HOSPITAL SEGAMAT
KM 6 JALAN GENUANG, 85000 SEGAMAT
Tel: 07-9433333, 9434528, 9434531,9434540, 9434544
No. Fax: 07 – 9434641
E-mel: hospsg @ tm.net.my
Medical Officer/ Paediatric surgeon
Paediatric Surgery
Hospital Sultanah Aminah, Johor Bahru
30th September 2024
PATIENT NAME : MOHAMAD RIZQIN HAIKAL BIN MUHAMAD RIDZAL
I/C NUMBER : 201002010693
AGE : 3 Years 11Months old
Weight : 14kg
DIAGNOSIS : COMPLEX RUPTURED PERIANAL ABSCESS TRO
PERIANAL FISTULA
REFERRING FOR CONTINUATION OF CARE
Thank you for seeing this patient.
This is a 3 years old malay boy with no known medical illness presented to us with
fever, productive cough and loose stool for the past 1 week. Otherwise, noted by
mother patient had perianal swelling since 3 days ago associated with pus discharge
since 1 day ago. He denied any trauma or insect bites. He also denied any vomiting or
abdominal pain.
At ED patient was looking lethargic
BP 98/62
HR 127
Temp 38.5
Spo2 96% under room air
Lungs clear, reduce air entry at left lower zone, no rhonchi
Per abdomen soft non tender
Perianal examination noted perianal wound with slough around the anus with
erythematous, no indurated area, no crepitus.
Perineal region no skin changes
Bilateral scrotal region non swelling testis non tender
Unable to do per rectal examination in view of patient in pain
We referred him to paeds medical team in our centre and below are their impressions
1) left lobar pneumonia TRO left pleural effusion
2) TRO primary immunodefiency disease
3) electrolyte imbalance secondary to GI losses)
In ward, he saturating under room air, he had one temperature spike, however settling
with paracetamol and tepid sponging, still having perianal pain and loose stool 2 times.
Tolerating orally minimally but no vomiting.
ACCREDITATION
AWARD
Ultrasound left thorax was done on 30/9/2024 noted left lungs collapsed consolidation
with minimal complex effusion.
Medications
1. IV cefotaxime 700mg TDS ( start on 30/9/24 – 2 doses)
2. IV Metronidazole 105mg TDS ( start on 30/9/2024 – 2 doses )
3. ORS PER PURGE
4. Syrup paracetamol 210mg QID
5. Mist KCL 0.5g BD
6. syrup ibuprofen 140mg BD
Case referred Dr Atikah MO Paeds surgical HSAJB
Case d/w MR Munis peaditric suegeon
Plan:
1. Takeover to HSAJB ward east 5 with referral letter and inx (including usg report)
2. To start IV cefotaxime and IV flagyl
3. for paeds medical team to liase with paeds medical HSAJB
Here I attached together his blood investigations and scan report.
Kindly do the needful. Thank you.
“PENYAYANG, BEKERJA BERPASUKAN DAN PROFESIONALISMA ADALAH
BUDAYA KERJA KITA”
Yours sincerely,
Medical Officer
Department of Surgery
Hospital Segamat
ACCREDITATION
AWARD
