MORNING REPORT

SHIFT: FEBRUARY 17TH 2017 (NIGHT)

dr. Sekar / dr. Ifa / dr. Dayat / dr. Dhani

dr. Lucky/ dr. Putri
dr. Hamid / dr. Adam
dr. Dina /dr. Iqbal

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New Patients
• Children Ward:
1. A, 6 years old boy, 26 kg with Abdominal pain suspected typhilis DD
appendicitis, acute lymphoblastic leukemia L2 standard risk, over
nourished
2. R, 7 months boy, 8,5 kg with acute diarrhea with moderate
dehydration, well nourished
3. A, 18 months boy, 11 kg with General Idiopathic Epilepsy DD
symptomatic epilepsy, fever due to UTI dd viral infection suspected
Dengue, micrositic hypochromic anemia due to fe deficiency dd
infection, well nourished

• HCU Neonatus:
1. Baby
• NICU: ( - )
• HCU Melati 2:
2
• PICU: (-)
I. Patient Identity
Name :A
Sex : boy
Age : 18 months
Addresses : Donorejo, Pacitan
Medical record : 01369648
Weight/Height : 11 kg

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II. Chief Complain

Seizure

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 III. Present Illness History
Nine days before admitted to hospital, in the morning, patient
had seizure. Seizure occurs throughout his body with his eyes glanced
up, for about 2-3 minute. Seizure stop without medication. Fever
when seizure was denied. After seizure, he was fully conscious, he
could communicate to his parents as usual. He had no fever, no cough,
no flu, nor diarrhea. In the afternoon, he had 3 times typical seizure,
so his parents took him to hospital in Bekasi. He had
electroencephalogram examination, and epileptogenic wave was
found. The doctor give him some medicine, but his parents didn’t give
regularly to their child.
Three days before admitted, his parents took him to Pacitan,
and he experienced same typical seizure 4-5 times, with fully
conscious, and could communicate after seizures. No fever, 5
cough, diarrhea, nor dyspneu.
 III. Present Illness History
Two days before admitted, the patient experienced same
typical seizure, but parents notice that the patient seems not as active
as usual, still can communicate with his parent, so his parents took
him to RSUD Pacitan. He was hospitalized for few days, and had
valproic acid, diazepam and some pulveres as medicine.
Eighteen hours before admitted, he experienced two times
typical seizure, with fever and passing stool 3 times a day. As he didn’t
get any better, his parents took him to RSDM.

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IV. History of Past Illness
History of Seizure : (+) since he was 1 year old
History of head trauma: denied
History of hospitalization: denied

V. History of Family Illness

History of Seizure denied

No family member were found to have some typical illness with patient

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VI. Pregnancy and Birth History

• During pregnancy, her mother routinely checked her

pregnancy to midwife. She was given vitamin, and she didn’t
consume any of medicine beside it and never been
hospitalized
• Baby boy was born in 35 weeks of pregnancy, Caesar delivery
due to vaginal bleeding, crying vigorously, no cyanosis or
icteric was found. His birth weight was 2800 grams

Conclusion: abnormal birth history and pregnancy of mother

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VII. Immunization Status

BCG : at 1 month
Hepatitis B0 : 0 month
DPT-HB-Hib : 2,3,4 months
Polio : 1, 2,3,4 months
Campak : at 9 month

Conclusion : complete immunization, appropriate with

Ministry of Health’s schedule 2014

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VIII. Nutrition History

Patient eat 3 times a day, rice with meat, fish, vegetables. the
portion of meal is half to adult’s portion, but often not finished
the meal
Conclusion : nutrition status is adequate

IX. Growth and Development

He is now 1.5 years old, he can walk with handling, say 1
words
His weight is 11 kg with body height 84 cm.
Conclusion : suitable for his age 10
 POHON KELUARGA

II

III

child. A, 18 months 11
old
XI. Physical Examination
General appearance: fully alert, E4V5M6
VS : heart rate: 130 x/menit body temp : 38.40C
resp rate: 26x/ menit saturation : 99%
• Head : normocephal with Head circumference 47 cm
(LK= 0 SD, nellhaus)
• Eyes : pale conjunctiva (-/-), icteric conjunctiva
(-/-), light reflex (+/+), isochoric pupil
3 mm/3mm
• Nose : nasal flare (-/-),discharge (-/-)
• Mouth : lips and tongue not cyanotic 12
• Neck : no enlargement of lymph node
LUNG:
• I: normal, symmetric, no retraction
• P: hard to evaluate
• P: sonor in both lung
• A: normal vesicular breath sound, additional breath sound (-/-)

CARDIAC:
• I : ictus cordis not visible
• P: ictus cordis palpable
• P: there is no cardiac enlargement
• A: 1st 2nd Heart sound normal intensity, regular, no murmur

ABDOMINAL:
I: abdominal wall // thorax wall
A: peristaltic in normal limit
P: shifting dullness (-), undulations(-)
P: there is no enlargement of the spleen and liver

EXTREMITIES:
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis artery was palpably
strong.
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GENITAL:
Phymosis +
Neurological Examination

Physiological reflexes Meningeal sign

- Biceps +2/+2 • Nuchal rigidity –
- Triceps +2/+2 • Kernig’s sign –
- Patella +2/+2 • Brudzinsky sign –
- Achilles +2/+2

Pathology reflexes
- Chaddock -/-
- Oppenheim -/-
- Schaeffer -/-
- Gordon -/-
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- Babinski -/-
 XII. Nutritional History
• Weight for Age: 11/11x 100% = 100% (Z score= 0SD)
• Height for Age: 84/82x100 % = 102% (0SD< Z score < +2 SD)
• Weight for Height : 11/11.5 x100 % = 96%

• Conclusion: well nourished, normoweight, normoheight

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XIII. Laboratory Findings (Feb 18th , 2017)
• Hb : 9.7 g/dl • Blood sugar : 82mg/dl
• HCT : 33% • Sodium : 137mmol/L
• AL : 6.1 thousand/ul • Potassium : 4.7mmol/L
• AT : 190 thousand/ ul • Chloride : 99mmol/L
• AE : 4.40 mil/ul • Calcium : 1.08mmo/L
• MCV : 73.9/um
• MCH : 22.0 pg Conclusion : micrositic
• MCHC : 29.8 g/dl hypochromic anemia
• Netrofil : 33.3%
• Limosit : 59.9%
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• Monosit : 4.4 %
EEG
• Epileptogenic wave and abnormal deceleration founded on
EEG recording.

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 Problem List
Eighteen months old boy, 11kgs with
Anamnesis Lab findings: micrositic hypochromic
1. Seizure, 4-5 times a day, 2-3 minute anemia
long, no fever, throughout body, EEG: Epileptogenic wave and abnormal
stop without any medication, fully deceleration founded on EEG recording.
alert after seizures
2. No head trauma
3. History if seizure without fever 5
months ago.
4. No family history of seizure

Physical findings
1. Fully alert
2. Body temp of 38.40C
3. Phymosis
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4. No neurological examination
abnormalities
Differential Diagnose
• General idiopathic epilepsy differentiated with symptomatic
• Fever on observation due to viral infection dd/ Dengue fever,
UTI
• Micrositic hypochromic anemia due to infection dd/ iron
deficiency
• Well nourished

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Working Diagnose
• General idiopathic epilepsy
• Fever on observation due to UTI
• Micrositic hypochromic anemia due to infection
• Well nourished

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PLAN
• Therapy
1. Admitted to pediatric neurology ward
2. Dietary: rice pack 1000 kkal/day
3. IVFD D5 ½ NS 11 drops per minute intravenously
4. Diazepam (0.3mg/kg) intravenous (if seizure come)
5. Valproic acid syrup (30mg/kg/day) = 160 mg/ 12 hours = 3.3
ml/12 hours
6. Paracetamol (10mg/kg) = 120 mg every 8 hours

• Diagnostic
• Brain CT scan
• Urinalysis and routine feces examination 21
• Iron status
Follow up on 18th February
General appearance: fully alert, E4V5M6
VS : heart rate: 130 x/menit body temp : 37.40C
resp rate: 26x/ menit saturation : 99%
• Head : normocephal with Head circumference 47 cm
(LK= 0 SD, nellhaus)
• Eyes : pale conjunctiva (-/-), icteric conjunctiva
(-/-), light reflex (+/+), isochoric pupil
3 mm/3mm
• Nose : nasal flare (-/-),discharge (-/-)
• Mouth : lips and tongue not cyanotic 22
• Neck : no enlargement of lymph node
LUNG:
• I: normal, symmetric, no retraction
• P: hard to evaluate
• P: sonor in both lung
• A: normal vesicular breath sound, additional breath sound (-/-)

CARDIAC:
• I : ictus cordis not visible
• P: ictus cordis palpable
• P: there is no cardiac enlargement
• A: 1st 2nd Heart sound normal intensity, regular, no murmur

ABDOMINAL:
I: abdominal wall // thorax wall
A: peristaltic in normal limit
P: shifting dullness (-), undulations(-)
P: there is no enlargement of the spleen and liver

EXTREMITIES: 23
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was palpably strong.
Neurological Examination

Physiological reflexes Meningeal sign

- Biceps +2/+2 • Nuchal rigidity –
- Triceps +2/+2 • Kernig’s sign –
- Patella +2/+2 • Brudzinsky sign –
- Achilles +2/+2

Pathology reflexes
- Chaddock -/-
- Oppenheim -/-
- Schaeffer -/-
- Gordon -/-
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- Babinski -/-
Nn. CRANIALIS Examinations

N. Olfaktorius (I) : cannot be evaluated yet.

N. Optikus (II) : isochoric pupil (2mm/2mm), light reflex +/+,
funduscopy was not performed
N. Okulomotorius (III), N. Troklearis (IV), N. Abduscens (VI)
Normal movement of eyes, pupils at center, no strabismus -
N. Trigeminus : corneal reflex (+/+)
N. Fasialis (VII) : symmetric face
N. Akustikus (VIII) : hearing dan balance test, not performed, N.
N. Glossofaringeus (IX) : no tongue deviation
N. Vagus : cannot be evaluated
N. Aksesorius (XI) : no shoulder paralyzed found
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N. Hipoglossus : cannot be evaluated
Working Diagnose
• General idiopathic epilepsy
• Fever on observation due to UTI
• Micrositic hypochromic anemia due to fe deficiency dd
infection
• Well nourished

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PLAN
• Therapy
1. Dietary: rice pack 1000 kkal/day
2. IVFD D5 ½ NS 11 drops per minute intravenously
3. Diazepam (0.3mg/kg) intravenous (if seizure come)
4. Valproic acid syrup (30mg/kg/day) = 165 mg/ 12 hours
=3.3ml/12 hours
5. Paracetamol (10mg/kg) = 120 mg every 8 hours

• Diagnostic
• Brain CT
• Urinalysis and routine feces examination
• Iron status 27
What are risk of epilepsy in
late preterm baby?
• P: Baby born with >30 weeks of
gestational age
• I: Late preterm baby with 34-36 week of
gestational age
• C: Baby with >36 week of gestational
age
• O: risk of epilepsy
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Thank You
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Patofisiologi

Dikutip dari : Stafstrom, 2005

Dikutip dari : Stafstrom, 2005
Klasifikasi ILAE 2010

Sumber : ILAE, 2010

Diagnosis Epilepsi
Epilepsi merupakan diagnosis klinis atas dasar
anamnesis dan pemeriksaan fisis neurologis

Dikutip dari : Mangunatmadja, 2014

Kejang atau bukan?
Klinis Kejang Bukan kejang
Awitan Tiba-tiba Gradual
Kesadaran Terganggu/ Tidak tergangggu
tidak (fokal sederhana)
Gerakan ekstremitas Sinkron Asinkron
Sianosis Sering Jarang
Gerakan abnormal mata Selalu Jarang
Serangan khas Sering Jarang
Lama Detik-menit Beberapa menit
Dapat diprovokasi Jarang Hampir selalu
Abnormalitas EEG selalu Tidak pernah

Dikutip dari : IDAI, 2016

 Obat Anti Epilepsi
OAE lini pertama

Obat Indikasi Kontraindikasi Dosis

fenobarbital Epilepsi umum, fokal Absans 4-6 mg/kg/hr (2
dosis)
fenitoin Epilepsi umum, fokal Mioklonik, 5—7 mg/kg/hr
absans (2dosis)
Asam valproat Epilepsi umum, fokal, - 15-40 mg/kg/hr ( 2
absans, mioklonik dosis) target awal :
15-25 mg/kg/hr
karbamazepin Epilepsi fokal Mioklonik 10-30 mg/kg/hari
absans (2-3 dosis)

Dikutip dari : IDAI, 2016

OAE lini kedua

Obat Indikasi Dosis

Topiramat Epilepsi umum 5-9 mg/kg/hari; 2-3 dosis
Epilepsi fokal o.5-1 mg/kg/hari dinaikan dosis setiap 1-2
minggu s.d 5-9 mg/kg/hari
Levetiracetam Epilepsi fokal 20-60 mg/kg/hari; 2-3 dosis
Epilepsi umum 5-10 mg/kg/hari dapat dinaikan setiap 5-7
Absans hari hingga dosis 30 mg/kg/hari
Mioklonik
Oxcarbazepine Epilepsi fokal 10-30 mg/kg/hari; 2-3 dosis
Benign Rolandic 5-10 mg/kg/hari dinaikan setiap 5-7 hari
epilepsy hingga 30 mg/kg/hari

lamotrigine Epilepsi umum 0.5-5 mg/kg/hari; 2-3 dosis

Epilepsi fokal Mulai 0.5 mg/kg/hari dinaikan setiap 2
Absans minggu hingga 5 mg/kg/hari
mioklonik

Dikutip dari : IDAI, 2016

Efek Samping Obat

Dikutip dari : Indian Academy of Epilepsy, 2009

When to stop?
Panduan penghentian OAE
Waktu memulai penghentian OAE
1. Setelah 2 tahun bebas kejang (syarat a,b,c terpenuhi)
a) Epilepsi idiopatik : tonik-klonik, absans tipikal
b) Pemeriksaan fisis, neurologis, dan perkembangan normal
c) Gambaran EEG normal
2. Setelah 3 tahun bebas kejang, pada kasus :
a) Epilepsi simtomatik
b) Sindrom epilepsi
c) Gambaran EEG abnormal walau 2 tahun telah bebas kejang
Kecepatan Tappering Off
1. Tappering off selama 3 bulan, jika syarat a dan b di bawah terpenuhi:
a) Epilepsi idiopatik yang bebas kejang dengan satu jenis OAE
b) Gambaran EEG sebelum tappering off normal
1. Tappering Off selama 6 bulan, pada kasus:
a) Epilepsi simptomatik
b) Sindrom epilepsi
c) Gambaran EEG sebelum tappering off masih menunjukkan gelombang epileptiform
d) Terdapat gangguan perkembangan

Dikutip dari : IDAI, 2016

Status Epileptikus
• Definisi
Kejang yang berlangsung terus menerus selama periode
waktu tertentu (> 30 menit) atau berulang tanpa disertai pulihnya
kesadaran diantara kejang.
Sumber : IDAI, 2016
 Diazepam Fenitoin Phenobarbital Midazolam
Dosis Inisial 0,3-0,5 mg/kgbb 20mg/kgbb 20 mg/kgbb 0,2 mg/kgbb bolus

0,02-0,1mg/kgbb drip
Maksimum dosis 10mg 1000mg 1000mg -
awal
Dosis ulangan 5 menit dapat Bila kejang berhenti, Bila kejang 10-15 menit
diulang kejang kembali berhenti, kejang
10mg/kgbb kembali
10mg/kgbb
Lama kerja 15 menit-4jam 12-24 jam 12-24 jam 1-6 jam
Catatan Dilanjutkan dengan Hindarkan Monitor tanda vital
fenitoin atau AED pengulangan
sebelum 48 jam
Efek samping Somnolen, ataxia, Bingung, depresi Hipotensi, depresi Hipotensi, depresi
depresi napas napas napas, aritmia napas

Dikutip dari : Mangunatmadja, 2014