Morning Report

Wednesday, May 9th ,2018

Team : DPJP :
dr. David Wyanto
dr. Seilly Jehosua, Sp.S
dr. Agus
dr. David Susanto
dr. Sarita
dr. Desi
dr. Feliana
dr. Rivan
dr. Angelina
 Statistics

1. Mr. F/20 yo/mild head injury 3rd day onset + 6. Mr. SH/37 yo/moderate head injury 2nd day
post traumatic vertigo onset
2. Mr. PAF/20 yo/meningitis Bacterial + 7. Mr. E/25 yo/moderate head injury 1st day
epilepsy focal symptomatic onset
3. Mrs. BR/68 yo/low back pain 8. Mrs. CCR/20 yo/mild head injury 1st day
4. Mr. SE/91 yo/mild head injury 1st day onset onset

5. Mr. SS/47 yo/cerebral infarction 1st day 9. Mrs. ALM/19 yo/mild head injury 1st day
onset + hypertensive emergency onset
10. Mr. TG/40 yo/moderate head injury 1st day
onset
Chief Complaint

Headache
 History
2 days before admission
• Patient felt headache on right side of
head, pulsating, reffered to back
• The headache was worsen in night and
cough. Better when took paracetamol.
• Patient felt fever for 2 days, intermittent
especially in night, shivering (+)
• Patient vomitted 1 time, contained food
and liquid
• Patient admitted to Bethesda Hospital
At Hospital
• Patient refferd to Kandou Hospital
• Fever (+), nausea (+), vomit (+), seizure
(-), weight loss (-), chronic cough (-),
decline in appetite (-), night sweat (-),
haemoptoe (-), discharge from the ear (-),
toothache (-)
• History of double vision (-), blurred vision
(-), trauma (-), travelling to malaria
endemic area (-)
History Past Illness
• History of hypertension (-), DM (-), heart disease (-), kidney disease (-)
• He had her first seizure 5 months ago, he seizure 3 times in 1 day with the same
pattern, he admitted to Kotamobagu Hospital, he took his medication regularly 1
week and after that he did not take any medication. He had no seizure in the last
4 months
• Pre ictal : no prodormal symptoms
• Ictal : head turning to the left, his eyes were closed, right hands were flexed
and jerk, right legs were straight and jerk, frothing mouth (+), bedwetting (-),
duration 2 minutes.
• Post ictal : patient was sleepy
 Physical Examination
• General Examination • JVP : normal
• Condition : Moderate • Thorax : rale (-/-), wh (-/-)
• Consciousness : Compos mentis • Cor : heart sound I-II
• BP : 110/80 mmHg normal, murmur (-),
• HR : 78 x/min gallop (-)
• RR : 20 x/min • Abdomen : flat, normal turgor,
• Temperature : 38.4 o C normal peristaltic
• SPO2 : 99% • Extremity : warm acral
• Conjungtiva : pale (-),icteric (-)
• Mouth :coated tongue (-)
 Neurological Examination
• GCS: 15 (E4M6V5), pupil round, equal 3mm, consensual
Light Reflex +/+, unconsensual light reflex +/+ •Sensoric state :
• Meningeal sign : nuchal rigidity (+), laseque >70/>70, Normoesthesia
kerniq >135/>135 •Autonomic state :
• FODS: Fundus reflex (+), Pupil : orange, clear border, Incontinentia urin et alvi -/-
cupping (+), A:V=2:3
• Cranial nerves : N II – NXII intact
• Motor state:
Muscle Strength 5555 l 5555 MT : N| N
5555 l 5555 N| N
PhyR : ++/++/++ | ++/++/++ PatR : - | -
++/++ | ++/++ -|-
 Diagnosis

• Meningitis Bacterial
• Epilepsy focal symptomatic
 Planning
• O2 adecuate
• Bedrest, head elevation 300
• Observation vital sign, GCS, pupil
• Pro Brain CT Scan Contrast
• Pro Lumbal puncture
• Communication, information,
education
• IVFD NaCl 0.9% 20 gtt
• Phenytoin capsule 100 mg every 12
hours per oral
• Folic acid tablet 400 mcg every 24
hours per oral
• Paracetamol tablet 500 mg every 8
hours per oral
• Ranitidine ampule 50 mg every 12
hours IV
• Domperidone tablet 10 mg every 8
hours per oral
 Laboratories at RSUP Kandou
• WBC : 24.100 /uL • RBG : 119 mg/dl
• Hb : 18.5 gr/dl • Na : 139 mEq/L
• HCT : 51.3 % •K : 4.7 mEq/L
• Trombocyte : 229.000 /uL • Cl : 119 mEq/L
• SGPT : 18 U/L • Anti HIV : Non Reaktif
• SGOT : 11 U/L • Osmolarity : 297
• Ureum : 22 mg/dl
• Creatinine : 0.7 mg/dl
ECG
RO THORAX
 Diagnosis

• Meningitis Bacterial
• Epilepsy focal symptomatic
Additional Planning

•Ceftriaxone vial 2 grams every 12 hours intravenous