Factors leading to abuse / neglect

1: paternal grandfather attempted to snatch the child away from maternal

grandmother's friend while sitting at the front site of car through the window
History
Patient and her older brother(faiz amyshar bin mohd fawwaz) was taken by their
mother (Wan anisah binti wan Rohamidun) to the police station to lodge a police
report against the father( Mohd fawwaz bin Haji sulaiman)for domestic violence.
Upon leaving the police station after lodging a police report, wan anisah, her mother
and her friend
was cornered by her father in law (Haji sulaiman bin Ahmad). Patient was laying
on the lap of a friend ( hamidah binti Hassan ic- 610601065036)
claimed that there was a struggle between Pn. Hamidah and En. haji Sulaiman)
through a partially opened
window in the front seat. En. Haji Sulaiman attempted to pull the child out through
the window.
Pn Hamidah claims that child had hit her head on the window and both forearms
were bruised. No other injuries
Patient started crying inconsolably after that
No open wounds
no seizures
No vomitting
Able to suckle and breast feed as usual after that
However mother claims that child cries out whenever she touches the both elbows
Physical Examination
Patient active on handling, pink
anterior fontelle normotensive
CRT< 2secs, warm and pink peripheries
Good pulse volume
Pupils: 3mm reactive bilaterally
good sucking relex
Moro;s complete
Good grasp relex
CVS: DRNM
RS: no SCR, no ICR
Clear
P/A: Soft, not tender
Not distended
Bowel sounds heard
bilateral elbows- redness present on the left>right
no bluish discolouration of limbs
child does not cry on movement of elbow joints.
No swelling
radial and ulna pulse palpable

Investigations
No fracture seen

Action Taken
Child was examined and x ray was reviewed by Dr. Azree
To treat as Soft tissue injury of left arm first
Bandage left forearm
TCA ortho clinic in 1/52 for a repeat Xray and reassessment
Child At Present In
(a):
mother and grandmother's protection
o
Temp ( C):
Posture:
Lying down
SBP (mmHg):
DBP (mmHg):
Pulse rate (/min):
Respiratory rate (/min):
SpO2 (%):

37
96
52
105
26
97

ortho clinic review

pb: assaulted by grandfather last week (11/8/14),
s/b ortho team at ED, treat as soft tissue injury of left arm.
progress:
mother claimed patient actively moving affected hand
tolerating orally well
no fever
no active complaints
l/e of left UL:
no bruises, not swollen, no erythematous changes
child does not cry on movement of elbow joints.
radial and ulna pulse palpable
xray of left humerus reviewed: no fracture seen
Clinical Plan
d/w mr yusuf
discharge ortho

ADDENDUM

20/08/2014
16:57:40

Faizah Binti Abdul

House
Orthopaedic
Rauf
Officer

tca prn