Morning Report

May 3rd, 2018

DEPT OF NEUROLOGY
H29
 DAFTAR OB NEURO

 Mrs A  epilepsi
 Mr S  CVA emboli
 Identity

 Name : Mrs A
 Age : 27 years old
 Address : Sekaran, Lamongan
 Admission : 5/2/18 15:00
 SUMMARY OF DATABASE

 Chief of complaint:
 seizure
 Chief Complaint

 Present history

Patient came to ER with seizure 5 hours before admitting to the

ER then patient had seizure once in the ER. Patient was conscious
after the attack and the seizure lasted not more than 5 minutes.
The first seizure was last Thursday, once and she was brought to
the nearest primary health care and then got another seizure
attack once. So she had a total of 4 seizure attacks; twice daily and
conscious in between the seizures. The seizure is a form of
stiffness on the left side of her body. Left leg and arm were flexed.
On the first attack, she had foam in her mouth and experienced
unconsciousness. The form of seizure remained the same on each
attacks. She complained tingling on her feet since a month before
the seizure attack. She also now complains weakness on both feet.
 Past history of Illness

•Dm (+), HT (+), seizure when she was a child, she felt weakness on
both feet since 4 months. Fell in sitting position (+) when she was in
junior high school. Gastritis (+)

 Family history

(-)

 Social history : She’s a housewife, she often

consumes medicines for her gastritis.
 Vital Signs

 BP
 126/89 mmHg

 Pulse
 113 x/min, strong, regular

 Temp
 36,9 C

 RR
 20 x/min
 A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (+)
 B: spontan, RR 20x/min, ves / ves, rh -/-, wh -/-,
SaO2 100% without O2 support.
 C: CRT <2’, PR 113 x/min, BP 126/89 mmHg
 D: GCS 456, PBI 3mm/3mm, LP +/+
 E: temp 36,9 C
 General condition : good
 Awareness : composmentis
 GCS : 456
 H/N : a -/i-/c-/d -
lymph node enlargement at neck (-)
 Thorax
 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
 Inspection
 flat

 Auscultation
 Met -, bowel sound + N

 Palpation
 Pain (-)

 Liver/Spleen within normal limit

 Percussion
 Tymphany
 Extremities

 Inspection
 Clubbing fingers (-), icteric (-), cyanosis (-), edema (-),

 Palpation
 Warm, dry and red, CRT <2’
 Status Neurologic
 GCS: 456  Fisiologic reflex:
 Meningeal sign:  BPR +3/+3
 Nuchal rigidity -  TPR +3/+3
 Kernig -/-  KPR +3/+3
 Brudzinski 1,2 -/-  APR +3/+3

 Nervus Cranialis:  Patologic reflex:

 NI: normal  Babinski -/-
 NII: PBI 3mm/3mm, light  Chaddock -/-
reflex +/+,  Hoffman trommer +/+
 N III, IV, VI: normal  Motoric: 5/5
 NVII: normal 3/3
 NVIII: normal  Sensoric: hypoaesthesia on
 N IX, X: normal dermatome L3
 N XI: normal
 N XII: normal
 Assesment

 Epilepsy
 Planning Diagnosis

 Complete Blood Count

 MRI with contrast
 Laboratory Findings

 Gula Darah Acak : 95 • Eritrosit : 5.40 [ 3.80 - 5.30 ]

 Urea : 16 [ 15 - 43 ]
 Serum Creatinin : 0.6 [ P 0.7 -
1.2 L. 0.8 - 1.5 ]
 Kalium serum : 4.5 (3.6-5.5)
 Natrium : 138 (135-155)
 Clorida : 102 (70-108)
 Lekosit : 9.4 [ 4.0 - 11.0 ]
 Neutropil : 60.8 [ 49.0 - 67.0
] • MPV : 4 [ 5 - 10 ]
 Limposit : 24.7 [ 25.0 - 33.0 ]
 Monosit : 8.5 [ 3.0 - 7.0 ]
 Eosinopil : 3.5 [ 1.0 - 2.0 ]
 Basofil : 2.5 [ 0.0 - 1.0 ]
• .Hemoglobin : 11.4 [ P13,0 -
18,0]
• Hematokrit : 35.9 [ P 35 - 47 ]
• MCV : 66.50 [ 87.00 - 100 ]
• MCH : 21.10 [ 28.00 - 36.00 ]
• MCHC : 31.80 [ 31.00 - 37.00 ]
• RDW : 14 [ 10 - 16.5 ]
• Trombosit : 517 [ 150 - 450 ]
• LED 1 : 72 [0-1]
• LED 2 : 90 [1-7]
 Diagnosis

 Diagnosis:
 Klinis : hipoestesi dermatome L3 dextra and L4 sinistra,
paraparesis, focal tonic convulsion
 Topis: Vertebrae S12-L1

 Etiologi: suspect epilepsy focal

• Dd : lumbal tumor
 Planning Therapy
Oxygen NRM 7lpm
Inf Asering 1500 cc/24jam
Inj valisanbe 5mg
Phenitoin 500 mg drip PZ 100 cc tetes pelan  jika kejang
Consult to dr. Dhimas, neurologist
 PLANNING MONITORING

 Vital Signs
 Patient’s complaint
 Adverse effect
 CBC
 PLANNING EDUCATION

 Inform her family about the disease, causes,

complications, intervention of the therapy and
prognosis.