Professional Documents
Culture Documents
dr. Ama / dr. Dini/ dr. Rizki/ dr. Anto /dr. Lubna/ dr. Ahimsa
dr. Wulan / dr. Pitra
dr. Ika/ dr. Aya
1
PATIENT ADMISSION
Melati 2 ward
• Child Y, 17 yo, 52 kgs, with acute cephalgia due to migraine dd TTH; vomit
without dehydration, history of cytotoxic cerebral edema, wellnourished
• Child R, 10 yo, 28 kgs, with symptomatic generalized epilepsy,
hydrocephalus, wellnourished
PICU
Pediatric HCU
• Child A, 15 mo, 7.5 kgs, with acute rhino pharyngitis, palatoschisis pro repair 2
palatoplasty, treacher Collins syndrome, laringomalasia, undernourished
PATIENT IDENTITY
Name :R
Sex : Male
Age : 10 years old
Body weight / height : 23 kgs
Address : Sragen
Medical Record : 01461750
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Appearance
Tone : normal
Irritability : normal
Consolability : normal
Look : normal
Speech : normal
Appearance Work of Breathing
Normal Normal
Work of Breathing
Breath sound : normal PEDIATRIC
ASSESMENT
Positioning : normal TRIANGLE
Nasal flare :-
Retraction :-
Circulation
Circulation
Normal
Pallor :-
Cyanosis :-
Mottled :- 4
Bleeding :-
CHIEF COMPLAINT
seizure
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CURRENT MEDICAL HISTORY
Seizure at home 2 times, fever (-), all over the body, ± 5 minutes, seizure was
stopped without given drugs, after seizure, patient was fully alert
Patient was brought to Sragen Hospital and being hospitalized there for 5 days and
was given phenytoin IV
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CURRENT MEDICAL HISTORY
Seizure once in the morning, all over the body, ±2 minutes, seizure was stopped
without given drugs, after seizure, patient was fully alert
Headache (-)
Good appetite
Defecation and urination within normal
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CURRENT MEDICAL HISTORY
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PAST MEDICAL HISTORY
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FAMILY MEDICAL HISTORY
No history of epilepsy
No history of congenital defect
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PREGNANCY AND DELIVERY HISTORY
Patient eat 3 times per day, with diet rice packs. He also drinks milk 4
times per day. Patient eats chicken, meat, vegetables, tofu, and tempe.
Conclusion: quantity and quality were adequate
Conclusion:
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wellnourished, normoweight, normoheight
PEDIGREE
II
III
Child R, 10 yo
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PHYSICAL EXAMINATIONS
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Head : macrocephaly, head circumference 71 cm (> +2 SD of Nellhaus)
Eyes : pale conjunctiva (-/-), icteric sclera (-/-), isochoric pupils diameters 2
mm/2mm, light reflexes (+/+)
Nose : nasal flare (-) epistaxis (-)
Mouth : dry lips (-), cyanosis (-) gum bleeding (-)
Ear : discharge (-/-)
Neck : Enlargement of lymph node (-)
Thorax : symmetric (+), retraction (-),
LUNG:
I: normal, symmetric, retraction (-)
P: fremitus same in both side
P: sonor in both lungs
A: normal vesicular breathing sound,additional breathing sound (-/-), crackles (-/-)
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CARDIAC:
I : ictus cordis was not visible
P : ictus cordis was not palpable
P : cardiac enlargement (-)
A : 1st 2nd Heart sound normal intensity, regular, systolic murmur (-)
ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds normal limit
P: tympani (+),
P: tender, good skin turgor
liver : no enlargement
spleen : no enlargement
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EXTREMITIES:
Warm, capillary refill time < 2 sec, and dorsalis pedis artery was strongly palpable
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PHYSICAL EXAMINATION
Meningeal sign
Physiological reflexes - Nuchal rigidity -
- Biceps +2/+2
- Kernig’s sign -
- Triceps +2/+2
- Brudzinsky sign -
- Patella +2/+2
- Achilles +2/+2
Lateralization (-)
- Patella +3/+3
Clonus: -/-
Pathology reflexes
- Chaddock -/-
Motorics
- Oppenheim -/- 55555/55555
- Schaeffer -/- 55555/55555
- Gordon -/-
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- Babinski -/-
LABORATORY RESULTS MAY 18TH 2019
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LABORATORY RESULTS
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HEAD CT SCAN 18/05/19
1. Hydrocephalus communicans
2. Mega sisterna magna
3. Macrocephallus
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DIFFERENTIAL DIAGNOSIS
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WORKING DIAGNOSIS
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THERAPY
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PLAN
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MONITORING
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FOLLOW UP ON MAY 19TH , 2019
SUBJECTIVE
Seizure (-)
Fever (-)
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PHYSICAL EXAMINATIONS
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Head : macrocephaly, head circumference 71 cm (> +2 SD of Nellhaus)
Eyes : pale conjunctiva (-/-), icteric sclera (-/-), isochoric pupils diameters 2
mm/2mm, light reflexes (+/+)
Nose : nasal flare (-) epistaxis (-)
Mouth : dry lips (-), cyanosis (-) gum bleeding (-)
Ear : discharge (-/-)
Neck : Enlargement of lymph node (-)
Thorax : symmetric (+), retraction (-),
LUNG:
I: normal, symmetric, retraction (-)
P: fremitus same in both side
P: sonor in both lungs
A: normal vesicular breathing sound,additional breathing sound (-/-), crackles (-/-)
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CARDIAC:
I : ictus cordis was not visible
P : ictus cordis was not palpable
P : cardiac enlargement (-)
A : 1st 2nd Heart sound normal intensity, regular, systolic murmur (-)
ABDOMINAL:
I: abdominal wall equal to chest wall
A: peristaltic sounds normal limit
P: tympani (+),
P: tender, good skin turgor
liver : no enlargement
spleen : no enlargement
33
EXTREMITIES:
Warm, capillary refill time < 2 sec, and dorsalis pedis artery was strongly palpable
34
PHYSICAL EXAMINATION
Meningeal sign
Physiological reflexes - Nuchal rigidity -
- Biceps +2/+2
- Kernig’s sign -
- Triceps +2/+2
- Brudzinsky sign -
- Patella +2/+2
- Achilles +2/+2
Lateralization (-)
- Patella +3/+3
Clonus: -/-
Pathology reflexes
- Chaddock -/-
Motorics
- Oppenheim -/- 55555/55555
- Schaeffer -/- 55555/55555
- Gordon -/-
35
- Babinski -/-
WORKING DIAGNOSIS
36
THERAPY
37
PLAN
38
MONITORING
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