Morning report

Friday 18/12/2015

ER

: dr. Rustina

Consultant

: dr. Marthin

Stroke unit

: dr.Christine

Ward

: dr. Daniel-dr.Theo

PATIENTS IDENTITY
Name

: Mrs. J

Age

: 38 years old

Gender

: Female

Occupation

: Housewives

MR Number

: C071612

Hospital admission : 17/12/ 2015

HISTORY (alloanamnesis)
Chief complaint
Onset

: decreased consciousness

: 4 days before hospital

admission
Location

: intracranial

Quality

: can be awaken with hard

stimulation
Quantity

: ADL dependent

HISTORY
Chronology :
1 months before Hospital Admission family said patient
complained headache (+)continuously, vomit (+), weakness (-),
tingling sensation, seizures(-).
2 weeks before hospital admission, family said that, patient start
to feel weakness ,patient had difficulty to walk, she need help to
walk headache became more severed, continuously, vomit (+),
Family said she started cant understand with conversation, but still
can talk fluently, then she brought to Ketileng Hospital(+), she had
some pain killers and her complaint about her headache decreased,

 4 days before hospital admission, family said she

she cant understand with any kind of conversation,
her headache become more severe didnt relieve
with pain killer. She cant walk, seizures (-), vomit (+).
1 days before hospital admission, family said the
patient looks unconscious, she started not to eat,
cant

communicate,

seizures(-),fever(-).

she

cant

walk,

HISTORY
Aggravated Factors : Extenuated Factors : Concomitant Symptoms : headache(+),
Vomit(+), weakness

HISTORY
Past Medical History
- Same complaint before denied
- Hypertension denied
- DM denied

CLINICAL FINDINGS
Present States
GCS
: E2M4V2
Vital signs
:
BP : 120/70 mmHg
HR : 80x/min
RR : 20x/min
Temp 36.5 (axilla)
Eye
: round pupil, isocor 3/3 mm,light reflex +/+
Thorax
: normal breathing, Rh-/-, Wh -/normal heart sound, murmur (-),gallop
(-)
Abdomen : unpalpable liver and spleen, ascites (-)

 Nn Craniales

: difficult to asses

Sensibilitas : difficult to asses

Vegetatif
: difficult to asses
Motorik
Movement

Superior

Inferior

+/ +

Strenght

+/ +

Lateralisation (-)

Tonus

N/N

N/N

Trof

E/E

E/E

RF

+++/+++

+++/+++

RP

+H,T/+H,T

+B,C/+B,C

Klonus

-/-

LABORATORY (17-12-2015)
Laboratory
Hb
Ht
Eritrosit
MCH
MCV
MCHC
Leukosit
Trombosit
RDW
MPV
Ur
Cr
GDS
Sodium
Kalium
Potassium

Value
13.1
41.3%
4.56 juta/mmk
29,9 pg
89.0 fl
34.3 g/dl
56.000/mmk
402.000/mmk
13.5
7.34
73 mg/dl
1.2 mg/dl
138 mg/dl
139 mmol/L
3.7 mmol/L
101 mmol/L

Normal Value
13-16
40-54
4,4-5,9 juta
27-32
76-96
29-36
3600-11000
150-400ribu
11.6-14.8
4-11
15-39
0,6-1,3
80-160
135-145
3,5-5,1
98-107

Head MSCT without Contras

17 -12- 2015

Head MSCT with Contras

17 -12- 2015

Impression
Hiperdens Lesion in Left Frontotemporal
Lobe with perifocal edema
Probably Intracerebral Hemmorhage

Chest X-Ray AP

Impression
Cor
Pulmo

: Normal state
: Normal State

ECG 17/12/2015

Impression : Normo Sinus Rhythm, with Non

Specific ST Changes

Ophtalmologist
Impression

: Papil Oedema ODS

DIAGNOSIS
Clinical Diagnose
Obs Unconsciousnes
Chronic Cephalgia
Topis Diagnose
Left Frontotemporal Lobe
Etiology Diagnosis
Susp Intratumoural Hemmorhage

Therapy
1. Consult : Ophtalmologist, RM
2. Therapy :
O2 3l/I nasal canul, head elevation 30 degree

IVFD RL 30 dpm
Inj Ranitidine 50 mg/12 hoursIV
Inj Deksamethasone 10 mg/ 6 h.o IV
Vitamin B1B6B12 1 tab/ 8 h.o P.O
InjTranexamat Acid 500 mg/ 8 h.o IV

 MONITORING :
GCS, vital signs, neurologic defcits, fluid
balance
EDUCATION :
diagnosis, management, complications,
prognosis

THANK YOU