Morning Report Wednesday, 22 November 2023 1 .pptx
- 2. STATISTICS 1. Mrs. MM/46 Y.O/Unconsciousness ec suspect urosepsis, Reattack CVD SI 2nd day onset, Anemia gravis ec GI tract bleeding, Melena and hematemesis ec NSAID gastropathy dd stress ulcer, type 2 Diabetes Mellitus, Chronic kidney disease, Hyperkalemia. 2. Mr. AA/66 Y.O/Post ROSC 1st day onset, Reattack CVD SI 1st day onset, Severe ARDS, AF RVR (CHA2DS2VASc 6, HASBLED 2), CHF FC II ec CAD dd/HHD, Reactive leukocytosis, Acute kidney injury dd acute on chronic kidney disease, Hepatopathy dd/ acute liver injury, Coagulopathy, Dyslipidemia, Partially compensated metabolic acidosis, Hematuria pro evaluation. 3. Mr. FB/30 Y.O/SDH at right frontotemporoparietal region 1st day onset, SDH at falx cerebral, Secondary IVH, Cerebral edema, Multiple cerebral contusion, Vulnus laceratum at left occipital region, Multiple vulnus excoriatum, Reactive leukocytosis. 4. Mrs. SM/40 Y.O/Triggered episodic vestibular syndrome ec BPPV, Dyspepsia syndrome, Leukocytosis, History of chronic suppurative otitis media at right ear.
- 3. STATISTICS 5. Mrs. MB/37 Y.O/Suspect multiple intracranial SOL, Focal seizure, Hemoptoe ec suspect lung tuberculosis, Chronic lymphadenitis at left neck, Leukocytosis pro evaluation, Hypokalemia. 6. Mrs. AL/19 Y.O/Cerebral commotion 2nd day onset, Reactive leukocytosis 7. Mr. N/50 Y.O/Unconsciousness ec intracranial SOL at right frontotemporal region suspect glioma, Symptomatic focal epilepsy. 8. Mrs. MJ/63 Y.O/Unconsciousness ec suspect metabolic dd/ sepsis, Type 2 diabetes mellitus with hypoglycemic episodic, Severe hypotonic hyponatremia, Suspect urosepsis, Chronic kidney disease, Hypertension on treatment, Anemia ec suspect occult bleeding, History of Abnormal uterus bleeding.
- 4. COVID SCREENING • Recent onset fever (-), cough (-), dyspnea (-) • History of travelling abroad on this past 2 weeks was denied • Recent history of domestic travelling was denied • History of contact with COVID-19 patients was denied • History of COVID-19 vaccination (+) • History of confirmed COVID-19 (-)
- 5. A 50-years-old male came with chief complaint of gradual unconsciousness since 4 days before admission
- 6. HISTORY OF PRESENT ILLNESS A 50-year-old male was admitted into emergency department with chief complaint of gradual unconsciousness since 4 days before admission. He could open his eyes spontaneously, but seemed less active and spoke incoherent. He had seizure 4 days before admission with semiology Pre ictal: Prodromal (-) Ictal: Aura (-), Head tilted to the left, eyes gaze to the left, foamy mouth (+), tongue bitten (-), clonic movement at the left hand followed by right hand, both leg stiffened, urinary incontinence (+). Post ictal: unconsciousness It was his first seizure, frequency 2 times, interval between seizures 3 hours, duration 2- 3 minutes. He tend to sleep, He regained consciousness 13 hours later when he was in the hospital. He could open his eyes but couldn’t respond properly when being called.
- 7. He complained headache since 2 months, before admission, gradually increase, felt all over his head with throbbing characteristic, worsened with activity and reduced when resting or taking pain medication, not worsened by coughing. According to his family, there were weakness on his left extremities since 2 months before admission. He experienced nausea and vomited since 2 months, not projectile characteristics containing food and fluid. History of weight loss 5kg since 1 months before admission. Other complaints such as chronic cough, night sweat, discharge from ears and nose, head trauma, chronic diarrhea were all denied
- 8. HISTORY OF PAST ILLNESS • History of hypertension, diabetes mellitus, lung, heart, kidney and liver disease were all denied • History of allergy was denied
- 9. GENERAL EXAMINATION • Condition : Moderate • Consciousness : Apathy • BP : 123/82 mmHg (MAP: 95.6) • HR : 68 bpm, regular • RR : 20x/min • Temp : 36.5oC • SpO2 : 97% room air • Conjunctiva : Anemic (-), icteric (-) • Cor : Regular heart sound I-II, murmur (-), gallop (-) • Pulmo : Vesicular/vesicular, ronchi -/-, wheezing -/- • Abdomen : Flat, normal peristaltic • Extremities : Warm, edema (-/-)
- 10. NEUROLOGICAL EXAMINATION • GCS : E4M5V3 = 12 • Pupil examination : Round pupil, isochor, 3mm/3mm, direct light reflex /, indirect light reflex / • Meningeal sign : Nuchal rigidity (-) , lasegue >70/>70, kernig >135/>135 • Cranial nerves : Impression of left 7th cranial nerve palsy UMN type • Fundoscopy : Hyperemic papillae, blurred boundaries, A:V ratio 2:3, obscuration of blood vessel (+) -> impression of grade 3 papilledema
- 11. • Sensory examination : N/T • Autonomic function : Urinary via catheter (+) • Motoric examination: Impression of left hemiparesis RIGHT LEFT RIGHT LEFT - - + - RIGHT LEFT Muscle Tone : Physiology Reflex : Pathologic Reflex : NEUROLOGICAL EXAMINATION + + + + + N N + + + + + + + + + +
- 12. WORKING DIAGNOSIS • Unconsciousness e.c suspect intracranial SOL • Symptomatic focal epilepsy
- 13. • Communication, Information, & Education • Elevation head 30 degree • O2 adequate • Non contrast Head CT scan • Chest X-ray AP, ECG, laboratory check • NGT installed with consent • IVFD NaCl 0.9% 500 cc/8 hours • Diazepam 10mg IV if seizure • Ranitidine 50mg/12 hours IV • Paracetamol 500mg/8 hours NGT PLANNING
- 14. LABORATORY TEST (22/11/2023) • Hemoglobin : 14.9 • Leukocyte : 8.800 • Thrombocyte : 227.000 • MCHC : 35.9 • MCV : 82 • MCH : 29.4 • Ureum : 21 • Creatinine : 0.8 • RBG : 106 • SGOT : 22 • SGPT : 20 • Natrium : 141 • Kalium : 3.9 • Chloride : 103 • PT : 1x • APTT : 0.8x • INR : 1.07 • Anti HCV/HbsAg/Anti HIV: Non reactive • Osmolarity : 298
- 15. ECG (22/11/2023) Impression : Sinus rhythm, 65bpm, normoaxis
- 16. CHEST X-RAY (22/11/2023) Impression : Cardiac and pulmo within normal limit
- 17. BRAIN CT NON- CONTRAST 22/11/2023
- 19. BRAIN CT NON-CONTRAST 22/11/2023
- 20. BRAIN CT NON-CONTRAST 22/11/2023
- 21. DIAGNOSIS • Unconsciousness ec intracranial SOL at right frontotemporal region suspect glioma • Symptomatic focal epilepsy
- 22. ADDITIONAL PLANNING • Dexamethasone loading 10mg IV then continued 4x5mg IV tap off/3 days • Levetiracetam 2x500mg NGT • Lactulose 1x30cc NGT • Consult to oncology division at ward • Head MRI with contrast at ward
- 23. TERIMA KASIH