Morning Report

May 10th 2019

A Boy Aged 12 Years 3 Month with Cephalgia

Observation ec Increased Intracranial
Pressure, Vomitus Observation ec Increased
Intracranial Pressure, Hydrocephalus non
Communicans ec SOL Intraventricular post VP
Shunt H1, and Tuberosclerosis
 IDENTITY

• Patient
👦 • Parents

Father’s Occupation : Government

Name : DAR Employees
Age : 12 Years 3 Months old Father’s Education : Diploma
Date of birth : January 20th 2007
Sex : Male
MR/Reg number : C753959/10167060
Date of admission : May 9th 2019 Mother’s Occupation : Housewife
Ward : Pediatric Mother’s Education : Senior High School
ANAMNESIS : May 9th 2019

Chief complaint: referred by pediactrics specialist with vomitus ec increased

intracranial pressure

The child complaints about a headache especially at the occipital region. A

headache just like a migraine, it has pulse, nausea (-), vomitus (+) not spray, fever
(-), seizure (+)  the child was taken by parent to the hospital and in charge for 3
days, said it was a typhoid  go home. At home the child still complains about a
headache (+), vomitus (+), nausea (-), fever (-), was taken by parents to the
pediatrics spesialits  observation vomitus dd/ increased intracranial pressure 
referred to Kariadi General Hospital

2 weeks prior to admission

ANAMNESIS
Past Medical History Family History

• History of febrile seizure at 20 months old, • Family history of seizure (-)

consumption of valproic acid

Sosio economic History Environmental History

A child has one siblings. Father is a goverment- school friend with same disease : unknown
employees and mother is a housewife neighbor with same disease (-)
Perinatal History

• she had >4x routine antenatal care to midwife during pregnancy

Prenatal • history of illness during pregnancy (-), DM (-), HT (-)
• history of taking medicines or herbal during pregancy (-)

• Born from G1P0A0, aterm, normal pervaginam

Natal
• Birth weight 3.800 grams, birth length : forget

• Cry right away after birth

Postnatal • No history of jaundice nor cyanosis
History of Immunization

• Hepatitis B : 4x (0,1,2,3 month)

• Polio : 4x (1,2,3,4 month )
• BCG : 1x (0 month)
• DPT : 3x (1,2,3 month)
• Campak : 1x (9 month)

• booster : (+)

Impression : Complete recommended routine

immunization, booster (+)
 History of Nutrition
– 0-6 months:
Exclusive breast milk, 12x/day
FOOD RECALL
– 6-9 months:
Breakfast Lunch Dinner
Breast Milk 12x/day + soft porridge 3 x
1 serving of rice 1 serving of rice 1 serving of rice
50ml) Friday
1 egg 1 serving of 1 egg
April 19, 2019
– 9-12 months: 1 serving of tauge meatball 1 serving of tauge
1 serving of rice
Breast milk 12x/day + porridge 3 x 70ml) 1 serving of rice
1 tofu
Saturday 1 tofu 1 serving of rice
– >12 months: April 20, 2019
1 bakwan
1 serving of peanut 1 egg
1 serving of peanut
Family Food 3 x 1 portion vegetables
vegetables
1 serving of rice 1 serving of rice 1 serving of rice
Sunday
1 serving of soup 1 serving of soup 1 serving of soup
April 21, 2019
1 serving of chicken 1 serving of chicken 1 serving of chicken

 adequate quality and quantity intake

 ANTHROPOMETRIC STATUS

Body weight : 60 kg
Height : 160 cm
BSA : 1,62 m2
-WAZ : NA
-HAZ : -1,03 SD
-WHZ : 1,60 SD

Impression : well nutrition, normal stature

HISTORY OF GROWTH DEVELOPMENT

The child is in junior high school. He

does well in school and has good
relationships with his friends.

Impression: Development according

to age
PEDIGREE
PHYSICAL EXAMINATIONS (May 10th, 2019)

 General state : looks well

 Consciousness : awake, GCS E4M6V5 = 15
 Vital sign :
• HR : 90 bpm
• Pulse : Regular, sufficient volume and pressure
• RR : 20 x/minutes
•T : 36,9 OC
• BP : 120/90 mmHg (P90)

 Head : operation wound covered by gauze surgery

 Eye : Anaemic (-/-), icteric (-/-), palpebral oedema (-/-)
 Nose : nasal flaring (-), epistaxis (-)
 Mouth : Cyanosis (-), pale (-)
 Pharynx : hyperaemic (-), tonsil: T1-T1 hyperemia (-), detritus (-)
 Neck : lymphadenopathy (-/-)
 Axila : lymphadenopathy (-/-)
 PHYSICAL EXAMINATIONS

THORAX
Lung
Inspection : symmetrical chest expansion, chest indrawing (-)
Palpation : equal fremitus on both lung sides
Percussion : Sonor in all lung fields
Auscultation : vesicular breath sound (+) normal; Rhonci (-/-), wheezes (-/-)

Heart
Inspection : ictus cordis non visible
Palpation : ictus cordis palpable on left midclavicular line SIC V, thrills (-)
Percussion : within normal limit
Auscultation : normal heart sound, murmur (-), gallop (-)
 PHYSICAL EXAMINATIONS

ABDOMEN
Inspection : distention (-)
Auscultion : normal bowel sounds
Percussion : tympanic, shifting dullness (-)
Palpation : epigastric pain (-), Spleen and liver not palpable
Extremity
Superior Inferior
warm +/+ + /+
Capillary refill <2”/ <2” <2”/ <2”
physiological reflexes +/+ +/+
Pathological reflexes +/+ +/+
Tonus N/N N/N
Clonus -/-
PHYSICAL EXAMINATIONS
Neurologics status: N. craniales:
■ Stiff nect: (-)
N. I : no complains
N II : no complains, light reflexes (+/+)
■ Brudzinski I: (-) N III : isocorous pupil, normal eye movements
■ Brudzinski II: (-) N IV : normal eye movements
■ Kernig: (-) N V : normal corneal reflexes
■ Laseque: (-) N VI : normal eye movements
N VII : perfectly closed eyelids, symmetrical smile
■ Pathological reflex: (-) N VIII : hard to assess
■ Babinsky (-) N IX : uvula deviation (-)
■ Chaddock (-) N X : swallowing disorders (-)
■ Oppenheim (-) N XI : lift the shoulder up (+/+)
N XII : tongue deviation (-)
LABORATORY EXAMINATIONS
Hematology Standar Denomination 9/5/19
Hematologi
Hb 10.5 – 15 g/ dL 15.5
Ht 36 – 44 % 46.1
RBC 3 – 5.4 10^6/ uL 5.82
MCH 23.00 – 31.00 Pg 26.6
MCV 77 – 101 fL 79.2
MCHC 29.0 – 36.0 g/dL 33.6
WBC 5 – 13.5 10^3/uL 10.7
Platelets 150 – 400 10^3/uL 279
RDW 11.6 – 14.8 % 12.5
LABORATORY EXAMINATIONS
Chemical Clinical
Glucose 80 – 160 mg/dL 90
Ureum 15 – 39 mg/dL 24
Kreatinin 0.60 – 1.30 mg/dL 1.0
Calcium 2.12 – 2.52 Mmol/L 2.4
Natrium 136 – 145 Mmol/L 143
Kalium 3.5 – 5.1 Mmol/L 4.3
Chlorida 98 – 107 Mmol/L 106
LABORATORY EXAMINATIONS
Diff Count Standard Denomination 9/5/19
Eosinophyl 2–4 % 2
Basophyl 0–4 % 0
Stab 2–5 % 2
Segmen 45 – 75 % 67
Limfocyte 20 – 40 % 25
Monocyte 3 – 12 % 4
Others -
Peripheral Blood Smear
Erythrocytes Normocytic, mild poicilocytosis (ovalocytes, pear shape)
Platelets Normal estimated count, giant shape (+), dominating with normal shape
Leucocytes Normal estimated count, relatives neutrophilia, neutrophil vacuolization
LABORATORY EXAMINATIONS
Coagulation Study Standard Denomination

Prothrombin Time 11.0 – 14.5 Second 13.9

PPT Control Second 13.8
Thromboplastin 24.0 – 36.0 Second
30.6
Time
APTT Control Second 30.2
LABORATORY EXAMINATIONS
LCS Staining (May 9th 2019)
Interpretation:
Phisis :
- Color : yellow
- Turbidity : clear
Protein : 840 mg/dL (H)
Glucose : 79 mg/dL
Leucocyte cells :
- PMN : 0/mmk
- MN : 3/mmk
Erythrocytes cells : 70/mmk
 LABORATORY EXAMINATIONS

MSCT Scan Kepala dengan Kontras (9 Mei 2019)

Kesan:
- Massa solid inhomogen bentuk lobulated pada intraventrikel lateral kiri dekat Foramen Monroe (ukuran ± AP 1,97 x LL 2,04 x
CC 1,93 cm)  curiga subependymal giant cell astrocytoma
- Multiple klasifikasi pada periventrikel lateral kanan kiri  mendukung gambaran tuberous sclerosis
- Hydrocephalus non communicans
- Tampak tanda tanda peningkatan tekanan intrakranial
 DIAGNOSIS
 increased intracranial pressure
 Hidrocephalus non communicans post VP Shunt ec SOL
intraventricular (H1)
 Tuberosclerosis
MANAGEMENT

IVFD RL 960/40ml/10tpm
Phenytoin Inj. 200mg/24hours
Dexamethason Inj. 10mg/6hours
IVFD Manitol 0,5gr/kgbw/8hours (150ml/8hours) give in 30
minutes
Per Oral:
- Valproic acid 375mg/8hours (20mg/kgbw/day)
- Acetazolamide 250mg/8hours (10mg/kgbw/day)
Programs
■ Head up 30o
■ Analgesic according to anesthesiologist division
■ BC/D/1 hour before mannitol, if BC ≤ -720ml 
replace RL 10cc/kgbw/hour
■ Free diet
■ Sit mobilization

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PROGNOSIS

Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam
Quo ad sanationam : dubia ad malam
 “
Thank you

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