CHAPTER I CASE ILLUSTRATION

1.1. Identity of Patient Name Sex Age Status Job Religion Race Address : Mrs. LL : Female : 53 years old : Married : Housewife : Christian : Chinese : Jatinegara, Jakarta Timur

1.2. Anamnesis

Chief Complaint Recurrent seizure that

History of Present Illness: Patient experienced seizure for the first time after 6 days of hospital care. Before, during and after the seizure patient was known to be unconscious. The seizure lasted around 1 minute and resolved by itself without any treatment. One-day later patient experienced second seizure with longer duration, 3 minutes, and patient was not conscious before, during and after the seizure. From patients husband, it is known that during the seizure, only right side of the patients body was shaking and head was told to turn to right side. Eyes were not turned up; mouth was not retracted to any sides. Patient was administered diazepam from IV line. Patient was unconscious after both seizures.

On December 2013 patient fell and found in the living room with bent legs. Patient didnt have any strength on both legs and could not stand. Patient was then taken to tukang urut once in a week but has no improvement. From December until before

admission, patient has never been able to stand nor walk, but patient are still able to use her hands. Patient was taken care by her husband, but still able to eat by herself. One week before admission patient started to have decreased consciousness and did not respond properly to questions and patient also sometimes have fever. Since then patient was brought to emergency unit. There was no history of headache, nausea/vomiting, coughing, difficulty in talking, blurred vision, swallowing, or seizure.

In 2012, patient was hospitalized in Persahabatan Hospital due to severe headache. Patient was diagnosed to have neurological abnormalities but it is not known for sure. Patient also took medication and was known to have improvement.

Past history of illness : In 2010, patient was diagnosed to have diabetes. Patient did not routinely take medication, the last 8 months patient never took any medication. Patient blood pressure was variable.

Family history

Patients mother had chronic kidney disease.

Social and life style history

Patient was a retired teacher. Patient has no activities at home. There was no history of smoking and alcohol consumuption. 1.3. Physical Examination General condition Consciousness Gait Blood pressure Heart rate Respiratory rate Temperature Skin : Moderate : Stupor : Can not be observed : 120/70 : 115x/min : 21x/min : 37.5 : Fair skin color, jaundice (-)

Eye

: Anemic conjungtiva (negative); icteric sclera (negative), Round pupil, isochor, diameter 3mm, direct light reflex +/+, indirect light reflex +/+.

Head ENT Neck

: Normochepal, no deformity. : Able to open her eyes when her name is mentioned. : Lymph node was not palpable; trachea located in the middle, JVP 5-2 cmH2O

Heart Lung Abdomen

: S1 S2 reguler normal, no murmur, no gallop : Vesicular/vesicular, rhonki -/-, wheezing -/: Flat, supple, hepar and lean are not palpable, tymphanic, bowel sound (+)

Extremities 2Neurological Status

: Warm, edema (-), weakness on both legs (+)

Glasgow comma scale: E4M6V5 Pupil : Size : 3mm/3mm

Shape : Round Direct light reflex : (+)

Undirect light reflex : (+) Convergent Isochoric : (+) : Yes

Meningeal sign Neck stiffness : negative Bruzinsky I : negative : > 70 o : >135 0

Bruzinsky II : negative Laseque Kernique

Cranial nerves There are no signs of hemiparesis of any cranial nerves.

N. I N. II

: not examined : normal

N.III, N.IV and N.VI : normal Eyelid : normal

Eye position : normal Eye movement: N.III N.IV N.VI N..V N.VII N.VIII N. IX, X N.XI N.XII OD OS

no paresis observed no paresis observed no paresis observed : no paresis observed : no paresis observed : could not be assessed : could not be assessed : could not be assessed : can not be assessed

Motorik Regarded as hemiparesis synistra (spastic) Upper Extremities Lower Extrimities Sensory Autonom Physiologic reflex : normal/normal : eutrophy/eutrophy : not examined : :

+2

+2

+2

+2

Pathologic reflex Babinski - / Oppenheim - / Gordon - / Schaefer - / -

Gonda - / Chaddock - / -

Laboratory Examination Peripheral Blood Count Hemoglobin Hematocrytes Leukocytes Trombocytes Result 17.5 51 32400 442000 Normal value 13.5-16.5 41-50 4500-10000 100000-450000

Clinical Chemistry SGOT SGPT Creatinine GFR Ureum 15 5 0.56 70.2 37 <27 <36 0.60-2.26 60.00-90.00 <50

Blood Gas Analysis pH pCO2 pO2 Total CO2 Base Excess O2 Saturation Standard HCO3 Standard Base Excess 7.350 33.10 139.10 19.50 -5.60 98.90 19.9 -7.4 7.350-7.450 35.00-45.00 75.00-100.00 21.00-25.00 -2.55-2.55 95.00-98.00 22.0-24.0

Electrolyte Natrium Kalium Chloride 129 4.0 90 132-147 3.30-5.40 94.0-111.0

Immmunoserology Procalcitonin 0.07 <0.1

Diagnosis Clinical diagnosis : Decreased level of consciousness, epileptic seizure, reactive

leukocytosis, hyponatremia. Topic diagnosis : Cerebral hemisphere sinistra

Pathological diagnosis: cannot be established Etiological diagnosis : SOL

Working diagnostic intracranial SOL

: Complex partial seizure dd/ simple partial seizure ec

Plan of diagnostic

CT-scan with contrast

Epilepsy Diagnosis Onset Symptoms Recurrence Localization Etiology : A: 3. Impaired Consciousness : B: 2b. Motor complex, 3. Impaired consciousness : C: 3. Recurrent : D: 1g. Hemispheric : E: 2c. Vascular dd/ 2d. Infection dd/ 2f. Metabolic

Management Non medikamentosa Consultation to internal medicine Head elevation 30 degrees Oxygen 3 lpm

Medikamentosa IVFD NaCl 0.9% 500 cc/24 hours

Liquid Diet 6x200 cc Cefepim 3x190 mg Levofloxacin 1x750 mg Omeprazole 2x40 mg Simvastatin 1x4 mg KCl pulv 3x500 mg Valsartan 1x80 mg

Prognosis Quo ad vitam Quo ad functional Quo ad sanatinam : dubia ad malam : dubia ad malam : dubia ad malam