IDENTITY OF PATIENT

– Name : Baby Mrs. Maria

– Sex : Male
– Age : 1 month
– No. MR : 524308
ANAMNESIS

– Chief Complain : seizure

– History of disease : patient comes in by
his mother with complaints of seizures.
The patient’s mother said the seizure had
taken 4 times, since morning. This
complaint has been going on for a long
time. Vomiting (-), fever (-).
PHISYCAL EXAMINATION

– General state : Moderate illness

– GCS : E4M6V5
– Heart Rate : 115x/minute
– RR : 44 x per minute
–S : 37,5 C
 SECONDARY SURVEY
Head : Normocephal, There is a former operating stitch and
bandaged on temporoparietal dextra . Bleeding (-),
Swelling (-),
Eye : Anemic conjungtive (-/-), icteric sclera(-/-), sunset eye
fenomena (-)
Ear : Otorhagia (-/-)
Nose : Rhinorea (-/-)
Mouth : Pale (-) ,cyanosis (-)
Neck : Palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : Symmetrical chest expansion
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultation : Vesikuler (+/+) Ronchi (-/-), Wheezing (-/-)
Abdomen:
– Inspection : convex
– Ausculation : bowel sound (+) normal
– Palpation : supel
– Percussion : timpanic

Extremities:
– Warm
– edema (-/-)
– CRT < 2 sec
Laboratorium

LAB 7 Januari 2020

HB 10,3gr/dL

WBC 11,02x103/uL

RBC 3,64x103/uL

Hematokrit 30,9%x103/uL

Neutrofil 55,4x103/uL

Limfosit 4,03x103/uL

Trombosit 386 x103/uL

ASSESMENT

Post VP shunt ec Congenital hidrocephalus

( POD 4 )
PLANNING

Planning S.BS Planning Sp.A

 Obs. Gcs TNRS  Paracetamol syrp 4x1/2

 Head Up 30  If T >38 give pamol supp
 Wound care ½ dari 125mg
 Cefixim 2x1/4
 Phenitoin 3x6mg
 Diazepam 2mg (if
seizure)
10 Identity of patient

• Name : Ms. A
• Sex : Female
• Age : 1 years old
• No MR : 52 00 12
 11 Anamnesis

– Chief complain : Decrease of conciousness

– History of disease:
A referral patient from a Malaka hospital with a decline in
consciousness since January 5, 2020. The complaint begins
with seizures and high fever since 1 day earlier. Cough and
cold complaints are already 3 weeks.
– Current complaints: fever (+), Seizures (+)
PHISYCAL EXAMINATION

General State : moderate ilness

GCS : E4V5M6
BP : 100/60 mmHg
T : 37,8⁰ C
HR : 140x/m
RR : 45x/m
SpO2 : 100% with O2 Nasal
 Secondary survey
Head : Normocephal
Eye : Palpebra hematom (-/-) anemic conjungtive(-/-), icteric
sclera(-/-), bruise (-/-)

Ear : otorhagia (-/-)

Nose : Rhinorea (-/-), blood (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion , lesion (-) bruise (-) wound (-)
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultasi : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
Abdomen:
– Inspection : flat, symetric,
– Ausculation : bowel sound (+) normal
– Palpation : Supel, organomegaly (-)
– Percussion : Tympanic
Extremities:
– Warm
– edema (-/-)
– CRT < 2 sec
Laboratorium

Hasil Lab ( 7 Januari 2020 ) Elektrolit

HB 8,0 Natrium 139

Wbc 21,41
Kalium 4,5
RBC 4,41
Klorida 102
Hematoktit 25,6
Calsium Ion 1300
Neutrofil 59,6 x103/uL

GDS 92 Total Calcium 2,7

 Assesment

– SOL Pineal Regional

Planning

Planning Sp.BS Planning Sp.A

• Observasi TNRS • O2 2 lpm

• O2 2 lpm • Ivfd D5 ¼ Ns 800cc/24 jam
• Using NGT and catheter • Inj. Ceftriaxone 2x400
• Manitol 4x50cc • Inj. Dexametazon 3x1 ml
• Phenitoin 2x20mg
• Paracetamol 4x100mg
• Ranitidin 2x8 Mg
THANK YOU