CASE CONFERENCE

Wednesday, 21st March 2018

dr. Disa
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IDENTITY
Name J
Age/Weight 2 yrs 9 mo/12 kg/
Sex Male
Address Pasar Kliwon, Surakarta
Medical Record No. 01412928
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CHIEF COMPLAINT

SEIZURE
 HISTORY OF
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PRESENT ILLNESS
• Patient experienced low-grade fever, temperature was increasing by time
• Parent had administered the patient with antipyretic
• Fever accompanied by cough and flu since 3 days prior to admission
• Decreased appetite and water intake
• Passes stool once a day, soft, brownish yellow, no mucous
• Fever and cough was not resolving, patient was brought to a midwife.
Patient was prescribed with antipyretic and powdered cough medicine

1 day prior to
admission
 HISTORY OF
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PRESENT ILLNESS

• High fever persists, seizure occurred.

• Seizure lasted less than a minute, body stiffened, eyes rolled upward,
unconscious.
• Seizure then ceased itself, patients started crying.
• Patient was brought to ER.

30 mins prior to
admission
 HISTORY OF
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PRESENT ILLNESS

• No seizure
• Full consciousness, irritable
• Fever (+), no vomiting

At the RSDM ER
 HISTORY OF PAST
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ILLNESS
• Previous history of seizure: denied

HISTORY OF FAMILY
ILLNESS
• Previous history of seizure: denied
• Previous history of cough: denied
 PHYSICAL EXAMINATION HC: 50 cm, mesocephal
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Nasal flaring (-), discharge (+/+)
Isochoric pupil
Appeared in moderate Ear discharge (-/-) (2mm/2mm), pupillary
distress, E4V5M6 reflex (+/+), anemic
HR: 132 bpm Dry mouth (-), conjunctiva (-/-), scleral
RR: 28 bpm tonsillopharyngeal redness icterus (-/-), tears (+/+),
(+), T2-T2, widened crypts sunken eyes (-/-)
T: 38.6oC (+), detritus (-)
Node enlargement (+)
Chest retraction (-) right anterior region, 1
Centor Scoring
cm x 1 cm x 1 cm,
Normal int. 1st and 2nd mobile, painless
Age 0
heart sound, murmur (-)
Node enlargement (+) 1 Vesicular (+/+),
Supple, normal bowel
Cough (+) 1 adventitious breath
sound, tympanic, no
Fever > 380C 1 sound (-/-)
hepatosplenomegaly
Tonsillitis 1
Warm extremities (+/+//+/+), strong ADP pulses, CRT < 2 secs
 NEUROLOGICAL EXAMINATION
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Physiological reflexes Meningeal signs

Biceps +2/+2 Nuchal rigidity +2/+2
Triceps +2/+2 Brudzinski I/II +2/+2
Patellar +2/+2 Kernig +2/+2
Achilles +2/+2

Pathological reflexes
Babinski (-) Motoric function Sensory function:
Oppenheim (-) 5555|5555 cannot be evaluated
5555|5555
Schaeffer (-)
Gordon (-)
 LABORATORY WORK-UP (21/03/18)
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Test Results Reference Range
Hb 11.2 g/dl 11.5 – 13.5
Hct 33 % 34 – 40
AL 8.5 Rb/ul 5.5 – 17.0
AT 243 Rb/ul 150 - 450
AE 4.23 Rb/ul 3.90 - 5.30
MCV 78.4 /um 80.0-96.0
MCH 26.5 Pg 28.0-33.0
MCHC 33.7 g/dl 33.0-36.0
RDW 11.9 % 11.6-14.6
MPV 8.4 Fl 7.2-11.1
PDW 16 % 25-65
 LABORATORY WORK-UP (continued)
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Eosinophils 0.40 % 1.00 – 2.00

Basophils 0.70 % 0.00-1.00
Neutrophils 63.30 % 29.00 – 72.00
Lymphocytes 26.80 % 60.00-66.00
Monocytes 8.80 % 0.00-6.00
Blood sugar 104 mg/dL 60-100
Na 138 Mmol/L 132-145
K 4.0 Mmol/L 3.1-5.1
Cl 104 Mmol/L 98-106
Ca 1.14 Mmol/L 1.17-1.29
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ASSESSMENT
1. Simple febrile seizure
2. Acute exacerbation of chronic tonsillopharyngitis
3. Undernourished (clinical)
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TREATMENT
1. Admitted to pediatric neurological ward
2. Pureed rice diet 1100 kcal daily
3. IVFD D5 ¼ NS 46 cc/hr (maintenance)
4. Paracetamol inj. (15 mg/kg/8 hrs) = 180 mg/8 hours
5. Diazepam inj. (0.3 mg/kg/inj) = 3.5 mg slow IV bolus (prn,
when seizure)
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PLANNING
• Urinalysis
• Routine fecal test
• Throat swab culture

MONITORING
• General appearance/vital signs every 4 hrs
• Fluid balance and diuresis every 8 hrs
• Seizure reccurences