Morning Report th

30 October 2017
On Duty :
dr. Andisty
dr. Milani
dr. Riko
dr. Ricky
dr. Rivan
dr. Windi
dr. Dennis
dr. Joanita

DPJP :
DR. dr Junita Maja P.S, Sp.S(K)
 Statistic
Mr. FA / 12 yo/ TTH
Mrs. ML / 17 yo / mild head injury
Mr. AH / 27 yo/ Cephalgia post trauma
Mrs KM / 70 yo/ Neuralgia trigeminal
Mr. LC / 20 yo / severe head injur
Mrs. NM / 28 yo / Susp Sol Intrakranial
Mrs. PK / 77 yo / Moderate head injury
Mr. TM / 8 yo / Moderate head injury
Mr. MR / 30 yo / Reattack cerebral infarct
Mr. RR / 20 yo / moderate severe injury
Mrs. HL / 87 yo / cerebral infarction onset
day 1
Mr. MA / 50 yo / Unsconsciousness ec Sol
Intracranial dd oligodendroglia
 Chief Complaint
Seizure
 History Taking
The patient came with the complain of sudden seizure 6 hours before admission.
The seizure happened when the patient was asleep at night.

Pre-ictal: no complain

Ictal : seizure happened 8 times, with the interval 10 times, the patient was
unconcious between seizure. The head was turned to the right, eyes turned
upwards, right limbs was raised with the same movement as the left limb, mouth
was foaming, tounge was bitten, the patient was wetting the bed, with duration
less than 3 minutes.

Post ictal: patient was unconcious

The patient complained of headache for the past two weeks. It happened
everyday and worsened when the patient coughed and strained. The patient had
taken pain killer but 4 hours after that the pain resurfaced. History of seizure
before was denied, family history of seizure was denied. Blurry vision, double
vision, history of trauma (-)
 History of past illnes
Hypertension (-).
History of diabetes mellitus (-), Cholesterol (-),
heart disease (-), kidney disease (-), stroke (-).
 Physical Examination
General examination:
General condition: severe, consciousness :
sopor
BP: 150/90 mmHg, HR: 110x/m reg, RR: 24x/m
T: 36C MABP 110
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 : E3M5V1, PERRL +/+ 4 mm/ 4mm
Meningeal Sign : nuchal rigidity (+), Lasegue (>70/>70),
Kernig (>135/>135)
Cranial Nerves : paraesis 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
AGM Cerebral Hemoragic

SSS (2.5x1) + (2x0) + (2x0) + (0.1x90) (3x1)

12 = -2.5 Cerebral hemoragic
 Diagnosis
Unsconsciousness ec susp Cerebral
Hemoragic.
Hypertension Grade II
Secondary general seizure
 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
Brain CT Scan
Obs GCS, TTV, Pupil
IVFD NaCl 0.9% 500cc/8 hours
Paracetamol 3x500 mg PO
Ranitidine 2x50mg IV
Lactulax syrup 0-0-CII NGT
Diazepam 10 mg max 20 mg IV prn
 Laboratory Examination
Leucocyte 17.200
Erythrocyte 3.67
Hb 16.6
Hematocryte 47.5
Trombocyte 288.000
SGOT / SGPT 17 / 23
Ureum 25
Creatinine 0.7
RBG 443
Chloride 102
Kalium 4.6
Natrium 142
 ECG
Sinus Tarcicardya
THORAX
BRAIN CT SCAN
 Working Diagnosis
Unsconsciousness ec Cerebral infarct regio temporoparietal
sinistra.
Hypertension Grade II
Epileptic focal symptomatik
DM type II
 Additional Planning
Diazepam 10 mg prn
Consult div Epileptic
Consult Internist
Pro IMC Neuro