CLINICAL CONFERENCE

Neurology Division
(New Case)
July 31th, 2023

Dody Abdullah Attamimi/ Presenter

Dhody Setiamal, Rima Khairunnisa, Cahya Kamila Bausat/Madya
Irfadah Dinar,Clara K Parannuan, Dina Fadhilah Monica/Senior
 PATIENT IDENTITY

A. A. 1 years 9 Months old, girl

MR Number 10340821
Date of Birth November 18th, 2021
Admission Date August 29th 2023

MEDICAL DIAGNOSIS

Post Seizure et causa suspected epilepsy

Patient’s picture
 HISTORY TAKING
Chief Complain
Seizure

History of Present illness

A Girl 1 years 9 months old with chief complaints of seizure experienced 6 hours before admitted to the hospital, frequency
2 times, with duration of < 5 minutes for every seizure, Generalized Seizure ,after seizure the child sleep. The seizure was
not preceded by fever.
No cough, no shortness of breath
No vomiting
Good appetite
Urinatiion and defecation within normal limit
History of Past Ilness

- History of seizures for the first time at the age of 4 months, frequency 1 time in 1 day, seizure duration was
< 1 minute, general seizure, and seizure was preceded by fever.
- No history of the same disease in the family.
- History of febrile seizure in family (patient aunt)
- No History of epilepsy in family
- There was history of head trauma at the age of 4 months,history of falling while playing on a swing
- History of controlled routinely at children's polyclinic Luwuk Hospital and received anti-epileptic drug
phenytoin at a dose of 25 mg/12 hours/oral for 1 year then increased 30 mg/12 hours/orally for 1 month
 History of Vaccination
MONTH YEARS
Vaccine
NOT
YET 0 1 2 3 4 6 7 8 9 12 15 18 24 3 5 6 7 8 11
GIVEN

Hep B v v v v

BCG V

DPT v v V

Hib v v V

OPV v v v v

IPV V

Measles v

PCV V

Rotavirus V

Japanese V
Encephalitis
Influenza V

Varicella V

Hepatitis A V

Tifoid V

Covid-19 v v
 PHYSICAL EXAMINATION
Vital Sign Anthropometry
General condition :
Body Weight: 10 kg
Moderately ill /well nourished /Compos Mentis GCS 15
E4M6V5 Body Height: 83 cm

Pulse: 110 beats/minute Head circumfrences : 49 cm (Normal range : 46-51 cm)

Breath : 22 times/minute
Temperature: 36.8 Celsius Body weight / Age = Between -2SD and Median (Normal
Pain Scale of FLACC : 1 Bodyweight)
SpO2 : 100 % via room air Height/ Age = Between -2SD and Median (Normal Stature)
Weight/Height = Between -2 SD and -1 SD = 88.5% (well
nourished)
Head Circumference: 49 cm (normocephal)
(Normal range : 46-51 cm)
Body weight / Age = Between -2SD and
Median (Normal Bodyweight)
Height/ Age = Between -2SD and Median
(Normal Stature)
Weight/Height = Between -2 SD and -1
SD = (well nourished)

No pale, no jaundice
No lymphadenopathy
Pharynx not hyperemic
Tonsil T1-T1 not hyperemic
Lung :
Inspection: Symmetric, no retraction
Palpation: vocal fremitus was normal
Percussion: Sonor
Auscultation: Vesicular breath sound
No Ronchi, No wheezing
PHYSICAL EXAMINATION
Heart :
Inspection: ictus cordis not visible
Palpation: no thrill
Percussion: normal cor
Auscultation: normal heart sound, no murmur
Abdomen :
Inspection: flat, following the breath movement
Auscultation: peristaltic was normal
Percussion: tympani
Palpation: no tenderness, hepar and lien was not palpable.
Extremities:
Warm extremities, CRT<2 seconds
 Neurological Status

Awareness: Glasgow comma scale 15 (E4M6V5)

Cranial nerves
Nervus I: Normal Signs of meningeal irritation: no neck stiffness
Nervus II: isochor, pupil 2.5mm/2.5mm diameter, Positive Motor :Tonus: normal
light reflex/positive Muscular strength: normal
Nervus III, IV, VI: movement of the eyeball within normal Physiological reflex: normal impression
limits Pathological reflexes: negative babinsky, negative clonus
Nervus V: positive corneal reflex Sensibility and the Autonomic Nervous System are normal
Nervus VII: parese facialis absent
Nervus VIII: hearing and balance was normal
Nervus IX, X, XI: no swallowing reflex
Nervus XII: no tongue deviation
 LABORATORY FINDING
Wahidin Sudirohusodo Hospital
Laboratory (August 28th, 2023)
Normal Value

Hb 12.4 11,0-14,0 gr/dL

MCV 76 80 -100 μm3
MCH 29 27 - 32 Pg
WBC 8700 6.0 – 17.0 x 103/μL
PLT 354.000 150 - 400 /mm3
NEUT 28.3 52 – 75 103/μL
LYMPH 60.0 20 – 40 103/μL
MONO 7.0 2 – 8 103/μL
Sodium 136 136-145
Potassium 5.1 3,5-5,7
Chloride 106 97-111
 Assessment

• Seizure
 Working Diagnosis

• Post seizure et causa suspect epilepsy

 TREATMENT

- Daily fluid requirements

Holiday Segar = 1000 cc / 24 hours
-enteral : 6x100 cc
- parenteral : infusion Dextrosa 5% 16.5 cc/hour/intravenous
- Phenytoin loading dose 10 mg/kgBB = 100 mg/intravenous (if seizure)
- Phenytoin dose of 5 mg/kgbb/intravenous = 25 mg/12hours/intravenous
- Valproat acid 15 mg/Bw
- = 1,5 cc/12 hours/oral
 PLANNING

- Electroencephalography
THANK YOU