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Morning report

Friday 14th August 2015

ER
: dr. Maria
Consultant : dr. Marthin
Stroke unit : dr. Putri
Ward
: dr. April dr Harris
Tandem : dr. Fathul - dr. Ramon

PATIENTS IDENTITY
Name
: Mrs. M
Age
: 70 yo
Gender
: Female
Occupation
: Unemployment
MR Number
: C542224
Hospital admission : 14th Augustus 2015

HISTORY (alloanamnesis)

Chief complaint : Seizure

Onset

: 2 weeks before hospital


admission

Quality

: tonic clonic seizure

Quantity

: ADL partly assisted by family

HISTORY

Chronolgy :
2 weeks before hospital admission, pt was having tonic clonic
seizure with eye drill upward, about 2-3 minutes, when it happen and
after that ps still conscious, seizure about to happen 8 times a day.
Her child told that ps difficult to swallow and lost of appetite. Nausea
(+), Vomit (-), Fever (-). Patient brought to Panti Wilasa Hospital and
being hospitalize about 4 days.
6 months before hospital admission ps diagnose with cervix carcinoma,
with history of vaginal bleeding for years.

HISTORY

Aggravated Factors : (-)

Extenuated Factors : (-)

Concomitant Symptoms : swallowing


difficulties, lost of apetite

HISTORY

Past Medical History


- 6 mo prior, pt diagnose from cervix cancer.
- no history of, hypertention, diabetes, heart disease, and
stroke

Family Disease History : no history of hypertension,


diabetes, heart disease, and stroke

Social Economic-Status And Personal History : pt works


as gold gilder. Pt has 5 children.

CLINICAL FINDINGS
Present States
General appearences
GCS
: E4M6V3
Vital signs
:

: weak

BP 150/70 mmHg
HR
88x/min
RR 18x/min
Temp 36,5oC (axilla)
Eye : pupil round, isocor 2,5/2,5 mm,light reflex +/+
Thorax : bronchovesicular breathing, Rh-/-, Wh -/normal heart sound, murmur (-),gallop (-)
Abdomen
: unpalpable liver and spleen, ascites (-)

Weight/height = 35 kg/1.5 m
BMI = 15,55

CLINICAL FINDINGS

Cranial Nerves :normal finding


Motoric
Sup
Inf
Movement
Strength
Tonus
Trophy
FR
PR
Clonus

+/+
+/+
444/444 444/444
N/N
N/N
E/E
E/Edema
++/++
++/++
-/-/-/-

CLINICAL FINDINGS

Sensibility : Nprmal Finding

Vegetative : DC (+), NGT (+)

LABORATORY FINDINGS
LABORATORY
EXAMINATION

14th Augustus 2015

Hb

12.0

12.00 15.00

Ht

38.4

35 47

Red blood cell

4.78

4.4 5.9

MCH

25.1

27 32

MCV

80.3

76 96

MCHC

31.3

29 36

White blood cells

20.6

3.6 11 x103

Platelet

258

150 400 x103

Blood glucose

134

80 140

Ureum

202

15 39

Creatinin

3.5

0.6 1.3

LABORATORY FINDINGS
LABORATORY
EXAMINATION

14th Augustus 2015

Magnesium

1.10

0,74-0.99

Calcium

4.2

2.12-2.52

Sodium

143

136-145

Potassium

4.3

3.5-5.1

Chloride

106

98-107

Electrolyte

FD = 2.9 L

ECG

Impression : Anteroseptal and lateral OMI

Thorax

14th Augustus 2015

Head MSCT-SCAN
14th Augustus 2015

DIAGNOSIS
I. Clinical Diagnosis
Observation of seizure
Dysphagia
Topical Diagnosis
Right eksternal capsule
Etiologic Diagnosis : Metastatic suspected of
carcinoma cervix dd/ Metabolic
II. Azotemia
III. Hypermagnesemia
IV. Carsinoma cervix

INITIAL PLANS &


THERAPY

CEREBRAL INFARCTION

1.

Consult to Gynecologist

2.

Consult to Nutritionist

3.

Therapy :

4.

Inffusion : NaCl 0,9% 30 dpm


Inj Phenytoin 200mg/24 ho IV
Inj Ranitidine 50 mg/12 ho IV
Inj Diazepam 10 mg slowly injected if seizure
Folic Accid 400 mg/ 8 ho PO
Vitamin B1 B6 B12 1 tab/8 ho PO

INITIAL PLANS &


THERAPY

AZOTEMIA

1.

Therapy
1.

IVFD NaCl 0,9% 30 dpm

Re-evaluation renal function test (ureum/creatinine)

MONITORING :
GCS, vital signs, neurologic deficits, fluid
balance

EDUCATION :
diagnosis, management, complications,
prognosis