Ward Round Report

• Male 67 YO
• unconciuosness
 Past History
• History of stroke, hypertension, DM, heart
disease, cholesterol, kidney disease  denied
• Smoking habit : 3 years (half pack a day)
 Physical Examination first day onset
• General condition: moderate sickness
• Consciousness: somnolen
• T: 140/90 mmHg, pulse 68, resp 21, temp 36.3
• GCS E3M5V4 (12)
• PERRL +/+, diameter 3/3 mm.
• Meningeal signs: nuchal rigidity -. . Lasegue
sign >70°/>70°, Kerniq sign >135°/>135°
• Nn. Craniales: paresis N VII dextra type UMN
impression
 Physical Examination
• Motoric examination:
MS : right hemiparesis impression
MT : ↓ N
↓ N
PhyR : +/+/+ ++/++/++ PatR : - -
+/+ ++/++ - -
Sensoric examination: not evaluated
Otonom status: incontinentia urine et alvi -
 Physical Examination 15th day onset
• General condition: moderate sickness
• Consciousness: composmentis
• T: 110/60 mmHg, pulse 68, resp 20, temp 36.5
• GCS E4M6Vafasia
• PERRL +/+, diameter 3/3 mm.
• Meningeal signs: nuchal rigidity -. Lasegue
sign >70°/>70°, Kerniq sign >135°/>135°
• Nn. Craniales: paresis N VII dextra type UMN
 Physical Examination
• Motoric examination:
MS : 5555 5555
5555 5555
MT : N N
N N
PhyR : ++/+++/+ ++/++/++ PatR : - -
++/++ ++/++ - -
Sensoric examination: not evaluated
Otonom status: incontinentia urine et alvi -
Laboratory Report (27th October 2017)
• Leucocyte 18930
• Erythrocyte 5.11x 10^6
• Hb 14.3
• Ht 43.5%
• Thrombocyte 351.000
• SGOT 15
• SGPT 20
• Ureum 21
• Creatinine 0.8
• Random blood sugar 128
• Chloride 102.0
• Kalium 4.30
• Natrium 131
Brain CT
Chest X-Ray
 EKG
• Sinus rhytm 64 x/m
 Diagnosis
CVD SH onset 17th day
(ICH r/ temporoparietooccipital S vol 50 cc)
Hypertension grade I
Hyponatremia (131)
 Treatment
• Family education
• Bed rest + head elevation 30°
• Mobilization right & left every 2 hour
• Chest physiotherapy + OH
• IVFD KaEn3B 500cc  21 gtt/mnt
• Paracetamol 3x500mg PO
• Ranitidine 2x150mg PO
• Lactulac syr. 0-0-CII PO