Morning Report

Morning Report
September, 2nd 2018
On Duty: dr. Kennytha DPJP : dr. Ansye G. N. Momole, Sp. S
dr. Yohanna
dr. Aryano
dr. Leopold
dr. Sarita
dr. Rony
dr. Windi
dr. Merry
Statistics
1. Mr. AH/ 63 yo/ Dx Encephalopathy metabolic, sequele of
cerebral infarction
2. Mr. EB/ 58 yo/ Dx Cerebral infarction onset H2
3. Mr. KR/ 19 yo/ Dx Mild head injury H1, right femur fracture
4. Mrs. SA/ 80 yo/ Dx Dizziness
5. Mr. LA/ 69 yo/ Dx Intracerebral hemorrhage left
thalamus region vol 16,8 cc onset H1, Secondary
bilateral posterior horn intraventricular
hemorrhage, post PTCA
6. Ms. KN/ 14 yo/ Mild head injury H1
7. Child HK/ 1y4mo/ Moderate head injury H1
Male 69 YO came with chief complaint
of unconsciousness
 History
before admission At admission
• A 69-years-old male presented to emergency room with • Patient tends to
sudden unconsciousness since 9 hours ago while his sleep, eyes
family tried to wake him up, he spoke incoherently and opening to
was unable to fully awake even if his family tried to wake speech, obeys
him up multiple times. commands,
• Before he went to sleep, he had no previous complaint of patient was
headache, nausea, vomiting. oriented,
• History of trauma, fever, and weight loss were denied. weakness at
• Left extremities were seen more active than right right extremities,
extremities. always look to
• Seizure (-), double vision (-), slurred speech (+), difficulty the left.
swallowing (-), vomiting (-), diarrhea(-), discharge from
the ear, nose, (-), tingling sensation (-), numbness (-),
facial droop (+)
• Alcoholism, smoking, drug abused were denied
• This is the first time patient has this chief complaint.
 History of past illness
 PTCA 2 years ago, history of myocardial infarction,
with routine drug consumption (Aspilet 1x80mg,
family did not remember nor bring the rest of the
drugs).
 History of hypertension 2 years ago, routine drug
consumption until the event (Telmisartan 1x80mg,
family did not remember nor bring the rest of the
drugs).
 Diabetes, kidney disease, liver disease were denied.
Scoring
 NIHSS: 17
 Physical Examination
 General Examination  Nose : normal
 Condition : moderate  JVP : normal
 Consciousness: sopor  Thorax : rale (-/-),
 BP : 120/60 mmHg wh (-/-)
 HR : 78x/min, regular  Cor : heart sound I-II
 RR : 18 x/min normal, murmur (-), gallop (-)
 Temperature : 37.3o C  Abdomen : flat, normal
 SPO2 : 98% turgor, normal peristaltic
 Conjungtiva : pale (-/-),  Extremity : sianotic (-),
icteric -/-) edema (-)
 Neurological Examination
 GCS :E3M5V3, Pupil isocor 3mm/3mm, direct light reflex+|+ , indirect light
reflex +|+
 Meningeal sign : nuchal rigidity (-), laseque >70/>70, kernig >135/>135
 Cranial nerves : impression of right N VII paresis.
 Left conjugate gaze deviation +.
 Funduscopy : papil orange, border clear, cupping +, A:V 2:3
 Motor state : hemiparesis impreesion (-)
Muscle Tone :  | N
 |N
PhyR +/+/+| ++/++/++
+/+ |++/++
PatR : - |-
- |-
 Sensoric state: cannot be evaluated
 Autonomic state : urinary and alvi incontinence -/-
 Diagnosis
 Hemorrhagic cerebrovascular disease
 Post PTCA
 Planning
 O2 via nasal canule 2-4 Lpm
 Counseling, information, education
 Bed rest + head elevation 30 degrees
 Oral hygiene and chest physiotherapy
 NGT and urine catheter with family approval
 IVFD NaCl 0.9% 20 gtt
 Simvastatin 1x20mg
 Paracetamol 3x500mg
 Lactulac 1x30cc
 Ranitidine 2x50mg IV
 Observe GCS and vital sign
 Additional Planning
ECG
Chest x-ray
Laboratory
Brain CT Scan Non Contrast
 ECG
 Sinus Rhytm 78x bpm
 Chest Xray:
within normal
limits

Thorax
x-ray
 BLOOD TEST
 WBC : 12.000/uL Na : 136 mEq/L
 Hb : 14,7gr/dl K : 4,7 mEq/L
 HCT : 40,7 % Cl : 104 mEq/L
 Trombocyte : 249.000 /Ul Osmolarity: 239,02
 SGOT : 19 PT : 0.86
 SGPT :12 INR : 0.82
 Ureum : 31 mg/dl APTT : 0.79
 Creatinine : 0.9 mg/dl
 RBG : 122 mg/dl
 Diagnosis
 Intracerebral hemorrhage left thalamic region, volume
16,8 cc, first day onset
 Secondary bilateral posterior horn intraventricular
hemorrhage
 Post PTCA
 Hematemesis
 Additional Planning
 Mannitol loading 300cc
 Continue mannitol infusion 150cc every 6 hours
 Tranexamic acid 3x1gr IV
 Paracetamol 3x1gr
 Admission to intermediate care ward
THANK YOU