Morning Report th

26 October 2017
On Duty :
dr. Andisty
dr. Riko
dr. Desy
dr. Sandy
dr. Irene
dr. Windi
dr. April
dr. Dennis

DPJP :
Dr. Imelda M Sumual, Sp.S
 Statistic
Mrs. YP / 62 yo/ BPPV
Mr. CBP / 19 yo / moderate head injury
Mr. NRS / 22 yo/ Extrapiramidal syndrom (Dystonia)
Mrs. SM / 25 yo/ Unconsciousness ec susp
Meningoenchepalitis Bacterialis + Sepsis ec pneumonia
+ epileptic symptomatic, electrolite imbalance + Anemia
Mr. AMR / 53 yo / Moderate head injur
Mr. KV / 54 yo / Cerebral infarction onset day 1
 Mr. NK / 65 yo / Sequelle of cerebral infarction
Mrs PMY / 63 yo / Unsconsciouness ec Sol
intrakranial + susp pneumonia
Mrs. AWY/ 32 yo / commotio cerebri day onset
1
Mr. Hamid / 49 yo / Unsconsciousness ec
metabolic
Mrs. MC / 33 yo / RVD st IV + susp
Toxoplasmosis enchepalitis
 Chief Complaint
Unsconsciousness
 History Taking
Unconsciousness was experienced by patient since 5
days before admission and happened gradually. At first
patient had a history of first child pregnancy
approximately 6 months before admission to the hospital.
At the age of 4 months pregnancy patient was
miscarriage and performed curettage at health center
and treated for 3 days. Then went for outpatient. 11 days
later the patient had a high fever, the temperature
reached 40 C intervals up and down, and got
decreased by febrifuge drugs, but then after the
medications discharged patient went back on fever. \
Patient also experience convulsions.
Pre ictal: the patient is conscious
Ictal: straight head, eyes glazed, staring straight in both
eyes, the lips are not skewed and not bitten, no
foaming mouth, hands pounding straight, legs
pounding straight.
Post ictal: the patient is unconscious.
The duration of the seizures is approximately 30
seconds, the frequency is approximately 5 times, the
average interval is 3-4
The patient was then treated again at health center Lolak for
3 days, and then referred to Marompia hospital for 11 days.
While in hospital Marompia patient was still not fully
conscious, inadequate contact. But the family told that
patient could still eat from the mouth and not choke. The
family refused to install the NGT. The patient performed
chest X-ray and then allegedly for a suspected pulmonary
tuberculosis infection. History of patient's headache was
spread to the neck and felt like stabbed, experienced 5
days before entering the hospital. Cough (+), shortness of
breath (+), weight loss (+), cold sweat (-). Patient had
complaints of cavities. History of vomiting (+), headache (-
), history of head trauma (-), limb weakness on one side (-),
the routine of drugs use (-). Patients have a history of not
menstruating during the last 4 months.
After the treatment at the hospital Marompia patient came
home at her own request. Patient was given OAT
medication during treatment and upon returning home. But
after that the patient did not consume the OAT medication.
The patient had to go to the doctor's office several times
and was fully aware. Two days before entering the hospital
the patient again gradually decreased consciousness.
Fever (+), seizures once a 30-second duration with the
same pattern, but there is little stiffness in left limb
compared to right before decreasing consciousness.
Patient complained of having headache. The patient was
then taken back to the health center Lolak, then referred to
the hospital Marompia, Kotamobagu hospital and referred
at last to the prof RD Kandou hospital.
 History of past illnes
Hypertension (-).
History of diabetes mellitus (-), Cholesterol (-),
heart disease (-), kidney disease (-), stroke (-).
 Habbit
Smoking (-)
Alcohol (-)
 Physical Examination
General examination:
General condition: severe, consciousness :
sopor
BP: 100/70 mmHg, HR: 80x/m reg, RR: 26x/m T:
39C
Conjunctiva: pale (-/-), sclera ikteric (-/-)
Thorax: rale +/+, wh -/-, heart sound I/II normal,
gallop -, murmur -
Abdomen : flat, normal turgor, peristaltic normal
Extremities : warm acral
 Neurological Examination
GCS : E2M5V3, PERRL +/+ 4 mm/ 4mm
Meningeal Sign : nuchal rigidity (+), Lasegue (<70/<70),
Kernig (<135/<135)
Cranial Nerves : Slight impression N VII UMN (S)
Funduscopy ODS : papil (round), cupping disc (+), A:V (2:3)
orange
Motoric State : slight hemiparesis (S)
MT: Phy R: Path R:
N N ++/++/++ ++/++/++ - -

N N ++/++ ++/++ + +

Babinski
Sensoric State : cannot be evaluated
 Diagnosis
Unsconsciousness ec susp
Meningoencephalitis Bacterialis dd/ TB.
Susp og Lung TB on withdrawal
Amenorrhea
Obs General seizure
Anemia on obs
Dyspepsia syndrome
Susp sepsis ec pneumonia
 Planning

Communication, information, education

02 2-4 LPM via nasal kanul
Bed Rest + Head elevation 30
Mobilization every 2 hours
Oral Hygiene + chest phisiotherapy
Pro NGT + cateter
Obs GCS, TTV, Pupil
Consult Obstetric and Gynecology
IVFD NaCl 0.9% 500cc/6 hours
Paracetamol 4x500 mg Drip if T > 38.5
Dexamethasone 10 mg (loading) IV continued 4x5 mg bid
IV
Ceftriaxone 2x2000 mg IV (skin test)
Ranitidine 2x50mg IV
Fenitoin 3x100 mg NGT
Folic acid 2x400 mcg NGT
Lactulax syrup 0-0-CII NGT
Diazepam 10 mg max 20 mg IV prn
 Additional Planning
Lab
ECG and expertise
Chest X-Ray
Brain CT Scan + Contrass
 Laboratory Examination
Leucocyte 20.100
Erythrocyte 3.67
Hb 10.3
Hematocryte 30.4
Trombocyte 178.000
SGOT / SGPT 19 / 11
Ureum 54
Creatinine 0.9
RBG 129
Chloride 100
Kalium 2.5
Natrium 133
Anti HIV Non reaktif
 ECG
Sinus rythm
 Working Diagnosis
Unsconsciousness ec susp Meningoencephalitis Bacterialis dd/
TB.
Susp of Lung TB on withdrawal
Amenorrhea
Obs General seizure
Anemia on obs
Dyspepsia syndrome
Sepsis ec pneumonia
Hypokalemia
Mild hyponatremia
Pneumonia
Cardiomegali
 Additional Therapy
KCL 25 meq + NACL 0.9 % 500 cc every 12 hours