8.

Susi susanti/2 month 12 days /110-29-68

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

Working Diagnosis
Management

Ct scan
Complete blood count
Transf prc 46cc