Ward rounD RePoRT

Identity : Mrs. NM, 28 yo

Dx : cerebral infarction
onset day 10, Secondary
headache
Los : 10 days
History Taking
chief complain : weakness in the right extremities, suddenly 2 days
ago and headache
patient came with chief complain the gradual loss of
conciousness 5 days before admission.The patient seemed
drowsy but was still able to be comunicated with and it got
worsen until 2 days before admission where the patient felt
the right side of limb could not be moved.
The patient also had headache. It felt like the head being
squeezed and it came and went and got better with pain
medicine only to resurface again. The patient felt headache
since 2 month ago and gets worse 2 weeks ago like
headachet gets worse when the patient strained and
coughed. The patient also admitted to be easily awake at
night. The patient also vomitted 2 days before admission
which happend 3 times and they were non projectile ones.
After vomitted, the patient became hard to be awaken.
Past History
Hypertension, kidney disease, hyper cholesterol and uric
acid, heart disease were denied.
Physical Examination
General status:

General condition: mild, awareness: somnolen

BP: 120/ 80.mmHg, HR: 98 x/m reg,

RR: 24 x/m , T: 37 C ,SO2 : 98% .

Neck: Deformity (-)

Thorax: Simetric Dextra=Sinistra, Rh-/-, Wh -/-, sign of injury (-)

Abdomen : soepel, normal turgor, normal peristaltic

Extremities : warm acral

Neurologic examination
GCS : E3M6V4 (13) perrl +/+ 3 mm/3mm

Meningeal Sign: Nuchal rigidity(-),Laseque (>70/>70)

,Kernig(>135/>135)

Cranial Nerves : paresis right N.7 umn

FODS cupping (+), orange, border (+), A:V 2:3

Motoric State : right hemiparesis

MT : / N FR : + /+/+/I++/++/++ PR : - / -
/ N +/+ I ++/++ -/-

Sensoric State : could not be evaluated

Autonomic State : inkotinentia urinet alvi -/-

Planning

O2 adequate 4-6 lpm via nasal kanul

Bed Rest + head elevation 30
Pro Cateter and NGT Urin
IVFD Nacl 0.9% 21 tpm
Ranitidin 2x50 mg IV
Loading dexamethasone 10 mg continued tappering off
start from 4x5 mg
Paracetamol 3x500 mg via NGT
CIE
 Brain CT Scan + Contras
EKG
Ro Thorax
Lab
Ro THorax
Laboratory
Hb : 15.4 g/dL SGOT : 28U/L

Ht : 39.9% SGPT : 25 U/L

WBC : 9200/uL Glucose : 112 mg/dL

PLT : 226.000 /uL

RBC : 5.240.000 /uL
Cr : 15 mg/dL
Ur : 0.5 mg/dL
Na :135 mEq/L
ECG

Normo Sinus Rhytm

Brain CT Scan
Wdx
Cerebral infarction onset day 10

Secondary headache
Planning Th
Bed Rest Head Elevation 30

O2 2-4 l/m via nasal canule

chest Physiotherapy + oral higiene

Mobiliation left and right/ 2 hour

IVFD : NaCl 0,9% 500 cc 20 gtt

Inj Ranitidine 50 mg 2x1 amp (iv)

Paracetamol Tab 500 mg 3x1

Ibuprofen Tab 200 mg 2x1

Aspilet Tab 80 mg 1x1

Planning
Check Fasting Laboratory

Consult Neurorestoration

Consult divisi pain

Follow up November 9th 2017
GCS : E4M6V5 (15) perrl +/+ 3 mm/3mm

Meningeal Sign: Nuchal rigidity(-),Laseque (>70/>70)

,Kernig(>135/>135)

Cranial Nerves : paresis right N.7 umn,

Motoric State : right hemiparesis

MS 11115555

1111 5555

MT : / N FR : + /+/+/I++/++/++ PR : - / -
/ N +/+ I ++/++ -/-

Sensoric State : normoestesia

Autonomic State : inkotinentia uri et alvi -/-

Therapi
Bed Rest and Head Elevation 30

IVFD NaCl 0,9% 500 cc 21 tpm

Aspilet 80 mg 0-1-1

Simvastatin 20 mg 0-0-1

Lactulac 0-0-2 c

Paracetamol 3x500 mg prn

Ranitidin 2x150 mg
Planning
Consult Neurorestorasi
Thank You