Nama : Aulia Pandu Aji Rabu, 12 Agustus 2020

NIM: 190070200011007
Periode : 22 Juni – 16 Agustus 2020

Notulensi Morning Report

IPD 12 Agustus 2020

Identity: Mrs. AP/19 yo/ Ward 26

Anamnesis : Heteroanamnesa
Chief Complain: Decrease of Consciousnes
 Patient came with abrupt onset decrease of consciousness since 5 days ago,
it was started with a cough and the patient felt a throbbing headache and are
unable to communicate with.
 Patient oftenly complained about her headache since 1 week ago and got
examined with a midwife where she was then referred to the hospital.
 She also complained nausea and vomiting since 5 days ago, 2 times per day,
vomited food with vlood with the volume 200-300 cc via NGT
 She reported she had black tarry stool since 5 days ago with the volume 150-
300 cc
Past Medical History:
Diagnosed with ITP since 4 years ago, did not routinely controlled herself
since 2 years ago
Family History:
History of hematological malignancy denied
Social History:
She is a student, she hasn't been married and live with her parents
Review of System:
NGT (+) brownish fluis, conjunctival hemorrhage
Babinski and chaddock reflex (+/+)
RT: melena (+)
Objective
 GA looked moderately ill; GCS 325 CM; BP 119/78 mmHg; HR 76 bpm; RR
22 bpm; Tax 36,7 C; SpO2 100% on NRBM 8 Lpm; NGT production:brownish
residue (+) 10 cc
 H/N/C: Conjunctival Haemorrhage(+) Pupil Isokor 3/3 mm
 Abdomen : Traube Space Dullness
 Ekstremitas : dbn
 Neurologic: NVII Within normal limit; NXII: Hard to evaluate; Pathologic
reflex: babinsky (+/+), chaddock(+/+), dextra lateralization, physiologic
reflexes within normal limit
 Lab 11/08/20: Throm: 48.000; Bil total 1.5; Bil direct 0.58; Bil indirect 1.01;
CRP 1.29; LDH 700
Nama : Aulia Pandu Aji Rabu, 12 Agustus 2020
NIM: 190070200011007
Periode : 22 Juni – 16 Agustus 2020


BGA : Metabolic acidosis fully compensated
ECG 11/08/20: Sinus Rhytm HR 87 Bpm
CXR 11/08/20: Normal
CT SCAN: ICH With Volume 46,47 on frontotemporal lobe sinistra with
hemisphere sinistra edema cerebri, causing subfalcine herniation for +/- 11mm
Problem List and Diagnosis
1. DOC
1.1 CVA ICH
2. ITP DropOut Treatment
3. Anemia + Thrombocytopenia + increase LDH + increase bilirubin mainly indirect
3.1 Evans Syndrome
3.2 ITP with Anemia Def. Fe concominant with blood loss
4. Upper GI Bleeding
4.1 Thrombocytopenia
4.2 Peptic Ulcer Bleeding
5. CVA ICH subcortex OH 6
Planning Diagnosis:
Reticulocyte Count, SI, TIBC, Endoscopy
Take Home Messages:
 Pada ITP sangat rentan terjadi komplikasi apabila tidak rutin melakukan
evaluasi pengobatan
 Pasien harus di edukasi mengenai warning sign ITP untuk segera control bila
mendapati tanda tanda tersebut
 Edukasi keluarga juga penting guna dukungan terhadap terapi ITP, agar tidak
terjadi dropout treatment
 Pada CT Scan didapati ICH. Perlu hati hati apabila ada clot pada ventricle
atau lainnya, dapat menyebabkan hydrocephalus