Morning Report

Saturday Morning, April 20 th

2019

AJK/SYT/KHI/MUB
No Name Gender Age Working
Diagnosis
Complex Seizure
Fever
1. MAP Boy 8 years 5 month
Undifferential Fever

3
1
New Patient of Emergency Unit at 11.45 PM, MAP,
Boy, 8 years 5 months,
BW: 25 kg BH : 140 cm
W/A: 92,5 % H/A : 106 % W/H :75,7 %(Moderate
Malnutrition)
Chief complain : Seizure
- It was experienced 10 minutes before admitted to
adam malik hospital, frequency 1 time, duration >
10 minutes, the seizure tend to be general, upward
rolling eyes. Seizure was trigered by fever, after
seizure patient was unconscious. Before that,
patient had seizure at home frequency 1 time,
duration > 5 minutes
- Fever was experienced since 1 day ago, high
temperature, decreased by paracetamol.
- History of seizure when the patient < 1 year at 6
years old, seizure trigerred by fever.
 - Reddish spot was found on chin
- History of spontan bleeding (epistaksis, gum
bleeding, melena) was not found
- Cough and cold was not found
- History of trauma was not found
- Urination and defecation was normal
- History of family members and neighbor have dengue
fever was not found
- History of illnes:
- Patient always absence according to his
mother
• History of medication
– Paracetamol
Physical Examination
General status :
Sensorium: Compos Mentis Temperature : 38,6oC
Anemis (-) Dyspnoe (-) Cyanosis (-) Edema (-)
Icteric (-)

Localized status:
Eye : Light reflexes (+/+), isochoric pupil Ø3mm/3mm,
pale inferior palpebral conjunctiva (-/-), icteric sclera
(-/-)
Ear : Within normal limit
Nose : Nasal flare (-), O2 nasal canule 1 lpm
Mouth: Laceration on tongue dextra, T1/T1, not hiperemis
Neck : within normal limit
Thorax : Symmetric Fusiform, retraction (-)
Heart rate : 100 bpm, regular, murmur (-)
Respiratory rate : 22 breaths/minute, regular,rales(-),
wheezing (-)
Abdomen : Peristaltic sound (+) normal,soepel, liver and
spleen was not palpable
Extremities : Pulse 100 bpm, regular, warm extremities, CRT<
2”, cyanosis (-),
edema (-), Blood pressure 90/60mmHg
Physiology reflex: APR / KPR normal
Pathological refrex : Babinsky (-), Gordon (-),
Oppenheim (-)
Meningeal sign : Kernig (-), Brudzinsky II (-/-)
Rumple leed test (+)
 Laboratory Result from Adam
Malik Hospital 20th April 2019
Eosinofil/Basofil
Hb : 11,5 gr/dL /Neutrofil/Limfosit/Monosit/
Ht : 34 % 0 /0,1 /86 /85,1
Leuko : 7.210 /μL /8
Tromb : 224.000/μL
Ca : 8,5
Na : 130
MCV : 79 fL K : 3,9
MCH : 28,6 pg Cl : 99
MCHC : 33,1 g/dL
GDS : 131 mg/dL

Dengue Ns1Ag : positif

Differential diagnosis
Complex Seizure Fever
Undifferential Fever

Working diagnosis
Complex Seizure Fever
Undifferential Fever

Therapy
IVFD D5% NaCl 0,45% 65 cc/hr micro
Diazepam suppositoria 10mg (if seizure happen)
Paracetamol : 3 x 250 mg
Terima kasih