Patient List

No Identity Admission to ER Diagnosis Planning

1. Mrs. Made Suatin/51 12th May 2019 at DOC dt susp ensefalopati uremicum Treatment from Internist
y.o/1154946 09.00 am + ICH a/r ganglia basalis sinistra + • O2 nasal kanul 2-4 lpm
hyperglikemia • Ivfd NS rehidrasi 500-
1.000cc
• Inj citicoline 2x250mg
• Inj omeprazole 1x40mg
• Inj novorapid 3x16 iu
• Inj levemir 0-0-16
• Po. PCT 3x500mg
• Po. Aminefron 3x1 tab

Consult to Neurosurgery
• Conservatif
 1. Mrs. Made Suatin/51 Y.o/1154946/
admitted 12th May 2019 at 09.00 am

Chief Complain : decrease of consciousness

History taking :
patients came with complaints decrease of consciousness 7 days before admitted to hospital. The patient
was found unconscious on the bed, its appear suddenly. The patient's family denies any history of headache
and vomiting. Patients also have complaints of weakness on the right (+) appearing suddenly, tingling (sde),
numbness (sde). Seizures (-). After that patient were taken to primary care and referred to Kapuas hospital
(treated 3 days by Neurologist), and then referred to Ansari saleh hospital (treated 3 days Internist and
neurologist), shortness and cough (-), abdominal pain (-) defecation(+) in normal limit, micturition (+) in
normal limit, history of lumps (-)
History of past Illness: DM (+) use glibenclamid twice a day for 15 years. Amputation (+) in right foot ring
finger 10 years ago
 Vital Sign
BP : 140/70 mmHg
HR : 80 bpm (regular, strong)
RR : 24 tpm
Tax : 36,7 0C
GCS : E3VxM6
SpO2 : 98% without O2 Supplementation
Physical Examination

Head • Sclera icteric (-/-), pale conjungtiva (-/-), pupil equal 3 mm|3 mm, light reflex (+|+)

• I : symetric respiratory movement, retraction (-)

Chest • P : sonor at all lung fields
• A : symmetric VBS, rhonchi (-), wheezing (-)

• I : distension (-)
• A : bowel sound (+) normal
Abdomen • P : soft, tenderness (-), defense muscular (-) tenderness (-) mass (-) ascites (-)
• P : tympani at all region

Extremities • warm extremities (+), edema (-), paresis (-), lateralization (+) to the right side
Neurological State
• GCS E3VxM6
• Pupil equal 3 mm|3 mm, light reflex (+/+)
• Meningeal sign (-)
• Babinsky reflex (+)
• Hemiparesis dextra
Clinical Picture
 Laboratory Finding
Examination Result Normal Value
Hemoglobin 9,1 12,00-16,00 g/dl
Leukosit 18,6 4,0-10,5 ribu/ul
Eritrosit 3,03 3,90-5,50 juta/ul
Hematokrit 26,0 37,00-47,00 vol%
Trombosit 182 150-450 ribu/ul
RDW-CV 11,7 11,5-14,7 %
MCV 85,8 80,0-97,0 fl
MCH 30,0 27,0-32,0 pg
MCHC 35,0 32,0- 38,0 %
Gran% 85 50 – 81
Limfosit% 8,9 20 – 40
Gran# 15,82 2,5 – 7,0
Limfosit# 1,65 1,25 – 4,0
 Laboratory Finding
Examination Result Normal Value

Random Blood Glucose 292 <200.00 mg/dl

SGOT 14 5-34 u/l
SGPT 12 0-55 u/l
Ureum 232 10-50 mg/dl
Creatinin 8,27 0.6-1.2 mg/dl
Natrium 123 135-146 mmol/L
Kalium 4,4 3,4-5,4 mmol/l
Chlorida 92 95-100 mmol/l
Thorax X-Ray
Head CT Scan
 Diagnosis
DOC dt susp ensefalopati uremicum + ICH a/r ganglia basalis sinistra +
hyperglikemia
 Management
Treatment from Internist : Consult to Neurosurgery
• O2 nasal kanul 2 – 4 lpm • Conservatif management
• Ivfd NS rehidrasi 500 - 1.000 cc
• Inj citicoline 2 x 250 mg
• Inj omeprazole 1 x 40 mg
• Inj novorapid 3 x 16 iu
• Inj levemir 0 – 0 – 16
• Po. PCT 3 x 500 mg
• Po. Aminefron 3 x 1 tab