No.

Name : Ch. MFR Sex : Male

Age : 11 mounths No. Reg : 671492

Chief complaint : Enlarged head

History taking : Suffered since 2 mounths before admitted to ER, the

proses is slowly. There were history of seizure once. No
history of vomiting.

Micturation : Normally

Defecation Normally
General Status
Moderate illness / well nourish / conscious

Vital Sign
PR : 108 x/mnt, strong, reguler,
RR : 24 x/mnt, symmetric L=R, thoracoabdominal
type.
T(Ax) : 37.4 °C
 Local Status
Cranial region
I : Seen enralged, dilatation of vascularitation
P : tenderness (-)
 Laboratory Result..........
WBC : 3.92 x 103 / μL

RBC : 4.87 x 106 / μL

HGB : 18.8 g/dL

HCT : 50.5%

PLT : 156 x103/ μL

CT / BT : 6‘00” / 2’00”

Blood Sugar : 283 mg/dl

Ureum : 29 mg/dl

Creatinin : 0,6 mg/dl

GOT / GPT : 42/7 μ/L

CT Scan
Kepala
AP Thorax
WORKING DIAGNOSIS : Hidrocephalus

MANAGEMENT : • IVFD
• Medicaments
• Report to senior Neuro surgery
advice : plan for VP shunt