3. Particulars of the patients
Name: Zafrin
Age: 1 months
Sex: Female
Religion: Islam
Address: Kishoreganj
Date of admission :06/05/23
Date of examination :10/05/23
4. Chief complaints :
1) Hanging swelling on lower back since birth.
2) Anus is present close to vulva .
5. History of present illness :
According to the statement of informant mother baby was born with
the complaints of hanging swelling in lower back involving
sacrococcygeal region since birth . Overlying skin of swelling is
normal and some area of skin is infiltrated with haemangiomatous
tissue . Her mother noticed that swelling is gradually increase in size
and anus is present close to vulva and swelling is not associated with
alteration of bowel and bladder habit .
6. She has no history of fever , jaundice , increased head circumferance
. With the above complaints she was admited MMCH pediatric
surgery depertment for batter management.
8. Birth history :
Zafrin was born by elective cesarean delivery at term with an
average weight(3.2 kg). After delivery her umbilical cord was cut
with brand new blade and tied with cord clamp.
9. Antenatal history :
She was on single time antenatal check up at 12 weeks of gestation
and could not any abnormality detected. Taking iron, calcium and
folic acid .
Feeding history :
She is on exclusive breast feeding .
11. Family history :
1st issue of non consanguineous parents. There is no positive
family history of such type of illness .
12. Socio -Economic history :
She was belongs to lower middle class family. Her father was
day labourer and only earning member .Lives on tinshed
house.
15. Temperature -98°F
BCG mark – present
Ear,Nose,Throat – normal
Lymph nodes – not palpable
Spine- normal
Hernial orifice – intact
16. Local examination of swelling :
There is hanging swelling in lumbosaccral region which is globuler
in shape 15 * 13 cm ,overlying skin is tense and shiny , no scar
mark present .Temperature of the swelling is normal and non
tender . Surface is bosselated , well defined margin , variegated in
consistency ( some are cystic and some are solid ) , flactuant but
not transilluminate and swelling is not compressible . Anus is
pushed anetriorly . No neurological abnormality and other
congenital anomalies .
17. Systemic examination :
Gastro intestinal system :
Inspection :
Mouth and oral cavity : No bleeding manifestation. Gum and
oral mucosa healthy.
18. Abdomen was schapoid shape , flanks are not full, umbilicus was
centrally placed,inverted. There was no engorsed vein and visible
peristalsis.
Palpation: Abdominal temperature is normal. It was non tender
and soft.
No organomegaly was found .
Digital rectal examination : Anal tone and grip were intact . A mass
like structure are felt by examining finger which was free from anal
mucosa not attached with rectum . Withdrawl of finger stained with
stool.
20. Nervous system :
Patient was conscious, oriented .
Cranial nerve was intact.
Motor functions were normal.
There was no flapping tremor.
Gait was normal.
Sensory functions were normal.
Planter reflexes absent
babyniskes sign - positive
21. Cardiovascular system :
1st and 2nd heart sound were audible in all cardiac
areas. There was no added sound.
22. Respiratory system
Breath sound was vesicular, there was no added
sound.
Other system examination revealed no abnormality.
23. Salient feature
Master Zafrin ,1 month aged girl , 1st issue of non consanguineous
parents, hailing from kishoreganj , presented with hanging swelling
in saccrococcygeal region since birth which is globuler in shape 15 *
13 cm ,overlying skin is tense and shiny , no scar mark present .
Swelling is gradually increase in size and swelling not associated
with alteration of bowel bladder habit .
24. Temperature of the swelling is normal and non tender . Surface is
bosselated , well defined margin , variegated in consistency ( some are
cystic and some are solid ) , flactuant but not transilluminate and
swelling is not compressible . Anus is pushed anetriorly .
25. She is on breast milk and immunization started as per EPI
schedule and no signifcant antenatal history . She is not anemic ,
non icteric , non dehydrated , non oedematous , head
circumferance normal and her vital sign within normal limit .
Abdominal examination reveals normal . Digital rectal examination
- Anal tone and grip were intact . A mass like structure are felt by
examining finger which was free from anal mucosa not attached
with rectum . Withdrawl of finger stained with stool. No neurological
deficit . other system reveals no abnormality .
