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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)
Onset
Quality
Quantity
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
HISTORY
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
+/+
+/+
444/444 444/444
N/N
N/N
E/E
E/Edema
++/++
++/++
-/-/-/-
CLINICAL FINDINGS
LABORATORY FINDINGS
LABORATORY
EXAMINATION
Hb
12.0
12.00 15.00
Ht
38.4
35 47
4.78
4.4 5.9
MCH
25.1
27 32
MCV
80.3
76 96
MCHC
31.3
29 36
20.6
3.6 11 x103
Platelet
258
Blood glucose
134
80 140
Ureum
202
15 39
Creatinin
3.5
0.6 1.3
LABORATORY FINDINGS
LABORATORY
EXAMINATION
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
Thorax
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
CEREBRAL INFARCTION
1.
Consult to Gynecologist
2.
Consult to Nutritionist
3.
Therapy :
4.
AZOTEMIA
1.
Therapy
1.
MONITORING :
GCS, vital signs, neurologic deficits, fluid
balance
EDUCATION :
diagnosis, management, complications,
prognosis