MORNING REPORT

SATURDAY,
January 11th 2013

Doctors in charge:
dr. Rio/dr. Novi/dr. Riska/dr. Zarrah
Consultant:
dr.Muhammad Hamdan Sp.S(K)

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 New Patients

No Patients Diagnosis Note

1 Tn Subagio/40yo Cerebral Neoplasm Seruni A

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 Consulted Patients

No. Patients Diagnosis Note

- - - -

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 Identity
 Name : Mrs. Ninis
 Age : 39 yo
 Sex : female
 Address : surabaya
 Occupation : housewife

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 History Present Illness

• Chief complaint : seizure

• Seizure happened 24 hours before admitted. Started with
skewed face to the right, followed by both arms and legs
jerking, eye deviation upward. Bitten tongue (+), bed wetting
(-). Seizure ± 5 minutes, when seizure patient was
unconscious. After seizure patient was conscious, headache
(+), weakness on half side of body (-)
• Headache (+) since 1 year ago. Felt all over the head,
paroxysmal.Getting worse in the last few months.

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• Vomitting(-),slurred speech (-), DOC (-)
• Weakness on half side of body (-), kkewed
face (-), numbness (-), tingling (-)
• double vision (-),blurred vision (-), fever (-)
• Micturation /defecation disturbances (-)

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 History of past illness
• History of seizure (-)
• HT (-), DM (-), stroke (-)
• Mass (-), trauma (-)
• Contraception (+), injection eevery 1 month for 17 years.

Family History :
• Epilepsy (-), tumor (-)
• Stroke (+), HT (-),DM(-)

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 General examination
 Vital Signs :
BP 120/90 mmHg PR 82x/m,regularly
RR 18x/mnt T :37,6°C
 Head & Neck : A-/I-/C-/D- ; JVP not increased , Bruits carotid-/-,
mass in the neck and axilla (-)
 Chest :
- Cardiac : Ictus Cordis ICS V MCL S
S1, S2 single ES-/G-/M-
- Lung : ves /ves, Rh-/-, Whz-/-
 Abd : H/L not palpable
 Extremity : Warm, edema -/-

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 Neurological Examination
 GCS : 456
 Meningeal sign : Nuchal rigidity (-) Brudz I-IV : (-)
 Cranial Nerves :
N.II, III : pupil round isokor 3mm/3mm
light reflex +/+
VODS > 2/60
Papil oedem -/-
N.III,IV,VI : wnl
N.VII : right facial palsy central type
Other cranial nerves : wnl
 Motor system : 5- / 5 Sensory system : wnl
5-/ 5

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 Reflexes :
The deep tendon or muscle stretch reflexes
The Biceps Reflexes +2/ +2
The Triceps Reflexes +2/+2
The Patellar Reflexes +2/+2
The Achilles Reflex +2/+2
Reflex superficial abdomen (-/-)
 Pathologic Reflexes
Babinski sign -/-
Chaddock sign -/-
Hoffmann & Tromner sign -/-
 Primitive Reflex
Palmomental -/-
• CV/ANS: dbn
• Cerebellar sign : dte

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 Diagnosis

 Clinical Diagnosis :
Chronic progressive headache
Slight right hemiparese
Right facial palsy central type
Contraception (+)
Topical Diagnosis :
Supratentorial
 Etiological Diagnosis :
Cerebral neoplasm

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 Laboratorium
BUN/Cr 3,3/0,54 mg/dL
OT/PT 20/19
Na 151 mmol/L
K 3,2 mmol/L APTT 28,4 (25,0)

Cl 109 mmol/L PT 11,1 (11,3)

BGA pH = 7,46 Alb 4,39 g/dL

pCO2 = 37,6 Glu 122 mg/dL
pO2 = 84,2 Hb 13,7
HCO3 = 37,6 WBC 8.700
BE = 3.3 Plt 275.000
SaO2 = 96,9

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 Imaging
• Head CT-scan and Thorax : on the viewer

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 Planning

 Diagnosis :
C NS
 Treatment :
- Head and trunk up 300
- IVFD PZ 2 fl / day
- Metamizole inj 3x1 amp/day
- Dexamethasone inj 4x1 amp/day
- Ranitidin inj 2x1 amp/day
-Phenytoin inj 3x100mg
- HCHP diet 1800 kal
 Monitoring : GCS, VS, SE
 Education : CIE

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THANK YOU

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