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CASE CONFERENCE

SATURDAY MORNING SHIFT,


MAY 18TH , 2019

dr. Ama / dr. Dini/ dr. Rizki/ dr. Anto /dr. Lubna/ dr. Ahimsa
dr. Wulan / dr. Pitra
dr. Ika/ dr. Aya

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PATIENT ADMISSION

Melati 2 ward

• Child Y, 17 yo, 52 kgs, with acute cephalgia due to migraine dd TTH; vomit
without dehydration, history of cytotoxic cerebral edema, wellnourished
• Child R, 10 yo, 28 kgs, with symptomatic generalized epilepsy,
hydrocephalus, wellnourished

PICU

• ,,,, E, 17 yo, 55 kgs, with dull abdomen trauma suspected


Child
spleen rupture, opened fracture of right femur, wellnourished
NICU

Pediatric HCU

• Child A, 15 mo, 7.5 kgs, with acute rhino pharyngitis, palatoschisis pro repair 2
palatoplasty, treacher Collins syndrome, laringomalasia, undernourished
PATIENT IDENTITY

 Name :R
 Sex : Male
 Age : 10 years old
 Body weight / height : 23 kgs
 Address : Sragen
 Medical Record : 01461750

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 Appearance
Tone : normal
Irritability : normal
Consolability : normal
Look : normal
Speech : normal
Appearance Work of Breathing
Normal Normal
 Work of Breathing
Breath sound : normal PEDIATRIC
ASSESMENT
Positioning : normal TRIANGLE
Nasal flare :-
Retraction :-

Circulation
 Circulation
Normal
Pallor :-
Cyanosis :-
Mottled :- 4
Bleeding :-
CHIEF COMPLAINT

seizure

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CURRENT MEDICAL HISTORY

 Seizure at home 2 times, fever (-), all over the body, ± 5 minutes, seizure was
stopped without given drugs, after seizure, patient was fully alert
 Patient was brought to Sragen Hospital and being hospitalized there for 5 days and
was given phenytoin IV

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CURRENT MEDICAL HISTORY

 Seizure once in the morning, all over the body, ±2 minutes, seizure was stopped
without given drugs, after seizure, patient was fully alert
 Headache (-)
 Good appetite
 Defecation and urination within normal

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CURRENT MEDICAL HISTORY

 Patient fully alert


 Fever (-)
 Vomit (-)
 Headache (-)
 Decrese of appetite (-)
 Defecation and urination within normal

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PAST MEDICAL HISTORY

 History of same illness : repeated seizure at 5


y.o., patient consumed anti-epileptic drugs and has been
stopped after 2 years free of seizure

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FAMILY MEDICAL HISTORY

 No history of epilepsy
 No history of congenital defect

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PREGNANCY AND DELIVERY HISTORY

• During pregnancy, his mother routinely checked up her


pregnancy to midwife. She was given vitamin, and she didn’t
consume any medicine beside it. She never got hospitalized
during pregnancy and has no fever.
• Baby boy was born in 37 weeks of pregnancy by spontaneous
delivery. The baby cried vigorously, no cyanosis and no jaundice.
His birth weight was 2800 grams, 48 centimeters in length.

Conclusion: Pregnancy history was normal and delivery11


history was normal
VACCINATION HISTORY
0 month : Hepatitis B0
1 month : BCG, polio 1
2 months : DPT1, hepatitis B1, polio2
3 months : DPT2, hepatitis B2, polio3
4 months : DPT3, hepatitis B3, polio4
9 months : Measles
1st elementary school DT
2ND and 3rd elementary Td (-)
school
Conclusion :
Complete immunization, 12
(inappropriate with Ministry of Health schedule 2007)
NUTRITION HISTORY

Patient eat 3 times per day, with diet rice packs. He also drinks milk 4
times per day. Patient eats chicken, meat, vegetables, tofu, and tempe.
Conclusion: quantity and quality were adequate

GROWTH AND DEVELOPMENT


He is 10 years old now, 29 kgs in body weight
Birth weight : 2800 grams, birth length : 48 cms.
No weakness at extremities, patient’s head was getting bigger since he was
born
Patient can walk and talk. Patient doesn’t go to school, last history of
education was a year ago at 3rd grade of elementary school. 13
Conclusion: growth and development are not normal
NUTRITIONAL STATUS

• Weight for Age:


29/33 x 100% = 87% (p25 <W/A <p50; normoweight)
• Height for Age:
• 130/139 x 100% = 93% (p10<H/A <p25; normoheight)
• Weight for Height :
• 29/27 x 100% = 107% (wellnourished)

Conclusion:
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wellnourished, normoweight, normoheight
PEDIGREE

II

III

Child R, 10 yo
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PHYSICAL EXAMINATIONS

 Moderate illness, fully alert


 Heart Rate = 114 bpm
 Respiratory rate = 22 times/ minute
 Temperature = 36.6o C per axillar
 Blood pressure = 110/60 mmHg
 SiO2 = 99%

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 Head : macrocephaly, head circumference 71 cm (> +2 SD of Nellhaus)
 Eyes : pale conjunctiva (-/-), icteric sclera (-/-), isochoric pupils diameters 2
mm/2mm, light reflexes (+/+)
 Nose : nasal flare (-) epistaxis (-)
 Mouth : dry lips (-), cyanosis (-) gum bleeding (-)
 Ear : discharge (-/-)
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (-),

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus same in both side
 P: sonor in both lungs
 A: normal vesicular breathing sound,additional breathing sound (-/-), crackles (-/-)

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CARDIAC:
I : ictus cordis was not visible
P : ictus cordis was not palpable
P : cardiac enlargement (-)
A : 1st 2nd Heart sound normal intensity, regular, systolic murmur (-)

ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds normal limit
P: tympani (+),
P: tender, good skin turgor
liver : no enlargement
spleen : no enlargement
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EXTREMITIES:
Warm, capillary refill time < 2 sec, and dorsalis pedis artery was strongly palpable

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PHYSICAL EXAMINATION

Meningeal sign
Physiological reflexes - Nuchal rigidity -
- Biceps +2/+2
- Kernig’s sign -
- Triceps +2/+2
- Brudzinsky sign -
- Patella +2/+2
- Achilles +2/+2
Lateralization (-)
- Patella +3/+3
Clonus: -/-
Pathology reflexes
- Chaddock -/-
Motorics
- Oppenheim -/- 55555/55555
- Schaeffer -/- 55555/55555
- Gordon -/-
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- Babinski -/-
LABORATORY RESULTS MAY 18TH 2019

Value Reference Units


Hemoglobin 12.8 10.8-12.8 g/dl
Hematocrit 37 35-43 %
Leucocyte 8.3 5.5-17.0 103/ul
Platelet 342 150-450 103/ul
Erytrocyte 4.78 3.90-5.30 106/ul
MCV 76.7 80.0-96.0 /um
MCH 26.8 28.0-33.0 pg
MCHC 34.9 33.0-36.0 g/dl
RDW 11.8 11.6-14.6 %
MPV 8.8 7.2-11.1 fl
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PDW 17 25-65 %
LABORATORY RESULTS

Value Reference Units


Eosinophil 4.20 0.00-4.00 %
Basophil 0.30 0.00-1.00 %
Netrophil 56.60 29.00-72.00 %
Lymphocyte 29.90 36.0-52.0 %
Monocyte 9.00 0.0-5.0 %
- %

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LABORATORY RESULTS

Value Reference Units

Sodium 135 129-147 mmol/L


Potassium 3,8 3.6-6.1 mmol/L
Calcium 1.12 1.17-1.29 mmol/L
Chloride 98 98-106 mmol/L
creatinine 0.7 0.3 – 0.7 mg/dl
ureum 33 < 48 mg/dl

Conclusion: within normal

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HEAD CT SCAN 18/05/19

1. Hydrocephalus communicans
2. Mega sisterna magna
3. Macrocephallus

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DIFFERENTIAL DIAGNOSIS

1. Symptomatic generalized seizure


2. Congenital hydrocephalus
3. Wellnourished

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WORKING DIAGNOSIS

1. Symptomatic generalized seizure


2. Congenital hydrocephalus
3. Wellnourished

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THERAPY

1. Admitted to neurology ward in conjunction with neurosurgery division


2. Rice packs diet 2000 kcal/day + milk 250 ml
3. IVFD D51/2NS 45 ml/hour
4. Phenytoin injection (3 mg/kgBW/day) = 75 mg/12 hours IV
5. Valproic acid (15 mg/kgBW/day) = 4.5 ml/ 12 hours po

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PLAN

CBC, electrolytes, Ur/Cr


Consult to neurosurgery division
Head CT scan

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MONITORING

• General appearance / vital signs /8 hours


• Fluid balance, diuresis / 8 hours
• Blood pressure/ 8 hours

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FOLLOW UP ON MAY 19TH , 2019

SUBJECTIVE
Seizure (-)
Fever (-)

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PHYSICAL EXAMINATIONS

 Moderate illness, fully alert


 Heart Rate = 108 bpm
 Respiratory rate = 22 times/ minute
 Temperature = 37o C per axillar
 Blood pressure = 110/60 mmHg
 SiO2 = 99%

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 Head : macrocephaly, head circumference 71 cm (> +2 SD of Nellhaus)
 Eyes : pale conjunctiva (-/-), icteric sclera (-/-), isochoric pupils diameters 2
mm/2mm, light reflexes (+/+)
 Nose : nasal flare (-) epistaxis (-)
 Mouth : dry lips (-), cyanosis (-) gum bleeding (-)
 Ear : discharge (-/-)
 Neck : Enlargement of lymph node (-)
 Thorax : symmetric (+), retraction (-),

LUNG:
 I: normal, symmetric, retraction (-)
 P: fremitus same in both side
 P: sonor in both lungs
 A: normal vesicular breathing sound,additional breathing sound (-/-), crackles (-/-)

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CARDIAC:
I : ictus cordis was not visible
P : ictus cordis was not palpable
P : cardiac enlargement (-)
A : 1st 2nd Heart sound normal intensity, regular, systolic murmur (-)

ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds normal limit
P: tympani (+),
P: tender, good skin turgor
liver : no enlargement
spleen : no enlargement
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EXTREMITIES:
Warm, capillary refill time < 2 sec, and dorsalis pedis artery was strongly palpable

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PHYSICAL EXAMINATION

Meningeal sign
Physiological reflexes - Nuchal rigidity -
- Biceps +2/+2
- Kernig’s sign -
- Triceps +2/+2
- Brudzinsky sign -
- Patella +2/+2
- Achilles +2/+2
Lateralization (-)
- Patella +3/+3
Clonus: -/-
Pathology reflexes
- Chaddock -/-
Motorics
- Oppenheim -/- 55555/55555
- Schaeffer -/- 55555/55555
- Gordon -/-
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- Babinski -/-
WORKING DIAGNOSIS

1. Symptomatic generalized seizure


2. Hydrocephalus communicans
3. Wellnourished

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THERAPY

1. Rice packs diet 2000 kcal/day + milk 250 ml


2. IVFD D51/2NS 45 ml/hour
3. Phenytoin injection (3 mg/kgBW/day) = 75 mg/12 hours IV
4. Valproic acid (15 mg/kgBW/day) = 4.5 ml/ 12 hours po

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PLAN

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MONITORING

• General appearance / vital signs /8 hours


• Fluid balance, diuresis / 8 hours
• Blood pressure/ 8 hours

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