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Morning Report August 3th, 2017

Morning Report August 3 th , 2017 DEPT OF NEUROLOGY M28
 

DEPT OF NEUROLOGY

M28

 

DAFTAR OB NEURO

DAFTAR OB NEURO  Ny. S  Meningioma  Ny. Amanah  Tetanus
 
  • Ny. S Meningioma

  • Ny. Amanah Tetanus

 
 

Identity

Identity  Name : Ny. S  : 40 years old Age  Address : Cungkup,Lamongan
 
  • Name

: Ny. S

  • : 40 years old

Age

  • Address

: Cungkup,Lamongan

  • Admission

: August 2nd, 2017 at

21.30 pm

 
 

SUMMARY OF DATABASE

SUMMARY OF DATABASE  Chief of complaint :  Seizure
 

Chief of complaint:

Seizure

 
  • Chief Complaint

Seizure

Seizure
 
  • Present history

Patient complained seizure attack since 3 hours before admitted to

hospital during activity. Seizure were experienced twice with

duration ±5 minutes without loss of consciousness, criteria of seizure were eyes glanced upward, stiff of extremity without

tongue bitten. Patient spoke with wrong articulation, Vomit admitted once before arrived to the hospital and once within the

hospital. Headace appeared since 7 days before, felt throbbing and

worsen a day. Defecation within normal limit and micturition felt normal limit. Patient had seizure again during hospital twice at 22.38 and 23.00. blurriness(-), hearing loss(-). Patient admitted that never got this complaint before

 
  • Past history of Illness

 Past history of Illness
 

HT (-) , DM (-),

  • Family history

No familial related

  • Social history : (-)

 
 

Vital Signs

Vital Signs  BP  123/71 mmHg  Pulse  82 x/min, strong, reguler  Temp
 
  • BP

123/71 mmHg

  • Pulse

82 x/min, strong, reguler

  • Temp

36,8 C

  • RR

24x/min

 
 A: clear, gargling (-), snoring (-), speak fluently (-), potential obstruction (-)  B: spontan,
  • A: clear, gargling (-), snoring (-), speak fluently (-),

potential obstruction (-)

  • B: spontan, RR 24x/min, ves / ves, rh +/+, wh -/-, SaO2 97% without O2 support.

  • C: CRT <2’, N 82 x/min, BP 123/71 mmHg

  • D: GCS 456, lateralisasi -, PBI 3mm/ 3mm, LP +/+

  • E: temp 36,8 C

 
 
 General condition : weak  Awareness : composmentis  GCS : 456  H/N :
  • General condition

: weak

  • Awareness

: composmentis

  • GCS

: 456

  • H/N

: a -/i-/c-/d -

lymph node enlargement at neck (-)

 

Thorax

Thorax  Inspection  Symmetrical, retraction -  Palpation  Thrill (-), fremitus WNL  Percussion
  • Inspection

  • Symmetrical, retraction -

  • Palpation

  • Thrill (-), fremitus WNL

  • Percussion

  • Lungs: sonor / sonor

  • Cor: N

  • Auscultation

  • Lungs: ves /ves, rh +/+, wh -/-

  • Cor: S1S2 single, M -, gallop -

 
 

Abdomen

Abdomen  Inspection  flat  Auscultation  Met -, bowel sound WNL  Palpation 
  • Inspection

  • flat

  • Auscultation

  • Met -, bowel sound WNL

  • Palpation

  • Pain (-)

  • Liver/Spleen within normal limit

  • Percussion

  • Tymphany

 

Extremities

Extremities  Inspection  Clubbing fingers (-), icteric (-), cyanosis (-), edema (-), atrofi lower extremity
  • Inspection

  • Clubbing fingers (-), icteric (-), cyanosis (-), edema (-), atrofi

lower extremity (-)

  • Palpation

  • Cold and wet, CRT <2’

 

Status Neurologic

 
 
Status Neurologic  GCS: 456  Fisiologic reflex:  Meningeal sign:  BPR +2/+2  Kaku
  • GCS: 456

 
  • Fisiologic reflex:

  • Meningeal sign:

  • BPR +2/+2

 
  • Kaku kuduk -

  • TPR +2/+2

  • Kernig -/-

  • KPR +2/+2

  • Brudzinski 1,2 -/-

  • APR +2/+2

  • Nervus Cranialis:

  • Patologic reflex:

  • NII: PRI 6mm/3mm, light

  • Babinski -/-

 

reflex +/+,

  • Chaddock -/-

  • N III, IV, VI: normal

  • Hoffman trommer -/-

  • NVII: normal

  • Motoric: 5-/5

 
  • N IX: normal

 

5-/5

  • N XII: normal

  • Sensoric: normal

 

Planning Diagnosis

 
Planning Diagnosis  Complete blood count  CT-Scan  Thorax photo  Random blood glucose
  • Complete blood count

 
   
  • CT-Scan

  • Thorax photo

  • Random blood glucose

 
 

Laboratory Findings

 
 
Laboratory Findings  Eritrosit 4.78  MCH 28,70  Hb 13.7  MCV 84,50  LED
 
  • Eritrosit

4.78

  • MCH

28,70

  • Hb

13.7

  • MCV

84,50

  • LED

1

22

  • MCHC

33,90

  • LED2

53

  • MPV

6

  • Limposit

38,6.

  • RDW

11

  • Basofil

1,0

  • Trombosit

232

  • Eosinopil

1,4

  • Clorida serum

105

  • Neutropil

53,7

  • Kalium serum

3,8

  • Hematokrit

40,4

  • Natrium serum

137

  • Monosit

5,3

  • GDA

162

  • Leukosit

18,0.

 
 
 

Ct scan results

 
Ct scan results  Edema cerebri sinistra  Meningioma frontalis sinistra
  • Edema cerebri sinistra

 
   
  • Meningioma frontalis

sinistra

 
 

Diagnosis

Diagnosis  Diagnosis:  Clinical : hemiparese dextra, convulsion, headache.  Topical : Meningen frontalis sinistra
 

Diagnosis:

  • Clinical : hemiparese dextra, convulsion, headache.

  • Topical : Meningen frontalis sinistra

  • Etiology: Meningioma, edema cerebri

 
 

Planning Therapy

Planning Therapy
 

IVFD asering

1500cc/24 hours

Inj Dexamethason Inj. citicolin

4x1 amp 3x500 mg iv

Inj. antrain

3 x 1 amp iv

Inj. ranitidin Inj. Phenitoin

2x50mg iv 3x100mg iv

 

PLANNING MONITORING

PLANNING MONITORING
 
  • Vital Signs

  • Patient’s complaint

  • Adverse effect

  • DL

 

PLANNING EDUCATION

PLANNING EDUCATION

Explain to the patient and his family about the disease, cause, complication, intervention of the therapy and prognosis.