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Ministry of Health, Malaysia

HOSPITAL SULTANAH BAHIYAH
Emergency
Patient ID :Muhammad Agil Zahran Bin
:ASO0414286 Name Hisyamuddin
NRIC
Sex : Male Age : 10Y9M
Encounter ID : 11314371 Encounter Type: IP
Location PHDW Encounter Date: 15/09/2012 21:01
Discharge Date 01/10/2012
16:41 Speclality :Paediatrics
Attending Practitioner: TeohSzeTeik, DR
Note Type : Discharge Summary Med/AncService : Peadiatric
Date/Time : 01/10/2012 117:14 Performed By :Izzati Bt Wan Maharuddin, DR

History
PICUsummary
Name
PID
:Muhammad Aqil Zahran Bin Hisyamuddin
:ASO0414286
DOB 13/07/2012
Mother?s IC :790921-02-5202
DOA 15/09/2012
DOD :01/10/2012
Age :2 months old
Weight :5 kg
Address :Lot 171, Lorong SeriHujung, 05300 Alor Setar, Kedah
Tel : 019-4484515

Diagnosis:
1) Post MVA with frontal chronic SDH, comminuted fracture of right frontal bone with frontal contusion
and dural tear

History of Presentingllness:
Child was referred from casualty for head injury. Alleged MVA on 15/09/2012 7pm, car versus car. A car hit from the
rear, mother was holding the child in arm sitting at the passenger seat behind. The impact of accident causing the
mother fell forward with head hitting on the seat of front passenger. Mother claimed child still held tightly in arms
during the accident, however noticed depression deformity over forehead of child. Child appeared drowsy after the
accident, cried minimal only on stimulation, no LOC, no fits, no vomiting. Mother sustained minimal abrasion wound
over the left forehead region, no LOC. Other 2children in the same vehicle had no injury, father as the driver
sustained fracture of upper limb. Child was rushed to hospital within 30minutes after accident.
While arrival to casualty, noticed child was drowsy, cried minimal on stimulation but stopped then, no fits seen.
Child was intubated for cerebral protection prior CT brain.

Past history:1s admission.

Socialfamily history: Father 33yo staff in Jabatan Pertanian, mother 33yo teacher. Child is the youngest in family,
eldest brother 4yo, 2nd brother 1year-4month old, both are healthy.
Feeding history:
Formula milk and breast milk.

Birth/developmentimmunization:
Child was born at term via SVD in INS, no known illness. Immunization completed upto his age.
Examination on admission:
Child appcared pale, intubated, col peripheries, noticed bifrontal fullness ?hematoma, bilateral pupils pin-point, no
ENT bleed. BP 82/43mm Hg(MAP 56), HR 177bpm, CVS DRNM, lungs equal breath sound and clear, abdomen soft
and not distended. Good pulse volume, CRT <2s. Tone normal, hyperreflexia of all limbs, no clonus, Babinski
withdrawal reflex.
Initial management:
Child was reviewed by neurosurgical team, treated as multiple ICB post-MVA, no surgical intervention yet, planned for
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repeat CT brain after 48 hours. Child was admitted to PICUfor ventilatory support.
1) kepp NBM
2) start |VD 1/5 NSD5% 18cc/hr.
3) Vmidazolam 2cc/hr (2mcg/kg/hr) (TF: 2/3 of full maintenance)
4) IV phenytoin 12.5mg TDS (2.5mg/kg/dose)
5) IV ceftriaxone 250mg BD (50mg/kg/dose)
6) Cerebral protection, keep head tiltup at 30degrees, keep PCO2 30-40mm Hg
7) Head chart
8) Ventilate on PSIMV, FiO2 0.3; P 18/5; rate 30
9) GCS chart hourly
10) DXT 6 hourly monitoring
11) V phenytoin 120mg over 30minutes (20mg/kg)
Inform DIL.
Investigations

Date 16/09 17/09 20/09 20/09 21/09 25/09

12pm 2230 0517
WBC 12.05 10.35 9.17 9.74 15.29
PMN 48.1 41 30.3 35.3 37.6%
Lymphocyte 37.9 35.2 47.5 41.5 47.2%
Hb 7.2(Tx) 13 10.9 9.4 8.2
Platele 331 197 299 335 528
HCT 20.9 36 32.5 25
Creatinine 24 27 13
Urea 5.0 4.7 0.6 0.9 1.4
Na+ 132 132 140 141 142
K+ 5.1 4.1 5.1 4.8 4.7
Ca2+ 2.14 2.13 2.19
Mg2+ 0.89 1.05
PO4 2.03 1.73 1.51
T Protein 49 51
Albumin 34 30
ALT 29 34
ALP 400 283
T.Bil
PT 15.3 12.2 13.2
APTT 38.0 36.3 39.8
INR 0.87 0.97
Blood C&S CONS NG 3/7
CRP 50.22 13.83
16/09/2012
blood C&S: Streptococcus coagulase negative
sensitive to cotrimoxazole, clindamycin,gentamicin, cefoxitin,cefazolin
resistant to penicillin anderythromycin
Repeat Blood C&S (17/09/12): Finalculture shows no growth
Progress and managemnent
15/09/2012
Child was kept in PICU for cerebral protection. CT brain reviewed by neurosurgical team noticed:
interhemisheric SDH at frontal region
small right frontal EDH
SAH at right hemisphere
no midline shift
basal cistern patent
right temporalbone fracture, frontal bone fracture - non depressed
( Non Surgical Lesion
In morning, child was started on feeding and he was tolerating well.
CT cervical spine: cervical spine alignment normal, no fracture seen.
16/09/2012
Cerebral protection continued.
Child was pink on ventilation, afebrile, breathing in phase. He was started on feeding with FSM at 15cc/3 hourly.
tolerated well.
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He was given 120cc packed cel transfusion in view of
At anaemia.
night, he developed high grade fever, syrup paracetamol 90mg QID
initiated.
17/09/2012
Ghild developed seizure, characterized by jerky movement of left upper and lower limbs with twitching of right
mouth, alsoassociated with desaturation to 70%. IV midazolam angle of
In evening, he developed 3rd episode of seizure, he was loaded increased to 4cc/hour (4mcg/kg/min)
with V phenobarbitone 120mg over 3ominutes
(20mg/kg/dose), then IV phenytoin increased to 18mg TDS.
Repeated CT brain showed multiple intracranial bleed (same as previous) with increasing cerebral
edema. They
Keviewed by neurosurgical team, condition explained to parents and no active neurosurgical intervention.
planned to wean off sedation progressively.
18/09/2012
Child was sedated, no further seizure seen, feeding tolerated.
IV phenobarbitone discontinued.
Reviewed by neurosurgical team , in view of increasing cerebral edema, child was started on IV mannitol 15ml BD for
5days (2.5ml/kg).
19/09/2012
No seizure seen, child was sedated, bilateral pupils 2mm reactive, breathing in phase, SP02 100%, tone normal.
IV midazolam progressive tapering down.
20/09/2012
Child had total 3 episodes of seizure (GTC) aborted after |V valium.
CT brain repeated noticed increasing size of right frontal contusion with associated perilesional edema.
Reviewed by neurosurgical team,planned for operation for removal of hematoma.
21/09/12
Operation done (left bur hole +aspiration of left drontal chronicSDH +right frontal craniotomy and dural repair).
Intraoperative findings:
left frontal chronic SDH
right frontal bone fracture with duraltear and herniation of brain tissue, frontal contusion
right frontal craniotomy done and dura repair with TissuDura 5x6cm and lyostypt
post-op brain lax and pulsatile
Repeated CXR post-op: clear lung fields bilaterally.
Feeding restarted post-op and child was tolerating wel.
No seizure.

22/09/2012
No seizure, ventilator setting gradually weaned down. Sedation weaned off.
Repeated CT brain post-op:
similar right frontal hemorrhagic contusion
chronic SHD right temporaland acute SDH along right tentorial leaf and falx unchanged
hypodense lesion on right parietal grey and white matter suggestive of ischaemic changes
left frontal subdural drain in situ
no hydrocephalus, no midline shift
basal cistern not effaced
increasing gap of lambdoid suture noted
23/09/2012-24/09/2012
Day 3and 4 post-burr hole. Child was extubated to HBO2, no stridor post-extubation.
Minimal drainage noted from operation site, drain was discontinued.
Child was restarted on feeding then increased gradually as tolerated.
No seizure seen.Child had suckling reflex, active on handling with normal tone.
However cannot swallow well. Hence continued with orogastric feeding.
25/09/2012
Day 5 post burr-hole. SpO2 100% on RA, No seizures.
Sucking stillpoor. Referred for sucking stimulation by occupational therapist, trial of minimal amount of oral feeding.
IV Phenytoin changed to syr. Phenytoin.
26/09/2012
Clinicaly active, no seizures observed. Trial on syringe feeding, he was able to tolerate, hence trial on bottle feeding.
with RT feeding continued (TF 100mL/kg/day).
Phenobarbitone was off. Syrup Phenytoin continued.
27/09/2012
Child was febrile, noticed thrombophlebitis over left cubital fossa, started on syrup cloxacillin 90mg QlD.
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 No seizZure. Page 4 of 4

28/09/2012
Ghild was afebrile, no fit seen since
less inflamed. Syrup phenytoin 20/9/12. Wound site
and syrup cloxacillin were was clean and not gapping. Thrombophlebitis over left arm
continued.
29/0912012
NO it noted, wound site
clean, Child is
Oral medications were well, active, afebrile, moving all 4
continued. limbs. Lungs: clear, CVS: DRNM, PA: soft.
30/09/2012
Neurosurgical team discharged child with TCA 2/52 on
naving small spikes of
One more day. Syrup temperature 37.2 C. Left hand 18/10/12. Child has
was not discharged from paeds yet as
still
thrombophlebitis
cloxacillin and syrup phenytoin were continued.
resolved and temperature monitored for
01/10/2012
Child remained afebrile for 24
Vomiting, was not tachypnoeic,hours. Child was allowed for discharge. Upon
lungs: clear, CVS: no murmur, discharge, child was feeding wel, had no
focusing. PA: soft, AFNT, tone normal, no clonus, and eyes not
Plan upon discharge:
1. Allow discharge
2. TCA paeds clinic on
3. Refer to eye as 6/11/2012, 11 am
4. Hearing
outpatient on 16/10/2012, 2 pm
assessment on 6/11/2012, 8.30 am
3. Refer occupational therapy as
6. Syrup cloxacillin 90 mg QID foroutpatient on 3/10/2012, 10.30 am
7. Syrup phenytoin 18 mg TDS foranother 3/7
TCA.
x1/52, then taper to syrup phenytoin 18 mg BD until TCA, KIV to off during
8. Syrup paracetamol 60 mg PRN x3/7

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07/05/2023