The Status Of Child Health Science

Medical Faculty of Unswagati

General Hospital of district Waled
Name
Number Id
Examiner

Identity
Name of patient
Age
Sex
Religion
Name of fathers
Age
Level Education
Occupation
Mother's name
Age
Education
Occupation
Address

: Abdul Mazid Zabir

: 110170001
:

: An. M J
No. MR
:
: 9 y.o
Date Of Admission : 12/06/2015
: Female
Date Of Examination : 12/06/2015
: Islam
: Tn.T
: 33 y.o
: Senior High school
: Traders
: Ny. N
: 28 y.o
: Junior High School
: Housewife
: Babakan wetan Rt. / Kab.Cirebon

Anamnesis
Chief Complain
Control Of Epilepsy
History of present illness
Patients come to the hospital Waled poly child escorted by her parents to control
epilepsy, patients with a diagnosis of epilepsy has been in since the month of February
2015 and has been done with the results of abnormal EEG, patients have to take
medication valproic acid syrup 2 x 9 cc for 1 month. According to his parents seizure last
5 hours before entering the hospital, and two days before entering the hospital, patients
also experience seizures. patients have seizures if people feel shocked and exhausted, the
last convulsions occurred three times with less than 5 minutes long. Seizures when
patients are not aware, eyes bulging upward, arms and legs stiff. Before the seizure patient
still conscious, patient seizure before going to want to see a black shadow, light spots and
paused. After the seizure the patient remains conscious, looked confused and exhausted.
This complaint is accompanied by headache front, intermittent headache, pain such as in
the puncture, the pain is not to interfere with their activities.
This complaint is not accompanied by a loss of consciousness, fever, cough, a cold,
breathlessness, nausea, and vomiting. Urination and defecation no complaints. During this
routine patient to control the child poly Waled hospitals and seizures take medication
regularly.
Formerly Disease history
- History of febrile seizures at the age of 1 and 2 years.
- History of head trauma denied

Family history of disease

- History of epilepsy in the family denies
- History of seizures with or without fever denied
Medical history
Treatment history of the month of February 2015 until now with the drug valproic acid
syrup (40 mg / kg / day) - 2 x 9 cc for 1 month.
History Growth and Development
A history of growth and development together with children his age.
- (2-3 months) looking up
- (4-5 months) lying flat on
- (7 months) sitting
- (9 months) stand
- (12 months) goes
Immunization history
According to his family of five are fully immunized. BCG scar marks there.
History Pregnancy and Birth
Prenatal
During a routine control of pregnant mothers with pregnancy in a local midwife, do not get
sick and do not take drugs or herbs.
Perinatal and Postnatal
Patients born to mothers P1A0, birth assisted by midwives, immediately cried weighing 3
kilograms and amniotic clear. Not experiencing premature rupture of membranes, no
bleeding pervaginum. Yellow history at the time of the baby denied. Patients were given
exclusive breastfeeding for 2 years.
Social history, economics and education
Patients in a family of middle-income parents Rp. 1,500,000., / Month. Patients sitting in
the class 2 elementary school, can attend classes as usual, do not stay in the classroom
and the achievement of the average patient.
3. Physical examination
General Apperance : Good
Awareness
: E4 M5 V6 Composmentis (Alert)
Vital signs
Blood pressure
Pulse
Respiratory
Temperature

: 100/80 mmHg
: 24 x / min
: 80x / min
: 36.7 C

Anthropometric status
Weight
: 21 Kg
Height
: 130 Cm

Nutritional Status
WFA
:
HFA
:
WFH
:
BMI / A
:
Generalists Status
Head
Normochepal shape, color black hair and not easily unplug it, conjungtiva not anemic,
sclera no jaundice
Ear
Symmetrical shape, no tenderness tragus and antitragus, less serumen, intact tympanic
membrane and not bulging.
Nose
Symmetrical shape, there is no deviation, no discharge, and no nasal flaring.
Mouth
Lips: not dry, no cyanosis, not pale
Tongue: no deviation, no dirty, and no hyperemia
Symmetrical uvula, tonsils T1T1 and no hyperemia
Neck
No deviation, no lymphadenopathy, and no enlargement of the thyroid gland.
Thorax
I: symmetry, chest wall movement nothing is left behind
P: tenderness absent, vocals symmetrical fremitus
P: resonant throughout the lung fields
A: Pulmo: Vesicular Breath Sound throughout the lung fields, no wheezing, no crackles,
and no slam.
Cor: s1 s2 reguler, no murmur, and no gallop.
Abdomen
I : soft, not epigastric retraction
A : normal bowel sound
P : tympanic sound
P : non distended, non tenderness, hepar and spleen non is palpable
Neurologic Status
Meningeal Reflex : Neck Stiffness (), brudzinsky I/II/III -/-/Cranial Nerve
: pupil is round, 3 mm, isochor, direct +/+, indirect +/+, symmetric
eye movment, facial symmetric.
Fisiologis Reflex : APR +/+ KPR +/+ normal
Patology Reflex : Babinski -/-, chaddock -/-, gordon -/-, gonda -/Motor
: no impression of parase
Sensory
: of painfull stimuli (+)

4. Further Diagnostic
Abnormal EEG results
5. Diagnosis
Epilepsy
6. Management
Non Medikamentosa
- Drinking seizure medication routine until 2-4 years seizure-free, if the free drug seizures
will be slowly lowered her dose up to 6 months.
- If the patient seizure, should not be given a drink or any
- Never leave a child alone in a dangerous place.
Medikamentosa
Valproate acid (45 mg / kgweight / day) = 2 x 9.4 cc