MORNING REPORT

SHIFT: FEBRUARY 9TH 2017

dr. Patra / dr. Devi

dr. Sekar /dr. Lubna / dr. Indra / dr. Prabu
dr. Winda / dr. Bayu
dr. Dilla /dr. Laras

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Patient Admissions
• Melati II Ward:
1. A, girl, 5 y.o 15 kg with first unprovoked seizure, well nourished
2. S, girl, 10 y.o 29 kg with symptomatic general epilepsy, ALL high risk
post chemoteraphy, well nourished.

• HCU Neonatus:

• NICU: ( - )
• HCU Melati 2: (-)
• PICU: (-)

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I. Patient Identity
Name :A
Sex : girl
Age : 5 years old
Addresses : Mojolaban, Sukoharjo
Medical record : 01368866
Weight/Height : 15 kg

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II. Chief Complaint

Seizure

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 III. Present Medical History
Two hours before admitted to hospital, patient had seizure.
Seizure occurs throughout her body with her eyes glared for about 5
minutes. Seizure suddenly stopped without any drugs. Fever before
seizure was denied. She had no cough, no flu, no vomits, no diarrhea.
Patient looked very sleepy after seizure.
Parents brought her to the doctor that near her house. Doctor
only gave her oxygen through nasal. Patient had no seizure and fever
at the time. She was sleeping, responsive only with pain. Because of
the limited facilities, she was referred to Moewardi Hospital.
As she arrived in hospital, she is fully alert, no seizure at all,
no fever, any headache was denied, she can communicate fluently.

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IV. Past Medical History
History of Seizure : denied
Hospital admissions : denied

V. Family Medical History

History of Seizure : denied

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

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VI. Pregnancy and Laboured 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. She never admitted to
hospital during the pregnancy.
• Baby girl was born in 40 weeks of pregnancy, normal delivery,
crying vigorously, no cyanosis or icteric was found. Her birth
weight was 2800 grams.

Conclusion: normal laboured and pregnancy history

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VII. Immunization Status

BCG : 1st month

Hepatitis B : after birth , 2nd , 4th , 6th months
DPT : 2nd , 4th, 6th months
Polio : 2nd, 4th, 6th months
Campak : 9th month

Conclusion : complete immunization, appropriate with

Ministry of Health’s vaccination schedule 2012

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VIII. Nutritional History

Patient eat three times a day, a plate of rice with side dish.
Good appetite.

Conclusion : enough quantities and qualities nutrition for

the age

IX. Growth and Developmental History

She is 5 years old with daily activity in kindergarten level B.
She has good relation with her friend.
Her weight is 15 kg with body height 103 cm.
Conclusion : growth and development suitable for her age 9
 POHON KELUARGA

II

III

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An. A, 5 years old

 XI. Physical Examination
General appearance: fully alert, moderate illness, well nourished
VS : heart rate: 112 x/m body temp : 37,00C
respiratory rate: 30x/ m SiO2 : 99%
• Head : Normocephal with Head circumference 50 cm
(-2 SD<HC<0SD, nellhaus),
major fontanella had clossured
• Eyes : anemic conjunctiva (-/-), icteric sclera(-/-),
isochoric pupil 3 mm/3mm, light reflex (+/+)
sunken eye (-)
• Nose : nasal flare (-/-),discharge (-/-)
• Mouth : moist(+), lips and tongue not cyanotic,
pharing hiperemi (-), T1/T1 hiperemi (-) 11
• Neck: enlargement of lymph nodes (-)
PULMO:
• I : normal, symmetric, no retraction
• P: vocal fremitus symmetric
• P: sonor +/+
• A: vesicular breath sound +/+, additional breath sound (-/-)

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

ABDOMINAL:
I: abdominal wall // thorax wall
A: peristaltic within normal limit
P: tympani (+), shifting dullness (-), undulations(-)
P: firm, no tenderness, no Liver nor spleen enlargement

EXTREMITIES: 12
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong palpable.
Neurological Examination
Meningeal sign
Physiological reflexes • Nuchal rigidity (–)
• Kernig’s sign (–)
- Biceps +2/+2
• Brudzinsky sign (–)
- Triceps +2/+2
- Patella +2/+2 Cranialis nerve examination :
N. I : smelling normal impression
- Achilles +2/+2 N. II : normal visus
N. III, IV, VI : eye movement within
normal limit
Pathological reflexes N. V : symmetrical chin
- Chaddock -/- N. VII : symmetrical facial
- Oppenheim -/- N. VIII : auditorik normal impression
N. IX :symmetrical uvula
- Schaeffer -/- N X :vomit reflex +
- Gordon -/- N XI : lift shoulder +/+
N. XII : tongue motoric +/+ 13
- Babinski -/-
 XII. Nutritional History
• Weight for Age: 15/18x 100% = 83% (W/A=p5)
• Height for Age: 104/107x100 % = 97% (p25<H/A<p50)
• Weight for Height : 15/17 x100 % = 88%

• Conclusion: well nourished, underweight, normoheight

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XIII. Laboratory Findings (Feb 9th , 2017)
• Hb : 11.0 g/dl • Blood sugar : 95mg/dl
• HCT : 35% • Sodium : 135mmol/L
• AL : 11.3 thousand/ul • Potassium : 3.9mmol/L
• AT : 321 thousand/ ul • Chloride : 98mmol/L
• AE : 4.06 mil/ul • Calcium : 1.07mmo/L
• MCV : 85/um
• MCH : 27.1 pg Conclusion : within normal
• MCHC : 31.9 g/dl range
• Netrofil : 76.9%
• Limosit : 16.10%
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• Monosit : 6.1 %
Problem List
A five years old girl, 15kgs with :
Anamnesis
1. Seizure, first time, 5 minutes, whole body, stopped without drug, sleepiness
after seizure
2. No fever, no headache
3. No history of diarrhea or vomiting
4. No family history of seizure
5. No history of past seizure

Physical findings
1. Fully alert
2. Body temp of 37.00C
3. No neurological examination abnormalities

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Laboratory findings within normal range
Differential Diagnose
• First unprovoked seizure due to :
• DD imbalance electrolyte
• DD epilepsy
• Well nourished, underweight, normoheight

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Working Diagnose
• First unprovoked seizure due to epilepsy
• Well nourished

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PLAN
• Therapy
1. Admitted to pediatric-neurology ward
2. Dietary: rice pack 1300 kkal/day
3. O2 nasal 2 liter per minute
4. IVFD D5 ¼ NS 52 ml/jam intravenous (maintenance)
5. Diazepam (0.3mg/kg) intravenous (if seizure come)
6. Paracetamol (10mg/kg) = 150 mg orally if temp >38oC

• Diagnostic
• Electroencephalogram
• Lumbal Puncture
• Brain MS-CT 19
FOLLOW UP (February 10th

2017)
Complaint : Fever (-), seizure (-), weakness (-)
General appearance: fully alert, moderate illness, well nourished
VS : heart rate: 98 x/menit body temp : 36,80C
respiratory rate: 24x/ menit SiO2 : 99%
• Head : Normocephal with Head circumference 50 cm
(-2 SD<HC<0SD, nellhaus),
major fontanella had clossured
• Eyes : anemic conjunctiva (-/-), icteric sclera(-/-),
isochoric pupil 3 mm/3mm, light reflex (+/+)
sunken eye (-)
• Nose : nasal flare (-/-),discharge (-/-)
• Mouth : moist(+), lips and tongue not cyanotic, 20
pharing hiperemi (-), T1/T1 hiperemi (-)
• Neck: enlargement of lymph nodes (-)
PULMO:
• I: normal, symmetric, no retraction
• P: vocal fremitus symmetric
• P: sonor +/+
• A: vesicular breath sound +/+, additional breath sound (-/-)

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

ABDOMINAL:
I : abdominal wall // thorax wall
A: peristaltic within normal limit
P: tympani (+), shifting dullness (-), undulations(-)
P: firm, no tenderness, no Liver nor spleen enlargement

EXTREMITIES: 21
The extremities was warm, capillary refill time < 2 sec, and dorsalis pedis
artery was strong palpable.
Neurological Examination
Meningeal sign
Physiological reflexes • Nuchal rigidity (–)
• Kernig’s sign (–)
- Biceps +2/+2
• Brudzinsky sign (–)
- Triceps +2/+2
- Patella +2/+2 Cranialis nerve examination :
N. I : smelling normal impression
- Achilles +2/+2 N. II : normal visus
N. III, IV, VI : eye movement within
normal limit
Pathological reflexes N. V : symmetrical chin
- Chaddock -/- N. VII : symmetrical facial
- Oppenheim -/- N. VIII : auditorik normal impression
N. IX :symmetrical uvula
- Schaeffer -/- N X :vomit reflex +
- Gordon -/- N XI : lift shoulder +/+
N. XII : tongue motoric +/+ 22
- Babinski -/-
Working Diagnose
• First unprovoked seizure due to epilepsy
• Well nourished

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PLAN
• Therapy
1. Admitted to pediatric neurology ward
2. Dietary: rice pack 1300 kkal/day
3. O2 nasal 2 liter per minute
4. IVFD D5 ¼ NS 52 ml/jam intravenous
5. Diazepam (0.3mg/kg) intravenous (if seizure come)
6. Paracetamol (10mg/kg) = 150 mg orally if t>38oC

• Diagnostic
• Electroencephalogram
• Lumbal Puncture
• Brain MS-CT 24
Clinical question :Is there any possible of the
occurrence of recurrent seizures in children
with first unprovoked seizures?

• P : population children with first unprovoked

seizures
•I:-
•C:-
• O : possibility of reccurent seizures