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Name: Sofea Mardiyana bt Rody

Gender: Female
Date of birth: 18/6/2005 7y10m
Race: Bajau
Religion: Islam
Address: Kg Dasar Baru, Lahad Datu
Contact number:0168121853
Date of admission: 29/4/2013

Chief complaint
Periorbital swelling for 2 days
History of present illness
Patient previously suffered from nephrotic syndrome in 2009, as diagnosed in
Hospital Lahad Datu.
Patient noted to have swelling confined to periorbital area for 2 days. Other area
such as face, abdomen, and calf were not involved. The swelling remained
constant throughout the whole day. Urine dip stick was done at home and
showed protein 4+. Otherwise, it was not associated with fever, dysuria,
urgency, dark coloured urine, sore throat and cloudy urine
Patient was then brought to Hospital Lahad Datu on the second day and
discovered to have hypertension with reading of 149/88mmHg. Patient
experienced frontal headache which is sudden and felt heavy. Otherwise, no
blurring of vision, no stiffness of the neck, no abdominal pain, no weakness in
upper and lower limbs.
At Hospital Lahad Datu, blood test was done together with prescription of
penicillin and prednisolone. She was required to take 5 pills each during the day
and night time for 10 days and then reduced to 4 pills for the next 7 days. She
was then referred to hospital likas for further management.
Currently, she is taking 3 pills of prednisolone each morning and night. Increase
appetite noted as well as increase in size of her torso. There was increase in
0.1kg in just one night. Antihypertensive(nefidipine) were also given.
Systemic review
Past medical and surgical history
1. Birth and neonatal history

Mother underwent regular antenatal scanning and check up at Hospital


Lahad Datu. It was an uneventful antenatal period. Patient was born at full
term via spontaneous vaginal delivery at Hospital Lahad Datu, measuring
3.4kg. There was no complication during the delivery.
Neonatal, mother noted birthmark over her lower left cheek. It was brown
in color with well demarcated margin, flat surface. Otherwise no neonatal
jaundice, no difficulty in feeding.
2. Past medical history
In 2009, patient presented with periorbital swelling for 1 week which
involved the face the 3rd day. However, it did not radiate to the abdomen
and calf. It worsen as soon as patient woke up in the morning and
disappeared at noon.
The periorbital swelling was preceded by sudden onset of fever associated
with chills and rigors. There was no loss of consciousness and fitting. The
fever worsen at night and relieved by syrup paracetamol. This episode was
associated with high blood pressure as well.
Patient treated as nephrotic syndrome with pednisolone in tapering dose
and was stopped in 2011.
3. Childhood infection
Type of illness
Measles-campak
Chicken pox-cacar air
Diphtheria
Whooping cough-batuk kokol
Tuberculosis
Mumps-beguk

IF yes then the age


-

Dietary history
Exclusively breastfed for 2 years and 3 months, on demand. Patient was
introduced to complementary food of porridge at 8m. She can tolerate adult solid
food at 1 year plus.
Immunisation (most recent one at what age and date)??
Development milestone??
1.
2.
3.
4.

Gross motor
Fine motor
Speech and language
Social and behavior/ school work

Drug history
Family history (family tree and hx of associated illness)
Social history

5 person staying in a wooden house with an electricity generator. They has to


purchase fresh water from the town. Father has a food stall and the salary is
meager to support the family. He smokes occasionally. Mother is a housewife and
takes of patient while she is sick.