Morning report

Saturday, Dec 15th 2018

ER : dr. Daniel
ICU : dr. Runi
Stroke unit : dr. Eko
Consult : dr. Ranu and dr. Lika
Tandem US : dr. Dicky
Ward : dr. Beirnes, dr. Barto and dr. Angel
 PATIENT’S IDENTITY

Name : Mr. S
Age : 35 yo
Gender : Male
Occupation : Furniture employee
MR Number : C 728115
Address : Jepara
Hospital admission : Dec, 15th 2018
 HISTORY (alloanamnesis)

Chief complaint : loss of consciousness

Onset : 5 days before hospital admission

Location : intracranial

Quality : eyes open with sound stimulus

• Quantity : ADL are assisted by the family
 HISTORY
Chronology :
± 3 months before hospital admission patient complains of headache,
the feeling of loss arises more and more burdensome. Patients every
2 weeks are taken to a family doctor to treat headaches.

± 9 days before hospital admission patient complained of weak left-

sided limbs, the left limb of the body is difficult to lift, can only be
shifted, urinary and defecation within normal limit. Headache is felt
more severe and does not diminish with medication. No vomiting, no
seizures, no altered in consciousness
 HISTORY

Chronology :
± 5 days before hospital admission patient tends to be drowsy,
difficult to wake up, the patient also has difficulty to
communicate, cannot make a sound and does not understand the
conversation, vomits twice at home, Seizure denied
The Family brought the patient to Kartini Hospital to seek medical
help, vomited 1 time in the Kartini Hospital and undergo
treatment for 5 days. Because there wasn’t any changes the
patient was referred to Kariadi Hospital.
 HISTORY
• Aggravated Factors : -

• Extenuated Factors : -

• Concomitant Symptoms : weak left-sided

limbs, difficulty communicating, vomiting
 HISTORY
Past Medical History
1. History of fever (-)
2. History of hypertension (-), DM (-), trauma (-)
3. No weight loss
4. Long cough is denied
Family Disease History :
1. There is no family of patients suffering from the same disease like
this

> Social Economic-Status And Personal History :

Patient is a furniture employee, has 2 children, use National insurance
for treatment
 CLINICAL FINDINGS
Present States
 GCS : E3M5Vsusp.afasia
 Vital signs :
BP 120/70 mmHg HR 76x/min
RR 20x/min Temp 36.7 (axilla)
Weight : 60 kg, Height : 165 cm
BMI : 22.7(normoweight)
Eye : pupil round, isocor 3/3 mm,light reflex +/+
Thorax : normal breathing, Rh-/-, Wh -/-
normal heart sound, murmur (-), gallop (-)
 Abdomen : unpalpable liver and spleen, ascites (-)
 CLINICAL FINDINGS
Neck : within normal limit
Cranial Nerves : difficult to evaluate, impression of central left nervus
VII paresis
Motoric Sup Inf
Movement +/ ↓ +/↓
Strength impression of lateralization to the left
Tonus N/ ↑ N/↑
Trophy E/E E/E
FR ++/+++ ++/++++
PR -/- -/B+
Clonus -/+
Sensibility : difficult to evaluate

Vegetative : DC (+), NGT (+)

 LABORATORY FINDINGS
LABORATORY Dec, 15th 2018
EXAMINATION
Hb 14.7 12.00 – 15.00
Ht 41.6 35 – 47
Red blood cell 4.89 4.4 – 5.9
MCH 30.1 27 – 32
MCV 85.1 76 – 96
MCHC 35.3 29 – 36
White blood cells 7.4 3.6 – 11 x103
Platelet 261 150 – 400 x103
 LABORATORY FINDINGS
LABORATORY EXAMINATION Dec, 15th 2018

Electrolyte
Blood Glucose 129 80-160
Ureum 49 15-39
Creatinin 1.1 0,6-1,3
Sodium 140 136-145
Potassium 4.2 3.5-5.1
Chloride 105 98-107

Osmolarity 303.4
Fluid Deficit 1L
CHEST X-RAY, Dec 15th, 2018
HEAD CT SCAN Dec 10th, 2018 at Kartini Hospital
ECG : Incomplete RBBB
Assessment
1. Clinical diagnostic :
loss of consciousness
paresis of central left nervus VII
lateralization to the left
vomiting
headache

Topis diagnostic : Right Corona Radiata

Etiologic diagnostic : Susp. SOL intracranial (

primary brain tumor
Dd : - Infection ( opportunistik infection, abses, tuberkuloma)
 Initial Plan
Therapy :
- Head up 30 degrees
- O2 nasal 3 lpm
- IVFD RL 20 drops/minute
- Inj. Dexamethason 10mg/8 ho iv
- Inj. Ranitidin 50mg/12 ho iv
- Paracetamol 500mg/8 ho po
- Vit B1B6B12 1 tab/8ho po
Program

• Head MRI with contrast

• VCT