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    Morning Report 3

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    chandra
    The patient is a 47-year-old male who presented with seizures. He experienced two seizures within an hour of each other, with shaking of the arms and legs and tongue biting. His vitals were stable. On examination, he had normal strength and reflexes. Blood tests showed elevated glucose and liver enzymes. The working diagnosis was Wernicke Korsakoff Syndrome based on his history of heavy alcohol use. Treatment included IV fluids, antacids, and anticonvulsants. CT scan of the head was recommended to further evaluate the seizures. The prognosis for life, function, and recovery was guarded.

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    Morning Report 3

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    chandra
    1 views17 pages
    The patient is a 47-year-old male who presented with seizures. He experienced two seizures within an hour of each other, with shaking of the arms and legs and tongue biting. His vitals were stable. On examination, he had normal strength and reflexes. Blood tests showed elevated glucose and liver enzymes. The working diagnosis was Wernicke Korsakoff Syndrome based on his history of heavy alcohol use. Treatment included IV fluids, antacids, and anticonvulsants. CT scan of the head was recommended to further evaluate the seizures. The prognosis for life, function, and recovery was guarded.

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    morning report

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    The patient is a 47-year-old male who presented with seizures. He experienced two seizures within an hour of each other, with shaking of the arms and legs and tongue biting. His vitals were stable. On examination, he had normal strength and reflexes. Blood tests showed elevated glucose and liver enzymes. The working diagnosis was Wernicke Korsakoff Syndrome based on his history of heavy alcohol use. Treatment included IV fluids, antacids, and anticonvulsants. CT scan of the head was recommended to further evaluate the seizures. The prognosis for life, function, and recovery was guarded.

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    1 views17 pages

    Morning Report 3

    Uploaded by

    chandra
    The patient is a 47-year-old male who presented with seizures. He experienced two seizures within an hour of each other, with shaking of the arms and legs and tongue biting. His vitals were stable. On examination, he had normal strength and reflexes. Blood tests showed elevated glucose and liver enzymes. The working diagnosis was Wernicke Korsakoff Syndrome based on his history of heavy alcohol use. Treatment included IV fluids, antacids, and anticonvulsants. CT scan of the head was recommended to further evaluate the seizures. The prognosis for life, function, and recovery was guarded.

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    of 17

    Jaga 09 April 2017

    Pembimbing: dr. Helly Habiballoh Luqmansyah, Sp.S


    Identitas Pasien
    Nama : Tn. A. Arun
    Usia : 47 tahun
    Jenis Kelamin : laki-laki
    Anamnesis
    Keluhan Utama
    Kejang
    Anamnesis
    Riwayat Perjalanan Penyakit
    Pasien kejang sebelum datang ke IGD, berdasarkan
    keterangan keluarga, pasien mengalami 2 kali kejang
    dengan durasi ± 15 menit dan selang waktu ± 1 jam
    diantara 2 kejang. Mata menoleh ke atas, lengan dan
    kaki kelonjotan dan lidah tergigit. Mual (-), muntah (-),
    sakit kepala (-), demam (-).
    Riwayat konsumsi alkohol ± 1 liter/hari.
    Anamnesis
    Riwayat Penyakit Dahulu
    Riwayat kejang sebelumnya disangkal
    Riwayat hipetensi disangkal
    Riwayat DM disangkal
    Riwayat penyakit jantung disangkal
    Pemeriksaan Fisik
    Tanda-tanda Vital
    TD : 150/100 mmHg
    HR : 92x/menit
    RR : 20x/menit
    T : 36,4oC
    Pemeriksaan Fisik
    Status Generalis
    Mata : CA (-/-), SI (-/-), RCL (+/+), RCTL (+/+)
    Leher : Tidak ada pembesaran KGB
    Cor : S1S2 reg, G(-), M(-)
    Pulmo : SND Ves (+/+), Rh (-/-), Wh (-/-)
    Abd : Soepel, BU (+)
    Ext : Akral hangat (+), edema (-)
    Pemeriksaan neurologis
    Kesadaran : E4V5M6
    Meningeal sign
     Kaku kuduk (-)
     Laseque (-)
     Kernig (-)
     Brudzinski 1 (-)
     Brudzinski 2 (-)
     Brudzinski 3 (-)
     Brudzinski 4 (-)
    Pemeriksaan neurologis
    Pemeriksaan saraf kranial
    N I Normosmia
     N II sulit dinilai
     NIII, NIV, NVI
    Pupil : Bentuk bulat, isokor, diameter 3 mm
    CA (-/-), SI (-/-), RCL (+/+), RCTL (+/+)

     NV
    Refleks Kornea (+/+)
     NVII
    Kesan Parese (-)
    N VIII sulit dinilai
    N IX sulit dinilai
    N X sulit dinilai
    N XI sulit dinilai
    NXII
    Atropi lidah (-)
    Fasciculasi (-)
     Kekuatan Motorik
    555 555
    555 555

     Refleks Fisiologis
    ++ ++
    ++ ++
    Pemeriksaan Laboratorium
    Parameter
    Leukosit
    Hasil
    6,67
    Satuan
    [10^3/µL]
    Nilai Normal
    4,5-11
    Hemoglobin 16.3 [g/dl] 13.6-18
    Eritrosit 5.80 [10^6/µL] 4.7-6.1
    Trombosit 321 [10^3/µL] 150-450
    GDS 159 [mg/dl] <140
    Ureum 9 [mg/dl] 10-50
    Creatinin 1,2 [mg/dl] 0,7-1,3
    Natrium 138 [mg/dl] 135-145
    Kalium 2,4 [mEq/L] 3,5 -51
    Albumin 3,48 [G/dl] 3,8-5,1
    GOT 93 [U/l] 0-37
    GPT 65 [mEq/L] 0 -42
    HBsAG Non Reaktif
    Diagnosis kerja
     Klinis : Serial tonik Sizzure Status
     Topis : Hemisfer serebri
     Etiologi : Wernicke Korsakoff Syndrome (WKS)
    Saran Pemeriksaan Penunjang
     CT scan Kepala
    Tatalaksana
     O2 2 lpm
     IVFD RL + KCL 10 tpm
     Inj.Omeprazol 40mg/24 jam
     Inj. Ondansentron 4 mg/8 jam
     Spironolactone 50 mg 1-0-0
     Sukralfat 3x1
     Inj.Midazolam 5 mg IV bolus lambatbila kejang
    Prognosis
     Quo ad vitam : Dubia ad bonam
     Quo ad functionam : Dubia ad bonam
     Quo ad sanactionam : Dubia ad bonam
    Terima Kasih

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