HT SEIZURE

1. Perkenalan dan menjelaskan prosedur

2. Identitas:
a. Nama
b. Usia
c. Alamat
d. Pekerjaan
e. Status pernikahan
f. Jenis kelamin
3. Chief complaint: LOSS OF CONSCIOUSNESS
4. RPS:
a. Site: -
b. Onset:
i. Kapan?
ii. Ada gejala prodromal?
1. Light-headedness, wobbly legs, vision going dim,
noises sounding distant?  faints (vasovagal syncope)
2. Aura (tunnel, déjà vu, dll)?  Seizure
c. Characteristics/quality:
i. Postural tone:
1. Loss of postural tone dengan atau tanpa few jerks
(convulsive movement cuma dikit doing)?  syncope
2. Tonic?  stiffening of limbs with extension of back
and limbs, eyes deviate upwards. May cry out
involuntarily
3. Clonic?  generalized flexion contractions of muscles
alternating with relaxation.
4. Tonic-clonic?
ii. Progresivitasnya gmn? Memburuk/membaik/sama aja?
d. Radiation: -
e. Associated symptoms: Pola seperti apa? Sejak kapan?
i. Hipotensi? Orthostatic hypotension
ii. Gangguan jantung?  cardiac syncope
f. Time course: Berapa lama?
i. Less tan 30 secons?  syncope
ii. Usually 1-2 minutes?  seizure
g. Timing: Pola lemas seperti apa? Tiap abis ngapain? Keluhan
tambahannya gmn?
i. Faints (vasovagal syncope)  usually doesn’t occur when
sitting or lying
ii. Blackouts (cardiac syncope)  can occur when sitting or lying
iii. Seizure  can occur when sitting or lying, can also happen
during sleep
h. Exacerbating / relieving factors:
i. Exacerbating; memperburuk/pencetus? (precipitating factors)
1. Faints (vasovagal syncope)  puasa, pain, emotional
events, prolonged standing
2. Blackouts (cardiac syncope)  biasa ga ada
precipitating factor yang jelas
 3. Seizure  biasanya terjadi spontan, tapi bisa dicetuskan
sleep deprivation and stress
ii. Relieving; memperbaik?
1. Faints  lying flat assists recovery
2. Blackouts  self-limiting
3. Seizure  self-limiting
i. Severity: Seberapa parah/mengganggu? Masih bisa bekerja?
5. RPD:
a. Riwayat lemas seperti ini sebelumnya?
b. Pernah dirawat di rumah sakit/menderita penyakit kronis? 
malignancy, PPOK, TB, penyakit paru yang lain, CKD, gangguan
hormone, hepatitis, autoimmune (SLE, dll), operasi bariarty
(gastrectomy), inflammatory bowel disease (Chrons’ disease dan
ulcerative colitis), gagal jantung, infeksi berulang (bisa menandakan
aplastic anaemia atau leukemia), orthostatic hypotension (jantung,
vasogenic)
c. Lagi hamil?  hemodilusi
d. Riwayat penyakit darah (thalassemia, sickle cell, dsb)? Termasuk:
i. Riwayat transfusi?
ii. Riwayat cuci darah?
e. Riwayat gangguan hormone:
i. Hypothyroid?  gejalanya suka kedinginan
ii. Ovarectomy?
f. Riwayat trauma? Sering berdarah?  gangguan koagulasi
g. Riwayat pengobatan:
i. Chemoterapy/radiasi?  aplastic anaemia, leukemia
ii. NSAIDs?  GI bleeding
iii. Chloramphenicol?  aplastic anaemia
iv. Obat kontrasepsi?
6. Riwayat Sosial Ekonomi:
a. Riwayat pola makan:
i. Menghindari makanan tertentu (misalnya vegetarian)? 
defisiensi nutrisi
ii. Pola teratur/tidak?
b. Riwayat merokok:  malignancy, PPOK, TB
i. Berapa lama (sejak kapan)?
ii. Berapa banyak?
c. Riwayat pekerjaan:  apakah ada exposure terhadap zat tertentu?
7. FIFE (Fear, Insight, Function, Expectation)
8. Review organ system (RESUME)
9. Terimakasih!