2. NIGHT SHIFT TEAM
ED : dr. Lika
ICU : dr. Sarah
Stroke Unit : dr. Firman
Consultant Team : dr. Rere and dr. Unay
US’s partner : dr. Ardi
Ward’s Team : dr. Tyas and dr. Mayang
Ward’s partner : dr. Palma and dr. Anin
3. PATIENT’S IDENTITY
Name : Mr. M
Medical Record : C894174
Age : 43 y.o
Gender : Male
Addres : Rembang
Occupation : Not working
Date of Admission : 25/10/2021
4. ANAMNESIS
Main complain : seizure
Onset : 2 years ago
Location : all part of body
Quantity : tonic-clonic seizures
Quality : Activity daily living, partly assisted by the family
5. CHRONOLOGY
- 2 years before admission, the patient suddenly had a recurrent tonic – clonic seizure
for about 1 minute. Before the seizure, he complained of throbbing headache that is
located all around head portion. during the seizure he was unconscious, the patient's
eyes was opened and foamed from the patient's mouth. Stiffness of the extremities to
jerking. After the seizure he was confuse and had left extremities weakness. Then the
patient was taken to the hospital and treated in Rembang and did MSCT head without
contrast. He suggested to reffered to Kariadi Hospital but he refused due to limited
funds
6. 10 days before admission, he got seizures again with the same
pattern. Tonic – clonic seizure with bulging eyes and foaming at the
mouth more than 5 minutes. Weakness of the left extremities (+), left
facial drooping (+), and according to the patient's family, he does not
connect when spoken to. Vomitus (+), double/blured vision (-). During
and after the seizure he is unconscious. Then the patient was taken to
the Rembang Hospital and treated for 5 days in the ICU and an MSCT
examination of the head was performed. It was said that there was a
brain cyst and a occlusion of cerebral blood vessel. The patient was
discharged and suggested to be referred to Kariadi Hospital.
3 days before admission, he got a seizure again with the same pattern.
Before the seizure, the patient complained of headache. Tonic-clonic
seizure on all over the body with the eyes looking up. During seizure
he is unconscious. The seizure’s duration is about 3 minutes. After the
seizure the patient sleeps for a while then do activity as usual.
7. Precipitating factors : -
Relieving factors : -
Accompanying symptom : weakness on left side extremities, dropping left face,
cefalgia, vomite
8. HISTORY OF MEDICAL CONDITIONS
Hypertension history (-)
Dyslipidemia history (-)
Trauma (-)
Diabetic Mellitus(-)
Stroke history(-)
TBC(-)
Long fever (-)
Tumor (-)
Smoker (+)
9. HISTORY OF FAMILIAL DISEASE
No family members of the patient suffered a similar condition.
SOCIOECONOMY STATUS
he is no longer working, his wife job is housemaid. He has 2
children (19 y.o and 15 y.o). He use BPJS for hospital
payment. Economic state looked decent
10. GCS : E4M6V4 (susp kognitif impairment)
BP 120/ 81
HR 70
RR 20
T 36,5
SpO2 : 99 % room air
Head : Normocephal
Thorax : Cor / Normal S1-S2, regular, no murmur
pulmo/ vesicular (+/+), ronchy (-/-), no wheezing
Abdomen : Flat, no mass palpable, normal bowel sound
GENERAL PHYSICAL EXAMINATION
11. STATUS NEUROLOGIS
eye : isochor 2.5mm/2.5mm Light reflex -/-
neck : nuchal rigidity (-)
Nn cranialis : parese N.VII sinistra sentral
Motoric Sup Inf
Movement +/decreased +/decreased
strength can’t identified, left lateralitation (+)
Tonus N/hipertonus N/hipertonus
Trophy E/E E/E
RF ++/+++ ++/+++
RP -/- -/+(B,C, gonda, bing)
clonus -/+
Sensibility : can not identified
Vegetativ : Defecation and urination are normal
17. Therapy
IVFD RL 20 dpm
Inj Ranitidin 50mg/12hours iv
Inj B12 1 amp/12hours iv
Aspilet 80 mg/24hours po
Parasetamol 500 mg/8hours po
KSR 600mg/8hours po
18. PLAN
Monitoring for general condition, vital signs, pain, seizure, and
neurological deficit
MRI MRA MRV head with contrast
risk factor laboratorium
Consult to Medical Rehabilitation Department
