Ward Round Report

Friday, 2017, August 25th

 Identity
Mr. BPJ, 76 yo
Diagnosis :
CVD SI anterior onset 3rd day
emergency HPT (Hipertensi?)
Hiperlipidemia
Hiperurisemia
Anemia pro.... suspect prerenal (8.9 g/dL)
suspect UTI (Urinary Tract Infection)
AKI DD/CKD
LOS : 6 days
Chief Complain : right limbs weakness
 History Taking
4 days before admission, he went to see
doctor because he wasnt feeling well
3 days before admission, he woke up to go to
bathroom then he realized the weakness of
his right limbs.
slurred speech (+), headache (-),
Nausea (-), vomiting (-).
Blurred vision(-)
 Past History
History of uric acid (+)
History of HT (-)
History of DM(-)
History of Hypercholesterolemia (-)
Medication:
CPG 75mg 1 times a day
Piroxicam 80 mg 3 times a day
Amlodipine 5 mg 1 times a day
N.. (ga kebaca)
 Physical Examination first day onset

General condition: moderate sickness

Consciousness: compos mentis
T: 210/120 mmHg, pulse 80, resp 20, temp
36,6
GCS 15
PERRL +/+, diameter 3/3 mm.
Meningeal signs: no neck stiffness.
Nn. Craniales: paresis N VII and XII type UMN
 Physical Examination
Motoric examination:
MS : 5555 4444
5555 2
MT : N
N
PhyR : ++/++/++ +/+/+ PatR : - -
++/++ +/+ - -

Sensoric examination: normoaesthesia.

Otonom status: no incontinentia urine et alvi.
Physical Examination 8th day onset (ane ga tau
datanya, ini apa ente isi sendiri?)
General condition: moderate sickness
Consciousness: compos mentis
T: 100/60 mmHg, pulse 80, resp 20, temp 36,7
GCS 15
PERRL +/+, diameter 3/3 mm.
Meningeal signs: no neck stiffness. Kerniq sign
-/-, Lasegue sign -/-.
Nn. Craniales: paresis N VII dextra type UMN
 Physical Examination
Motoric examination:
MS : 2222 5555
3333 5555
MT : N
N
PhyR : +/+/+ ++/++/++ PatR : - -
+/+ ++/++ - -

Sensoric examination: normoaesthesia.

Otonom status: no incontinentia urine et alvi.
 Laboratory Report (5 May 2017)
th

Leucocyte 14190
Erythrocyte 3.10 x 10^6
Hb 8.9
Thrombocyte 652.000
SGOT25
SGPT 27
Ureum 28
Creatinine 1.4
Random blood sugar 89
Chloride 95
Kalium 3.8
Natrium124
Brain CT
Chest X-Ray
 EKG
Sinus rhytm 90 x/m
 Diagnosis
CVD SI anterior onset 3rd day
emergency HPT (Hipertensi?)
Hiperlipidemia
Hiperurisemia
Anemia pro(isi sendiri ane ga kebaca) suspect
prerenal (8.9 g/dL)
suspect UTI (Urinary Tract Infection)
AKI DD/CKD
 Treatment
Bed rest and elevation of the limbs by 300
Ranitidin 2x50mg inj.
Paracetamol 500 mg 3x1 P.O.
Atorvastatine 20 mg 0-0-1 P.O
CPG 75mg 0-1-0
Nicardipine 10 mg in NaCl 0.9% 500cc start 50
dpm
Treat together with internal dept.