morning_report 14th agustust
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Morning reportFriday 14th August 2015
ER : dr. Maria
Consultant: dr. Marthin
Stroke unit: dr. Putri
Ward : dr. April – dr Harris
Tandem: dr. Fathul - dr. Ramon
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PATIENT’S IDENTITY
Name : Mrs. MAge : 70 yoGender : FemaleOccupation : UnemploymentMR Number : C542224Hospital admission : 14th Augustus 2015
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HISTORY (alloanamnesis)
Chief complaint : Seizure
Onset : 2 weeks before hospital admission
Quality : tonic clonic seizure
Quantity : ADL partly assisted by family
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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.
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HISTORY
Aggravated Factors : (-) Extenuated Factors : (-) Concomitant Symptoms : swallowing difficu
lties, lost of apetite
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HISTORY Past Medical History
- 6 mo prior, pt diagnose from cervix cancer. - no history of, hypertention, diabetes, heart disease, and stroke
Family Disease History : no history of hypertension, diabetes, hea
rt disease, and stroke
Social Economic-Status And Personal History : pt works as gold gilder. Pt has 5 children.
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CLINICAL FINDINGS
Present States General appearences : weak GCS : E4M6V3 Vital signs :
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
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CLINICAL FINDINGS
Cranial Nerves :normal finding Motoric Sup Inf
Movement + /+ +/+Strength 444/444 444/444Tonus N/N N/NTrophy E/E E/EdemaFR ++/++ ++/++PR -/- -/-Clonus -/-
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CLINICAL FINDINGS
Sensibility : Nprmal Finding
Vegetative : DC (+), NGT (+)
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LABORATORY FINDINGS
LABORATORY EXAMINATION
14th Augustus 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
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LABORATORY FINDINGS
LABORATORY EXAMINATION
14th Augustus 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
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ECG
Impression : Anteroseptal and lateral OMI
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Thorax
14th Augustus 2015
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Head MSCT-SCAN
14th Augustus 2015
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DIAGNOSIS
I. Clinical DiagnosisObservation of seizureDysphagia
Topical DiagnosisRight eksternal capsule
Etiologic Diagnosis : Metastatic suspected of carcinoma cervix dd/ Metabolic
II. AzotemiaIII. HypermagnesemiaIV. Carsinoma cervix
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INITIAL PLANS & THERAPY
CEREBRAL INFARCTION1. Consult to Gynecologist
2. Consult to Nutritionist
3. Therapy :4. Inffusion : NaCl 0,9% 30 dpm
Inj Phenytoin 200mg/24 ho IVInj Ranitidine 50 mg/12 ho IVInj Diazepam 10 mg slowly injected if seizure
Folic Accid 400 mg/ 8 ho PO
Vitamin B1 B6 B12 1 tab/8 ho PO
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INITIAL PLANS & THERAPY
AZOTEMIA
1. Therapy
1. IVFD NaCl 0,9% 30 dpm• Re-evaluation renal function test (ureum/creatinine)
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MONITORING : GCS, vital signs, neurologic deficits, fluid balance
EDUCATION : diagnosis, management, complications, prognosis