morning_report 14th agustust

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

PATIENT’S IDENTITY

Name : Mrs. MAge : 70 yoGender : FemaleOccupation : UnemploymentMR Number : C542224Hospital admission : 14th Augustus 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, 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.

HISTORY

Aggravated Factors : (-) Extenuated Factors : (-) Concomitant Symptoms : swallowing difficu

lties, lost of apetite

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.

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

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 -/-

CLINICAL FINDINGS

Sensibility : Nprmal Finding

Vegetative : DC (+), NGT (+)

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

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

ECG

Impression : Anteroseptal and lateral OMI

Thorax

14th Augustus 2015

Head MSCT-SCAN

14th Augustus 2015

DIAGNOSIS

I. Clinical DiagnosisObservation of seizureDysphagia

Topical DiagnosisRight eksternal capsule

Etiologic Diagnosis : Metastatic suspected of carcinoma cervix dd/ Metabolic

II. AzotemiaIII. HypermagnesemiaIV. Carsinoma cervix

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

INITIAL PLANS & THERAPY

AZOTEMIA

1. Therapy

1. IVFD NaCl 0,9% 30 dpm• Re-evaluation renal function test (ureum/creatinine)

MONITORING : GCS, vital signs, neurologic deficits, fluid balance

EDUCATION : diagnosis, management, complications, prognosis