MORNING REPORT

MORNING REPORT 6TH NOVEMBER 2017

On Duty :
- dr. Andisty
- dr. Leopold
- dr Inggread
- dr. James
- dr. Adryan
- dr. Yonathan
- dr. Eudon
- dr. Carolina
- dr. Joanita
DPJP : dr. Sekplin Sekeon MPH, Sp.S
STATISTIC
Mr. ATB / 45 yo / Unsconsciousness ec cerebral hemoragic region thalamus sinistra
vol 18.75 cc onset day 1.
Mrs HS / 48 yo / Unsconsciousness ec metabolic
Mr. ME / 49 yo / mild head injury
Mrs TY / 42 yo / Tention type Headache
Mr. YK / 20 yo / Mild head injury
Mrs. TW / 36 yo / Reattack cerebral infarction onset day 1
Mr. FT / 52 yo / Unscnsciousness ec susp SSP Infection
Mr. JP / 69 yo / LBP
Mr. TA / 36 yo / Susp Abses Cerebri
Mr. PN / 45 yo / Commotio Cerebri
Mr. NK / 47 yo / Unsconsciousness ec cerebral hemoragic region ganglia basalis
dextra
CHIEF COMPLAIN
Unsconsciousness
 5 hours before admission At hospital
Male 45 years old, came with sudden loss of Unsconsciousness
consciousness 5 hours before admission. Before
that,patient was changing the clothes. Suddenly
the patient felt headache on the front part that
strechtes to the back with stabbing like pain. The
complaine happened along with slurred speech
and the weakness of right limbs. Vomit (-), seizure
(-), double vision (-), fever (-), trauma (-), ear
dying (-). The weakness of right limbs was
residing. This complained was the first time for
patient. Patient seemed drowsy but was still
responsed if the family call his name and 3 hours
before admission the patient became hardly to be
awaken. Patient reffered to advent hospital and
after Brain CT scan, the patient reffered to RSUP
HISTORY PAST ILNESS
Hipertension (+) uncontrolled 5 years ago.
Diabetes mellitus (-), Cholesterol (-), Heart disease (-), kidney disease (-), stroke (-).

Habbit :
Smoking (+)
Alcohol (-)
 Physical Examination
General examination:
General condition: moderate, consciousness :
somnolen
BP: 200/120 mmHg, HR: 102x/m reg, RR: 24x/m
T: 36C MABP 146.67
Conjunctiva: pale (-/-), sclera ikteric (-/-)
Thorax: rale -/-, wh -/-, heart sound I/II normal,
gallop -, murmur -
Abdomen : flat, normal turgor, peristaltic normal
Extremities : warm acral
 Neurological Examination
GCS : E3M5V4, PERRL +/+ 3 mm/ 3mm
Meningeal Sign : nuchal rigidity (-), Lasegue (<70/<70), Kernig
(<135/<135)
Cranial Nerves : paresis impresion N VII UMN D
Funduscopy ODS : papil (round), cupping disc (+), A:V (2:3)
orange
Motoric State : hemiparesis impresion D
MT: Phy R: Path R:
N +/+/+ ++/++/++ - -

N +/+ ++/++ - -
Babinski
Sensoric State : cannot be evaluated
Autonomic State : incontinence urine et alvi via cateter -/-
AGM Cerebral Hemoragic

SSS (2.5x2) + (2x1) + (2x0) + (0.1x120) (3x0) 12 = 7 Cerebral

Hemoragic
 Diagnosis
Unsconsciousness ec Cerebral Hemoragic onset
day 1
Hypertension Emergency

 Planning
Communication, information, education
02 2-4 /Lpm
Bed Rest + Head elevation 30
Oral Hygiene + chest phisiotherapy
Pro NGT + cateter
Lab
ECG and expertise
Chest X-Ray
Obs GCS, TTV, Pupil
IVFD NaCl 0.9% 500cc/8 hours
Paracetamol 3x500 mg PO
Lactulax syrup 0-0-CII NGT
Nicardipin 10 mg + NS 0.9% 100 cc, start from 50 gtt.
Evaluated every 15 minutes.
Manitol 20% If osm normal and blood pressure < 130/80
mmHg. Loading 350 cc continued 4x175 cc 6 hours later.
 Laboratory Examination
Leucocyte 7438 OSM 302.115
Erythrocyte 5.43 x 10 6
Hb 16.5
Hematocryte 46.1
Trombocyte 272.000
SGOT / SGPT 18 / 12
Ureum 28
Creatinine 0.7
RBG 251
Chloride 104
Kalium 3.9
Natrium 138
 ECG
Sinus Tarchycardia
THORAX
BRAIN CT SCAN
 Working Diagnosis
Unsconsciousness ec Cerebral hemoragic region thalamus sinistra
vol 18.75 cc onset day 1
Hypertension Emergency
DM tipe 2
Hematemesis ec stress ulcer
ADDITIONAL PLANNING
Manitol 20% loading 350 cc continued 4x175 cc if blood pressure <130/80 6 hours later.
Consult Internist
Tranexamat acid 3x500 mg IV
Omeperazol 2x40 mg IV
Sulcrafate 4xCII
Novorapid 3x4 unit
Levemir 1x10 unit
Obs Blood Presure, TTIK, GCS, Pupil, liquid in the NGT and cateter
Entering IMC