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 August 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, ps was having tonic

clonic seizure with eye drill upward, about 2-3 minutes,
when it happen and after that pt still conscious, seizure
about to happen 8 times a day. Her child told that pt lost
her appetite. Nausea (+), vomit (-), fever (-), headache (-),
history of seizure before (-). Pt brought to panti wilasa
hospital and being hospitalize about 4 days.
6 months before hospital admission pt was diagnosed
carcinoma cervix with history of vaginal bleeding for
years.
HISTORY

Aggravated Factors : (-)

Extenuated Factors : (-)

Concomitant Symptoms : lost of apetite

 HISTORY
Past Medical History
-6 mo prior, pt had diagnosed from carcinoma cervix with a
history of vaginal bleeding
- no history of hypertiension, diabetes, heart disease, and stroke

Family Disease History : no history of hypertension, diabetes,

heart disease, and stroke

Social Economic-Status And Personal History : pt didnt work. Pt has

5 children.
 CLINICAL FINDINGS
Present States
General appearences : weak
GCS : E4M6V3
Vital signs :
BP 150/70 mmHg HR 88x/min
RR 18x/min Temp 36.5 (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 = 15,56
 CLINICAL FINDINGS
Cranial Nerves : normal finding

Motoric Sup Inf

Movement +/+ +/+
Strength 444/444 444/444
(general weakness)
Tonus N/N N/N
Trophy E/E E/Edema
FR ++/++ ++/++
PR -/- -/-
Clonus -/-
CLINICAL FINDINGS
Sensibility : Normal finding

Vegetative : DC (+), NGT (+)

 LABORATORY FINDINGS
LABORATORY EXAMINATION 14th August 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 August 2015

Magnesium 1.10 0,74-0.99
Calcium 4.2 2.12-2.52
Electrolyte
Sodium 143 136-145
Potassium 4.3 3.5-5.1
Chloride 106 98-107
FD = 2,9 L
Thorax 14th August 2015

No enlargement of
cardiac
Bronchopneumoni
Head MSCT-SCAN 14th August 2015

Right eksternal
capsule infarction
No result of
intracranial space
occupying lession
Cerebral aging
athropy
Theres no sign of
increasing
intracranial
pressure
ECG 14th August 2015
ECG 14th August 2015
Normosinusrhytm
 DIAGNOSIS
I. Clinical Diagnosis
Seizure observation
Topical Diagnosis
Cerebral cortex
Etiologic Diagnosis : Metabolic dd/ Metastatic suspected of
carcinoma cervix

II. Azotemia
III. Hypermagnesemia
IV. Carcinoma Cervix
V. Khakeksia
VI. Leukocytosis
 INITIAL PLANS & THERAPY
1. Planing
Consult to Gynecologist
Consult to Nutritionist
EEG

1. Therapy :
Inffusion : NaCl 0,9 % rehidration 1 L, next 30 dpm
Inj Phenitoin 200 mg/ 24 ho IV
Inj Ranitidine 50 mg/12 ho IV
Inj Diazepam 10 mg IV -> slow injected if seizure
Folic accid 400 mcg/ 8 ho PO
Vitamin B1 B6 B12 1 tab/8 ho PO
 MONITORING :
GCS, vital signs, neurologic deficits, fluid balance

EDUCATION :
diagnosis, management, complications, prognosis