Morning Report

Thursday, April 26st 2018

RIA/ARB/LII
No Name Gender/Age Working Diagnosis
1 TKA Girl/2 years 10 Simple febrile seizure ec
months acute tonsilofaringitis
1
New Patient of emergency room at 08.35 pm, TKA, girl, 2
years 10months, address: Stella raya street, Medan
BW : 13,4 kg, BL : 94 cm
W/A : 0<SD<2 H/A: 0<SD<2 W/H: -1<SD<0

Chief complain : seizure

History of disease:
- Seizure was happen ± a hour ago with opened eyes
and stomped hands and feet, one time, < 5 minutes,
fever when convulsion (+), awake after convulsion (+)
History of seizure month ago.
- Fever (+) 2 day before admisson, high grade fever and
relief by drug. She was still fever at emergency room
- Cough (-), cold (-)
- Nausea (-), vomit (-)
- Urinary and defecation were normal
History of previous illness :
None

History of previous medication :

Sanmol drop 1,2 cc
Stesolid rectal 10 mg (1x)

History of family :
Her mother had the history of febrile seizure

History of growth and development :

Normal

History of immunization :
Corresponding her ages
Physical Examination
General status :
Alertness : GCS CM Temperature : 38,6 C
dyspnoe (-), cyanosis (-), edema (-), icteric (-), anemis (-)

Localized status:
Head : Eye : isochoric pupil Ø3mm/3mm, sekret (-/-)
Ear/nose/mouth : nose flare (-), tonsil T2-T2
hyperemis, eksudat (-)

Neck : node enlargement (-)

Thorax : Symmetrical fusiform, no retraction
Heart rate : 120 beat/minute, regular, murmur (-)
Respiratory rate : 22 times/minute, regular, stridor
(-/-)
Abdomen : soft, peristaltic sound (+), no palpable liver and
spleen
Extremities : warm extremities, pulse 120 bpm, regular,
capillary refill time (CRT) < 3 second
Different diagnosis
Simple febrile sizure ec - Acute tonsilofaringitis
- Viral Infection

Working diagnosis :
Simple febrile seizure ec Acute tonsilofaringitis
Therapy :
• Paracetamol 4 x 1,5 cth
• Diazepam rectal tube 10 mg when seizure
• Outpatient
Time Sens HR RR Sat. Temp Additional
(pm) (bpm) (tpm) O2
(%)
21.00 CM 118 28 98 38,4
Education

22.00 CM 110 23 99 38 Observation

23.00 CM 92 20 99 37,1 outpatient