MORNING REPORT

Night Shift In Emergency Room

Saturday, April 13rd , 2019
19.00 p.m – 07.00 a.m

DM : Aisyah Imas Setiawati/6120018028

MEDICAL SPECIALIST: Dyah Yuniati, dr., Sp. S
Saturday, April 13rd , 2019 19.00 p.m – 07.00 a.m
1 in patient
1 patient diagnosis with BPPV
 Patient Identity
• NAME : Ny. T
• AGE : 59 y.o
• GENDER : Female
• MARRIAGE STATUS : Married
• EXAMINATION DATE : April 13rd, 2019
 ANAMNESIS
• MAIN COMPLAINT
Dizziness
• Current history
Patients come to the emergency room with complaints of dizziness. Complaints were felt after she wake
up in the evening. Complaints accompanied by and nausea and vomiting. The patient admitted the
complaints more worse when the patient moved her head and when she stand up. The complaints
become better when the patient rest while closing his eyes. There is no tinnitus. No decreased of hearing.
No double vision.
 ANAMNESIS

Past medical history :

Diabetes Melitus
Family history :
no one experienced same illness
History of drug use :
Glibenclamid 3x1
Metformin 3x1
 OBJECTIVE
• PHYSICAL EXAMINATION
• General state: Weak
• Awareness: compos mentis
• GCS: 456
• VAS: 0
• VITAL SIGN
• BP : 100/57 mmHg
• Pulses : 97x/min, regular
• RR : 18x/min
• Temperature : 36°C axillar
 NEUROLOGY EXAMINATION
• MRC right left
5 5
5 5

• NERVUS CRANIALIS
• NI : not evaluated
• N II : visus normal, visual field normal
• N III : Ptosis (-) PBI 3/3mm
• N III/ IV/VI : normal, nistagmus (-/-)
• N V : within normal limit
• N VII : within normal limit
• N VIII : within normal limit
• N IX/X : within normal limit
• N XI : within normal limit
• N XII : within normal limit
 PRIMITIF REFLEX
• FISIOLOGI REFLEX • Refleks palmomental : -/-
• BPR : +2 / +2
• Refleks Glabella : -
• TPR : +2 / +2
• KPR : +2 / +2 Cerebellar Sign
• APR : +2 / +2 • Finger to nose : Overshoot
• PATOLOGiCAL REFLEX • Disdiadokinesia : +
Refleks Babinski : -/ - MENINGEAL SIGN
Refleks Chaddock : - / - • KAKU LEHER : -
Refleks Oppenheim : - / - • KAKU KUDUK : –
Refleks Gordon : - / - • BRUDZINKY I : –

Refleks Schaffer : - / - • BRUDZINKY II : –

Refleks Gonda : - / - • BRUDZINKY III : –

Refleks Stransky : - / - • BRUDZINKY IV : -

Refleks Hoffmann/ Tromner : - / - • KERNIG SIGN : –

Additional Examination
• ECG
• Random plasma glucose : 368
• Laboratory Test :
ECG
 Leukosit 10.00 ribu/uL 3,8-10,6 ribu/uL

Basofil 0.442% 0-1 %

Neutrofil 89.93% 39,3-73,7 %

Limfosit 5.447% 25-40%

Eusinofil 0.030% 2-4 %

Darah
Monosit 4.150% 2-8 %
Lengkap
Eritrosit 3.88 juta/uL 4,4-5,9 juta/uL

Hemoglobin 12.17 g/dL 13,2-17,3 g/dL

Hematokrit 35,5% 40-50 %

Trombosit 361 ribu/uL 150-440 ribu/uL

MPV 6.420 fl 7.2 – 11.1

MCV 91.4 fl 80-100 fL

MCH 31.3 % 26.0-34.0 pg

MCHC 34.3% 32-36 %

11
•Fungsi Ginjal

BUN 10-20 mg/dL

28.0 mg/dL

Kreatinin 0,45 – 1,1

1.24 mg/dL
mg/dL

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 SOAP
Subjective Objective Assesment Planning
• Patients come to the - GCS 456 CLINICAL DX PLANNING DIAGNOSIS
emergency room with - BP : 100 / 50 - Dizziness Test Dix Halpike
complaints of dizziness. mmHg - Nausea BUN,SK
Complaints were felt after she - Pulse : 97x/minute - Vomiting CT Scan
wake up in the evening. - RR : 18x/minute GDA
- Temperature : 36,3 °C TOPIC DIAGNOSIS
• Complaints accompanied by
axillar Posterior canalis semicircularis Planning Theraphy
and nausea and vomiting.
- VAS : 0 (no pain) Eppley Manouver
• The patient admitted the Inf. RL 14 tpm
complaints more worse when ETIOLOGY DIAGNOSIS
Cerebellar Sign Inj. Diphenhydramine 10mg 3x1
the patient moved her head BPPV (Benign Positional Paroxysmal
Finger to nose : Inj. Ondancentron 4mg 2x1
and when she stand up. Vertigo)
Overshoot Tab Betahistin Mesilate 6 mg 3 x 1
• The complaints become Disdiadokinesia : + Tab Flunarizin 5mg 2 x 1
DD
better when the patient rest Meniere Disease
while closing his eyes. DIET
Vertigo central
Calori 30 ccal/kgWeight
• There is no tinnitus. Neuritis Vestibularis
• No decreased of hearing. Education and communication
SECONDARY DIAGNOSIS
Eppley manouver
• No double vision. Diabetes Melitus
Bed rest untill complaints gone
Avoid stress
avoid trigger factors
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JAZAKUMULLOH KHOIRON
KATSIR