes: not sunken, no periorbital oedema, cornea and conjunctiva moist and shiny. Palpebral
conjunctiva: pink. No jaundice in good sunlight.
Ears: no ear discharge.
Nose: no nasal discharge.
Mouth: Oral mucosa: moist and pink, not cyanosed, tonsils not enlarged, no petichiae, no
vesicles or ulcers over palate, no bleeding inside the mouth or gum, gum is healthy and pink,
no dental caries. Tongue is not coated.
Neck: no thyroid swelling + lymph node enlargement
Lymph nodes: no neck, axillae, inguinal, epitrochlear and femoral nodes.
Skin turgor is good.
Skin: BCG scar left upper limb
Anthropometric measurements:
Weight: 48 kg (between 50th to 75th percentile)
Height: 156 cm (50th percentile)

Vital signs:
Pulse rate: 90 beats per minute, good volume, regular rhythm
Respiratory rate: 25 breathe per minutes
Blood pressure: 114/72 mmHg (90th percentile)

SYSTEMIC EXAMINATION:
Respiratory Examination
Inspection: Type of respiration is abdominothoracic. Chest movements equal on both side,
no chest recession, no visible pulsations, no visible apical impulse, no surgical or other scars,
no engorged veins, trachea is in the midline.
Palpation: Chest expansion is symmetrical on both side of the chest by palpation in front and
back. Apex beat is at left 5th intercostal space within the midclavicular line, the trachea is in
the midline. Tactile fremitus is negative. Vocal fremitus is negative
Percussion: Normal dullness over the heart in the precordium and the liver. Others are
resonance.
Auscultation: Breath sounds are heard equally on both sides. Type of breath sounds:
vesicular breath sound and no added sound.

Abdominal Examination
Inspection: Abdomen was not distended. It moves with respiration. The umbilicus was
inverted and centrally located in the midline. There were multiples injection scars around the
umbilicus, other than that there were no lipodystrophy, no surgical scars, no dilated veins, no
visible pulse and no visible peristalsis.
Palpation: Soft, non-tender, no guarding and no rebound tenderness. Liver and spleen were
not palpable. Kidneys were not ballotable.
Percussion: Resonance.
Auscultation: Bowel sounds were heard twice in 1 minute. No renal bruit

INVESTIGATION:

1) Capillary blood sugar : 21.8 mmol/L (High)

2) Venous pH : 7.08 (Low)
3) HCO3 : 6 (Low)
4) Serum Ketone : 2.2 (Ketonaemia)
5) Urine FEME (Dipstick) :
Urine FEME
Result

Interpretation

Glucose, urine

+- A

High

Urine Ketone Bodies

1+A

Normal

Nitrite

Negative

Normal

Leukocytes

Negative

Normal

Blood in urine

Negative

Normal

Bilirubin in urine

Negative

Normal

Protein, urine

1+A

Normal

Urobilinogen

Negative

Normal

Color

Yellow

High

Clarity

Turbid A

Normal

pH, urine

6.0

Low

Urine Specific Gravity

>1.025

High

1)

PROVISIONAL DIAGNOSIS: Idiopathic Nephrotic Syndrome

Points for

Points against

1. Has history of daily periorbital

swelling which starts in the worsen
and subside throughout the day
1

Presence

of

third

space

fluid

accumulation present such as ascites,

pedal edema and scrotal swelling.
1

Urine was noted to be frothy and

tested positive for urine

No gross or microscopic hematuria

noted

MANAGEMENT:
DISCUSSION:

UNIVERSITI KUALA LUMPUR

ROYAL COLLEGE OF MEDICINE PERAK
(UNIKL-RCMP)
CASE WRITE UP 2
PAEDIATRIC POSTING

NAME OF STUDENT: CEDILLA CHEONG KAI SHIM

YEAR OF STUDY: YEAR 5
POSTING: PAEDIATRIC SESSION: 4/7/16 19/8/16
GROUP: 6A
SUPERVISOR: DR SHYAM ISHTA PUTHUCHEARY