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

Onset
hospital

: Seizure

: 2 weeks before
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
TrophyE/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

Platelet

258

150 400 x103

Blood glucose

134

80 140

Ureum

202

15 39

3.6 11 x103

LABORATORY FINDINGS
LABORATORY
EXAMINATION
Magnesium

14th August 2015

1.10

0,74-0.99

4.2

2.12-2.52

Sodium

143

136-145

Potassium

4.3

3.5-5.1

Chloride

106

98-107

Calcium
Electrolyte

FD = 2,9 L

Thorax

14th August 2015

No enlargement of cardiac
Bronchopneumoni

14th August 2015

Head MSCT-SCAN

Right
eksternal
capsule
infarction
No result of
intracranial
space
occupying
lession
Cerebral
aging athropy

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.

2.

Planing
Consult to Gynecologist
Consult to Nutritionist
EEG
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