DUTY REPORT June 10, 2013

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Sub Division Infeksi

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Respirologi
Gastrologi Hepatologi Neurologi Gizi & met. Allergi Imm. Endokrin Hemato Nefrologi Kardiologi Perinatologi

PGD
NICU Klas I Total

J, Boy, 2 8/12 years old,

Chief Complain : repeated seizure since 4 hours ago

Present illnes history: - Cough since 1 day ago, no mucous, not following with cold and breathlessness - Fever since 5 hours ago, high, continuing, no shivering, no sweating - Repeated seizure since 4 hours ago, frequency 3x, duration 3 minutes, interval 1 hour, seizure all part of the body, both eyes look up, he concious after seizure, this is the first seizure - No vomitus - No history of head trauma - No history of liquid come from ears - Mixturation and defecation are normal

 He had been brought to clinic 4 hours ago, had been given anti convulsant drug through anus, and syrup for fever, then he suggested to be hospitalized in hospital In emergency room M Djamil Hospital, he got seizure 1x, and got stesolid supp I

Past illnes history: Never suffer seizure with or without fever before Family illnes history: No family member suffer seizure with or without fever

Sosioeconomic history
- 7th son from 7 siblings, normal delivery, mature, birth weight 3800gram, birth height forgot, directly cry - History of grow distrubed and development was normal - Basic imunization was complete - Hygiene and sanitation was lacking.

General Examination
Conciousness
BP HR Alert 90/60 mmHg 108 x/mnt

Temperature
RR GA BL BW

38,8 C
26 x/mnt Moderate 81 cm 10 kg

Nutrition status

Undernourished W/A : 71,4% H/A : 96,8% W/H : 76,9%

None None None None

Sianosis Edema Anemis Ikterus

Physical Examination
Skin Lymph node Head Eye Ear Nose Throat Warm Not palpable Round, simetric, head circumference 50 cm (Normal standard nellhaus) Conjunctiva not anemic, sclera not icteric, pupil diameter 2 mm, light reflex +/+ N In normal limit In normal limit Tonsil T2-T2 hyperemic, detritus was not present, cripti was not widening Faring hyperemic

Neck

JVP difficult to examine No neck rigidity

Lung

I P P A

: normochest, simetric : fremitus right = left : sonor : vesikuler, no rhonchi, no wheezing

Heart

I P P A

: ictus not seen : ictus palpable at LMCS RIC V : heart border difficult to examine : sinus rhytme, no murmur

Abdomen

Ins : no distention Pal : Supel, liver and spleen was not palpable Per : timpani Aus : peristaltic sounds (+) normal No abnormality

Back

Genetalia

In normal limit puberty state: A1P1G1

Anus Extremity

rectal toucher was not performed warm acral, good refilling capiller Fisiologis reflex +/+ normal
Patologis reflex: -/Babinsky -/Chaddok -/Gordon -/Schoefer -/Oppenhaim -/tanda rangsang meningeal brudzinsky I negative brudzinsky II negative kernig sign negative

Laboratorium
URINE
Protein +

Blood
Hb Leucocyte DC Metamyelocyte Myelocyte 11,8 g/dl 12.700/mm3 0/0/16/46/31/4 2% 1%

Reduksi Leukosit Eritrosit Bilirubin Urobilinogen Macroscopis Mikcoscopis

FESES
yellow Eritrocyte (-), Leucocyte (-)

Diagnosis

Therapy

Complex febrile seizure Acute tonsilofaringitis Undernourished Luminal 75 mg IM continued by Luminal 2x45 mg po Paracetamol 4x120 mg po Soft meal 1000 kcal

Morning Follow Up Subjetif Objectis

Fever (+) not high

No seizure

moderate illl, HR 106 x/mnt, T= 37,8C

alert RR 24 x/mnt,

No vomit
Cough still present No breathlessness Mixturation normal Defecation normal

eye : conjunctiva was anemic, sclera was not ikterik Thorax :no retraction Cor : regular rhytm, no murmur Pulmo : vesikuler, Rhales -/-, WH /-

Luminal 2x45 mg po Paracetamol 4x120 mg po Soft meal 1000 kcal

Abd : distension(-), Intestinal sound(+) N, Ekstr : warm, perfusion is good, Impresion ; febris