Patient List

No Identity Admissio Diagnosis Treatment

n to E.R.
5. Mr. April 6th Observation of left VS Obs
Syarifuddin/ 2015 at hemiplegia due to susp IVFD NS
brain metastase primary Oxygenation
18.00
63yo/1-14 WITA
right lung tumour Inj antibiotic
-58-13 Inj analgesic-
antipiretic

Complete blood
count
Thorax X ray
Head CT SCAN
(from reffering
hospital)

Consult to
Neurosurgeon
Head CT SCAN
with contrast
Hospitalised

C
A L R T
ECG
5. Mr. Syarifuddin/ 63yo/1-14 -58-13
April 6th 2015 at 18.00 WITA
Chief Complain :
Paralysed left upper and lower extremities
History :
2 weeks before admission patient began felt weakness
on his left extremities. Its gradually getting weaker day by
day until he no longer able to move both of his left lower
and upper extremities. The patient also lost his ability to
talk, so no more verbal communication was able to
conduct. The patient had complained persistent cough for
recent month. Its getting more often day by day. History of
bloody cough was denied. History of long persistent cough
before was denied. He was brought to Dorrys Sylvanus
Hospital before got referred to Ulin Hospital for further
treatment
C
L R T
ECG
Vital Sign
BP : 140/90 mmHg
PR : 88 bpm
RR : 24 tpm
T : 36,7oC
SpO2: 94%

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ECG
 Head/Neck
General Status

5 0

5 0
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ECG
Neurological Status

GCS E4V5M6 (15), Round and

symmetric pupils diameter
(3mm/3m), Light reflexes (+/+),
Brill hematom (-/-), Battles sign
(-/-), parese (-), lateralization (-)
C
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ECG
Cranial Nerves
NI : Hard to evaluate
NII : (+/+)
NIII : (+/+)
NIV: Hard to evaluate
NV ; Hard to evaluate
NVI; Hard to evaluate
NVII : Hard to evaluate
NVIII : Hard to evaluate
NIX: Hard to evaluate
NX : Hard to evaluate
NXI: Hard to evaluate
NXII : Hard to evaluate
Clinical Pictures

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ECG
Local Status

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ECG
Laboratory Result April
6 2015
th

Items Result Normal Value Unit

Hemoglobine 12,0 14.00 - 18.00 g/dl

Leukocyte 12,6 4.0 10.5 thousand/ul

Eritrocyte 4,28 4.00 5.50 million/ul

Hematocrit 35,3 32.00 44.00 Vol%

Thrombocyte 214 150 450 Ribu/ul

RDW-CV 14,7 11.5 14.7 %

MCV 82,5 80.0 97.0 Fl

MCH 28,0 27.0 32.0 Pg

MCHC 33,9 32.0 38.0 %

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ECG
 Items Result Normal Value Unit

Gran% 79,7 50.0-70.0 %

Lymphosite% 12,0 25.0-40.0 %

MID% 8,3 4.00-11.00 million/ul

Gran# 10,10 2.50-7.00 Billion/ul

Limfosit # 1,5 1.25-4.0 Billion/ul

MID# 1 Billion/ul

C
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ECG
 Items Result Normal Value Unit
GDS 106 <200 Mg/dL

SGOT 90 0-46 U/l

SGPT 133 0-45 U/l

Ureum 37 10-50 mg/dL

Creatinin 0,7 0,7-1,4 mg/dL

Natrium 130,8 135-146 mmol/L

Kalium 4,6 3,4-5,4 mmol/L

Chloride 95,6 95-100 mmol/L

C
A R ECG
Thorax X-Ray April 6th 2015

C
A L ECG
T
Head CT-SCAN March 30th 2015 at
Palangkaraya Hospital

A L R ECG
Working Diagnosis
Observation of left hemiplegia due to
susp brain metastase primary right
lung tumour

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ECG
Management
VS Obs
IVFD NS
Oxygenation
Inj antibiotic
Inj analgesic-antipiretic

Complete blood count

Thorax X ray
Head CT SCAN (from reffering hospital)

Consult to Neurosurgeon
Head CT SCAN with contrast
Hospitalised
C
A L R T
ECG