Morning Report

Monday, 5 February 2018

Dept of Neurology
G29
DAFTAR OB NEURO 4/02/2018
 Mr. Sugeng CVA Bleeding IVH
Identity
 Name : Mr. S
 Age : 61 years old
 Address : Lamongan
 Admission: February 5th, 2018 at
23:00
SUMMARY OF DATABASE
 Chief of complaint:
 Loss of consciousness
 Chief Complaint
Loss of Consciousness

 Present history

Patient were admittd to hospital from PKM cepu.

Patient’s family complained Mr. S were suddenly Unconscious

by 7 hours before admitted to hospital. Patient were known ridding a
bicycle then found fall and unconscious by the neighbours. Patient
didn't complain any headache, or Nauseous feeling before, and
there's no seizure either. Never been like this before.
 Past history of Illness

•HT (+), DM (denied) , Never been like this before

 Family history

No family history of CVA, HT , DM

 Social history : (-)

Vital Signs
 BP
 182/111 mmHg
 Pulse
 130 x/min, strong, reguler
 Temp
 36.7 C
 RR
 24x/min
 Primary survey
 A : clear, gargling (-), snoring (-), speak fluently (-), potensial
obstruksi (-)
 B : spontan, RR 24x/menit, ves/ves, Rh -/-, Wh -/-, SaO2
99% tanpa O2 support
 C : CRT < 2” N 130x/min TD 182/111mmHg
 D: GCS: 224, lateralisasi:-, PBI 3mm/3mm, RC +/+
 E : temp 36.7 C
 General condition : weak
 Awareness : somnolen
 GCS : 224
 H/N : a -/i-/c-/d -
lymph node enlargement at neck (-)
 Thorax
 GCS 224
 K/L: a -/ I -/c -/d -
 Tho: sim, ret -/-,
 P: ves/ves; rh -/-, wh -/-,
 C: S1S2 single, murmur -, gallop -
 Abd: soepel, met -, BU +, H/L ttb, pain -
 Ext: aie - , warm, wet, edema -/-
 Abdomen
 Inspection
 flat
 Auscultation
 Met -, bowel sound + N
 Palpation
 Pain (-)
 Liver/Spleen within normal limit
 Percussion
 Tymphany
 Extremities
 Inspection
 Clubbing fingers (-), icteric (-), cyanosis (-), edema (-),
 Palpation
 Wet and cold, CRT <2’
Status Neurologic
 Meningeal Sign : kernig-,
Brudzinski 1,2-
 Nervus Cranialis
 N II : PBI 3/3mm refleks
cahaya +/+, visus OD
>2/60
 N III, IV, VI : hte
 N VII : hte
 N XII : hte
 RefleksFisiologis
 BPR +3/+2 TPR +3/+2
 APR +2/+2 KPR +2/+2
 Refleks Patologis
 Trommer +/- Hoffman
+/-
 Chaddock -/- Babinski
+/-
 Motorik : Lat;-
 Sensorik: Hte

Labroratory
 Gula Darah Acak : 121[70 - 130 ]  Hematokrit : 39.86 [ L 40 -
 Kalium Serum : 4.1 [ 3.6-5.5 ] 54 P 35 - 47]
 Natrium Serum : 139 [ 135-155 ]  MCV : 82.40
 Clorida Serum : 104 [ 70 -108 ] [ 87.00 - 100 ]
 Urea : 45 [ 15 - 43 ]  MCH : 26.60
 Serum Creatinin : 1.3 [ P 0.7 - 1.2 L. [ 28.00 - 36.00 ]
0.8 - 1.5 ]
 SGOT : 29 [ 0 - 35 ]
 MCHC : 32.20
[ 31.00 - 37.00 ]
 SGPT : 16 [ 0 - 35 ]
 Lekosit : 12.4 [ 4.0 - 11.0 ]  RDW : 10 [
 Neutropil : 96.4 [ 49.0 - 67.0 ]
10 - 16.5 ]
 .Limposit : 14 [ 25.0 - 33.0 ]  Trombosit : 235 [ 150 -
 Monosit : 0.7 [ 3.0 - 7.0 ] 450 ]
 Eosinopil : 1.2 [ 1.0 - 2.0 ]  MPV : 6 [ 5 - 10 ]
 Basofil : 0.2 [ 0.0 - 1.0 ]  .Laju Endap Darah 1 : -[ 0 -
 .Eritrosit : 4.82 [ 3.80 - 5.30 1]
]  .Laju Endap Darah 2 : -[ 1 -
 .Hemoglobin : 12.8 [ P13,0 - 18,0 7]
L14,0 -18,0 ]
 Diagnosis:
 Klinis : sudden uncosciousness, vomiting, HBP,
 Topis: Intraventrikel, Hemisfer cerebri sinistra
 Etiologi: suspect CVA Hemoragik, IVh ICH
• (Siriraj Score: (2.5x1)+(2x1)+(2x0)+(0.1x111)-(3x1)-12)=0,6)
 Planning Therapy
 Head Up 20-30 degree
 O2 nasal 3 lpm
 inf.Pz1500 cc/24 H
 inj.pantoprazole 2x1 amp
 inj.citicolin 3x250 mg
 Ondancetron prn
 Tranexamic acid 3x1
 nimodipin
PLANNING MONITORING
 Vital Signs
 Patient’s complaint
 Adverse effect
 DL
PLANNING EDUCATION
 Explain to the patient and his family about the disease, cause,
complication, intervention of the therapy and prognosis.