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

1
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: (-)

2
I. Patient Identity
Name :A
Sex : girl
Age : 5 years old
Addresses : Mojolaban, Sukoharjo
Medical record : 01368866
Weight/Height : 15 kg

3
II. Chief Complaint

Seizure

4
 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 5
can communicate fluently.
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

6
VI. Pregnancy and Laboured History

During pregnancy, her mother routinely checked

her pregnancy to midwife. She was given vitamin,
and she didnt 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

7
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 Healths vaccination
schedule 2012

8
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 9
her age
 POHON KELUARGA

II

III

10

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
Nuchal rigidity ()
Physiological reflexes Kernigs sign ()
- Biceps +2/+2 Brudzinsky sign ()
- Triceps +2/+2
Cranialis nerve examination :
- Patella +2/+2 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 -/-
NX :vomit reflex +
- Gordon -/- N XI : lift shoulder +/+ 13
- Babinski -/- N. XII : tongue motoric +/+
 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

14
XIII. Laboratory Findings (Feb 9th , 2017)
Hb : 11.0 g/dl Blood sugar :
HCT : 35% 95mg/dl
AL : 11.3 thousand/ul Sodium :
AT : 321 thousand/ 135mmol/L
ul Potassium :
AE : 4.06 mil/ul 3.9mmol/L
MCV : 85/um Chloride : 98mmol/L
MCH : 27.1 pg
Calcium :
MCHC : 31.9 g/dl
1.07mmo/L
Netrofil : 76.9%
Limosit : 16.10%
Monosit : 6.1 %
Conclusion : within 15
normal range
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
6. Fully alert
7. Body temp of 37.00C
8. No neurological examination abnormalities

Laboratory findings within normal range 16

Differential Diagnose
First unprovoked seizure due to :
DD imbalance electrolyte
DD epilepsy
Well nourished, underweight, normoheight

17
Working Diagnose
First unprovoked seizure due to epilepsy
Well nourished

18
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 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
19
. Electroencephalogram
. Lumbal Puncture
.
FOLLOW UP (February 10 th

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
Nuchal rigidity ()
Physiological reflexes Kernigs sign ()
- Biceps +2/+2 Brudzinsky sign ()
- Triceps +2/+2
Cranialis nerve examination :
- Patella +2/+2 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 -/-
NX :vomit reflex +
- Gordon -/- N XI : lift shoulder +/+ 22
- Babinski -/- N. XII : tongue motoric +/+
Working Diagnose
First unprovoked seizure due to epilepsy
Well nourished

23
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 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 24
. Brain MS-CT
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