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2/13

DUTY REPORT

June 10, 2013


3/13

No Sub Division Old New Home Move Total

1 Infeksi

2 Respirologi

3 Gastrologi

4 Hepatologi

5 Neurologi

6 Gizi & met.

7 Allergi Imm.

8 Endokrin

9 Hemato

10 Nefrologi

11 Kardiologi

12 Perinatologi

13 PGD

14

15NICU

Klas I

Total


4/13

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 3minutes, 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


5/13

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


6/13

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, birthweight 3800gram, birth height forgot, directly cry

- History of grow distrubed and development wasnormal

- Basic imunization was complete

- Hygiene and sanitation was lacking.


7/13

General Examination

Conciousness AlertBP 90/60 mmHgHR 108 x/mntTemperature 38,8 CRR 26 x/mntGA ModerateBL

BW

81 cm

10 kgNutrition status Undernourished

W/A : 71,4%

H/A : 96,8%W/H : 76,9%

Sianosis NoneEdema NoneAnemis NoneIkterus None


8/13

Physical Examination

Skin WarmLymph node Not palpableHead Round, simetric, head circumference 50 cm (Normal

standard nellhaus)Eye Conjunctiva not anemic, sclera not icteric, pupil

diameter 2 mm, light reflex +/+ NEar In normal limit

Nose In normal limitThroat Tonsil T2-T2 hyperemic, detritus was not present,

cripti was not widening

Faring hyperemicNeck JVP difficult to examine

No neck rigidity


9/13

Lung I : normochest, simetric

P : fremitus right = left

P : sonor

A : vesikuler, no rhonchi, no wheezingHeart I : ictus not seenP : ictus palpable at LMCS RIC V

P : heart border difficult to examine

A : sinus rhytme, no murmurAbdomen Ins : no distention

Pal : Supel, liver and spleen was not palpablePer : timpani

Aus : peristaltic sounds (+) normalBack No abnormality


10/13

Genetalia In normal limit

puberty state: A1P1G1Anus rectal toucher was not performedExtremity warm acral, good refilling capiller

Fisiologis reflex +/+ normalPatologis reflex: -/- tanda rangsang meningeal

Babinsky -/- brudzinsky I negative

Chaddok -/- brudzinsky II negative

Gordon -/- kernig sign negative

Schoefer -/-

Oppenhaim -/-


11/13

Laboratorium

BloodHb 11,8 g/dlLeucocyte 12.700/mm3DC 0/0/16/46/31/4Metamyelocyte 2%Myelocyte 1%

URINEProtein -Reduksi -Leukosit -Eritrosit -Bilirubin

Urobilinogen -+FESES

Macroscopis yellowMikcoscopis Eritrocyte (-),

Leucocyte (-)


12/13

Diagnosis Complex febrile seizure

Acute tonsilofaringitis

Undernourished

Therapy Luminal 75 mg IM continued by

Luminal 2x45 mg po

Paracetamol 4x120 mg poSoft meal 1000 kcal


13/13

Morning Follow Up

Subjetif Objectis

Fever (+) not

high

No seizure

No vomit

Cough stillpresent

No

breathlessness

Mixturation

normal

Defecation

normal

moderate illl, alert

HR 106 x/mnt, RR 24 x/mnt,

T= 37,8C

eye : conjunctiva was anemic,

sclera was not ikterik

Thorax :no retractionCor : regular rhytm, no murmur

Pulmo : vesikuler, Rhales -/-, WH -

/-

Abd : distension(-), Intestinal

sound(+) N,

Ekstr : warm, perfusion is good,

Impresion ; febris

Luminal 2x45 mg po

Paracetamol 4x120

mg po

Soft meal 1000 kcal

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