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This document contains a medical case summary for a 2 month, 12 day old patient named Susi susanti who presented with decreased consciousness and seizures. The patient's history includes being born prematurely at 7 months gestation via c-section and having previous hospitalizations, including for seizures. On examination, the patient's vital signs were abnormal and her fontanelle appeared enlarged. Laboratory findings showed anemia. The working diagnosis is for further evaluation and the patient received a CT scan, blood tests, and a blood transfusion.
This document contains a medical case summary for a 2 month, 12 day old patient named Susi susanti who presented with decreased consciousness and seizures. The patient's history includes being born prematurely at 7 months gestation via c-section and having previous hospitalizations, including for seizures. On examination, the patient's vital signs were abnormal and her fontanelle appeared enlarged. Laboratory findings showed anemia. The working diagnosis is for further evaluation and the patient received a CT scan, blood tests, and a blood transfusion.
This document contains a medical case summary for a 2 month, 12 day old patient named Susi susanti who presented with decreased consciousness and seizures. The patient's history includes being born prematurely at 7 months gestation via c-section and having previous hospitalizations, including for seizures. On examination, the patient's vital signs were abnormal and her fontanelle appeared enlarged. Laboratory findings showed anemia. The working diagnosis is for further evaluation and the patient received a CT scan, blood tests, and a blood transfusion.
Chief complain: decreased of consciousness and seizure History : 1 days ago her mother complaint the patient look ill and dont cry, before that, patient was born via sectio caesaria when week of pregnancy 7 month. After that, patient was hospitalized and care one week with incubator. One month after that patient take care in hospital, she got seizure and she hospitalize again.. Birth status Born via SC she was born premature Physical Examination Vital sign :
HR = 120 times/minute RR = 60 times/minute BT = 37.8C Primary Survey Eyes : Anemic conjunctivae (-), icteric sclerae (-) Nose : Epistacsis (-) Mouth : Moist mucosa Neck : No lymph nodes enlargementmen, torticolis (-) a/r chepalis: fontanella looks enlarge Head/Neck I : Symmetric respiratory movement, vertebra within normal limit A : Symmetric VBS, no rhonchi, no wheezing Thorax I : quiet distended, inflamation umbilicus (-) P : soft, no mass palpable, hepar and lien palpable A : bowel sound (+) Abdomen Felt warm on both upper and lower extremities, no oedem, no paralysis, no congenital abnormality Extremities Clinical picture Laboratory Findings Hb = 6.8 g/dL WBC = 4.02 /uL RBC = 2.23 mil/uL Ht = 58.7 vol% Trom: 166 rb/ul Gds: 43 mg/dl