Duty Report

Tuesday June 2nd, 2015

ER: dr. Henny

Consult : dr. Astari
Stroke Unit : dr. Fati
Ward: dr. April and dr. Theo
 Patient Identity
Name : Mr. M

Age : 65 years old

Address : Semarang

Occupation : Farmer

Class : III/ BPJS

Room : Rajawali 3B

Admission date : June 2nd, 2015

Registry. : C508198
 RECENT HISTORY
Main Problem : Weakness on right side extremity
Location : Right extremity
Onset : 2 weeks before admission
Quality : Right Upper extremitty can move right
or left side, right lower extremity can
move against gravity
Quantity : ADL helped by family.
 Cronology:

2 weeks before admission, patient feel weaknes on his right

extremity, it become more severe so he cant walk by himself.
2 days before admission patient also feel headache (+), heavy to
breath (+), difficult swallowing (+), seizure (-), double vision (-),
blur vision (-), vomit (-). urinate & defecation within normal.

Medical History :
6 months before admission, patient had a craniotomy because of
intracranial tumor
Aggravating factor :-
Relieving factor :-
Other Symptoms : hard to breath, headache, difficult
swallowing
 PAST HISTORY
- 6 months before admission patient had a craniotomy because of
intracranial tumor

FAMILY HISTORY
- No records of similar disease
SOCIAL-ECONOMY HISTORY
Class 3 BPJS
 Physical Examination
GCS E4M6V5
Vital Sign :
BP: 110/80 mmHg
HR : 100x /minute
RR : 28x / minute
T : 36 C
 NEUROLOGICAL STATUS
Head : Mesocephal, Simetris

Eye : Pupil round, isochor, 3mm/ 3 mm,

Light reflex +/+ (normal)

Neck : nuchal rigidity (-)

Cranial nerves : N. VII & XII right central paralysis

 Motoric Superior Inferior
Movement /+ /+
Strength 222/555 331/555
Tonus /N /N
Trophy E/E E/E
Physiologic Reflex +++/++ +++/++
Pathologic Reflex H/- -/-
Clonus -/-

Sensibility : whitin normal

Vegetative : whitin normal

LABORATORIUM and
Additional
examination
 Laboratory Examination 02/06/2015
Examination RESULT Normal Point

Routine Hematology

Hb 13,7 13 - 16 g/dl

Ht 41,8 40 52 %

Erythrocyte 4,9 4.3 - 6.0 mil /ul

Leukocyte 9.300 4800 - 10800/ul

Thrombocyte 349.900 150000 - 400000/ul

MCV 86,2 80 96 fL

MCH 28,3 27 - 32 pg

MCHC 32,8 32 36 g/dL

 Examination Result Normal point

Kimia klinik:
Ureum 50 20 - 50 mg/dl
Creatinine 1,02 0.5 1.5 mg/dl
Random glucose level 110 < 140 mg/dl
Sodium 138 135 147 mmol/L
Potassium 4,0 3.5 5.0 mmol/L
Chloride 108 95 105 mmol/L
 June 2nd 2015
X-foto Thoraks
Right cor border
covered
Nodular spotting
on upper-center-
lower left pulmo
& right pulmo
metastatic
suspicious
Right pleural
effusion
Theres no
metastatic view
on bones
 Brain MSCT
Des 24th 2014
Slightly solid
enhancement
intracranial solid
mass, lobulated,
not stricted &
irreguler line on
left
temporoparietal
lobe with
perofocal edema
suspected as
anaphlastic
astrocytoma
Increase
Intracranial
pressure sign
DIAGNOSIS
I. Clinical Diagnostic :
Spastic right hemiparesis
Chronic Progresive Cephalgia
Disphagia
Topis Diagnostic : left temporoparietal lobe
Etiology Diagnostic : Intracranial tumor (post
craniotomy)
II. Pleural effusion
 Brain MSCT
NGT
BGA laboratory
Program Consult Physical medic rehabilitation
Consult Physical Nutrition
Consult Internist
Consult Surgeon

O2 3 lpm
IVFD RL 20 dpm
Therapy Inj Dexamethasone 10 mg / 8hrs (i.v)
Inj. Ranitidin 50 mg/12hrs (i.v)
Paracetamol 500 mg/ 8 hrs (p.o)
 Vital sign, GCS ,
Neurologic Deficite
MONITORING

DIAGNOSIS,
THERAPY,
EDUCATION PROGNOSIS