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    Status Epilepticus

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    Rivan Ho
    The document lists the doctors on duty and includes statistics on 10 patients seen at the hospital. It then provides detailed history, physical examination findings, diagnosis, planning and test results for a 35-year-old female patient admitted with seizures and unconsciousness. Key details include the patient experiencing multiple seizures with jerking and extended limbs, being unconscious between seizures. Her past medical history includes a brain surgery in 2004. Exams find abnormal heart rhythm and brain CT scan. She is diagnosed with status epilepticus.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Status Epilepticus

    Uploaded by

    Rivan Ho
    21 views17 pages
    The document lists the doctors on duty and includes statistics on 10 patients seen at the hospital. It then provides detailed history, physical examination findings, diagnosis, planning and test results for a 35-year-old female patient admitted with seizures and unconsciousness. Key details include the patient experiencing multiple seizures with jerking and extended limbs, being unconscious between seizures. Her past medical history includes a brain surgery in 2004. Exams find abnormal heart rhythm and brain CT scan. She is diagnosed with status epilepticus.

    Original Description:

    Status epileptikus

    Original Title

    Status Epilepticus (2)

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    The document lists the doctors on duty and includes statistics on 10 patients seen at the hospital. It then provides detailed history, physical examination findings, diagnosis, planning and test results for a 35-year-old female patient admitted with seizures and unconsciousness. Key details include the patient experiencing multiple seizures with jerking and extended limbs, being unconscious between seizures. Her past medical history includes a brain surgery in 2004. Exams find abnormal heart rhythm and brain CT scan. She is diagnosed with status epilepticus.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    21 views17 pages

    Status Epilepticus

    Uploaded by

    Rivan Ho
    The document lists the doctors on duty and includes statistics on 10 patients seen at the hospital. It then provides detailed history, physical examination findings, diagnosis, planning and test results for a 35-year-old female patient admitted with seizures and unconsciousness. Key details include the patient experiencing multiple seizures with jerking and extended limbs, being unconscious between seizures. Her past medical history includes a brain surgery in 2004. Exams find abnormal heart rhythm and brain CT scan. She is diagnosed with status epilepticus.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 17

    Doctors On Duty :

    dr. Rivan
    dr. Riane
    dr. Bill
    dr. Hendy
    dr. Ronald
    dr. Chenny

    DPJP : dr. Arthur Mawuntu, Sp.S


    Statistic :
    1. Mrs. HS/ 75 yo / Dlx : Paraparesis LMN ec LBP ec
    Spondilosis
    2. Mrs. HK /19 yo / Dx : TB Paru putus obat + Susp. TB
    MDR
    3. Mrs. DM/ 78 th / Dx : CVD SI Emboli onset 2nd day
    4. Mr. AN/ 38 yo / Dx : Severe Head Injury
    5. Mr. WF/ 38 yo/ Dx : CVD SI + Afasia + Disfagia
    6. Mr. MG/ 8yo/ Dx : Severe Head Injury
    7. Mrs. PE / 76 yo / Dx: Unconsciouss ec Metabolic
    8. Mrs. SK / 35 yo / Dx : Status Epilepticus
    9. Mr. RAR / 23 yo / Dx : Moderate Head Injury
    10. Mrs. KL / 64 yo / Dx : Meningoencephalitis TB
    History Taking
    Woman, 35 yo was admitted to hospital with chief complaint seizure 2 hours
    and unconsciousness before hospital admission.

    Seizure > 6x
    Seizure:
    - pre iktal : Headache ( + )
    - iktal : Each seizure 3-4 minutes, during seizure his arms and legs were
    jerking and then extended, left ward glancing of the eyes(+),
    foaming mouth (+), wet his panties (+). He was unconscious during
    seizure
    -Post iktal : unconsiousness (+)

    Seizure interval : 15 minutes 20 minutes after the previous seizure with same
    pattern
    Febris (-)
    Slurred speech (-). Mouth deviation (-)
    Dizziness (-), dispneu (-)
    Vomit (-), nausea (-)
    History of Past Illness
    History of Trauma (+) year 2004 with operating
    trepanasi
    Seizure (+) since 2006
    Febrile convulsion (-)
    Stroke, DM, kidney disease, Uric Acid, Lung disease ,
    Cholestrol , Heart Disease were all denied.
    Physical Examination
    General status:
    General condition: severe. unconsciousness: Coma(after
    diazepam injection)
    BP: 150/100 mmHg HR: 110 x/m reg, RR: 26 x/m , T: 36,7
    C ,SO2 : 98%
    Conjungtiva : anemis (-/-), sclera ikteric (-/-)
    JVP ; normal
    Thorax : Rh -/-, Wh -/-, heart sound I/II normal, gallop -
    , murmur
    Abdomen : soepel, normal turgor, normal peristaltic
    Extremitas : warm acral
    Neurologic examination
    GCS E2M5V3 (10) PERRL, +/+ 3 mm/3 mm;
    Meningeal Sign: Nuchal Rigidity (-) laseque (-/-) kernig (-)
    Cranial Nerves: paresis impression(-)
    Funduscopy: color orange, border of papil clear, cupping (+),
    A:V 1:3
    Motoric State : Hemiparesis impression(-)
    MT : N N FR : ++/++/++ ++/++/++ PR : - -
    N N ++ ++ ++ ++ - -
    Sensoric State : not evaluated
    Autonomic State : incontinentia urine et alvi (-)
    WDX
    Status Epilepticus
    Planning
    Head neck back elevation 30
    O2 nasal 6-8 lt/mnts
    IVFD NaCl 0,9% 500 cc 14 gtt/mnts
    Diazepam inj 5 mg (IV) repeated 2 times and continue with
    status epilepticus management : NaCl 0,9 % 100 cc + 10 amp
    fenitoin (20 minute)
    Paracetamol 500 mg 3x1 (IV)
    Inj Ranitidin 2x1 amp (iv)
    Fenitoin cap 3x100 mg
    Folic Acid tab 2x1
    NGT and catheter (approval from fam)
    Obs VS/GCS/ pupil per hour
    Lab
    EKG + Expertise
    Brain CT Scan
    X Foto Thorax
    ECG
    Sinus Rythm with Left Atrial Abnormality
    Laboratory Examination
    Hb : 12.2
    Ht : 35.4
    WBC : 15.500
    PLT : 409.000
    RBC : 4,06x106
    SGOT : 30
    SGPT : 29
    GDS : 147
    Kreatinin : 1,1
    Ureum : 26
    Na : 147
    K : 4,70
    Cl : 106,0
    Chest X-RAy
    Brain CT-Scan
    TERIMA KASIH

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