MORNING

REPORT
September 14th, 2023
IDENTITY

● Name : Mr. Andrianus

● Age : 50 years old
● Gender : Male
● Address : Batu
● Arrival Date : September 14th 2023
● Patient Type : Non-trauma
 ANAMNESIS
Main Complaint: decrease of conciousness

Illness:
The patient experienced decreased consciousness and was unable to communicate
since (8/9/2023) morning. The patient has a history of seizures and weakness in the
left half of the body. A day before the MRS at Baptist Hospital, the patient felt weak
when he came out of the bathroom and suddenly experienced a loss of
consciousness and only snored. Decreased consciousness (+), slurred speech (-),
swallowing problems (-), nausea (-), vomiting (-), headache (-), seizures (-), blurred
vision (-), double vision (-), numbness (-), tingling (-),
History of disease: DM (-), HT (-), epilepsy (-), stroke (+)
Medical history: had a history of trepanation in 2014 at Baptist Hospital
Family History: CVA (-), HT (-), DM (-)
Social History: drink coffee 3-4x//day, smoking (-), alcohol (-)
Allergic history: food allergies – drugs allergies –
 GENERALIST STATUS

Conciousness: comatose
GCS: 111
TD : 119/80 mmHg
HR : 114 x/mnt
RR : 28x/mnt
Suhu: 38⁰C
SpO2: 83% on NRBM 15 lpm
 PHYSICAL
HEAD/NECK: EXAMINATION
Pulmo:
Head: Inspection: normal chest wall shape, retraction
Head/neck: a/i/c/d -/-/-/+ 2mm/2mm isochor (-)
pupils, RCL +/+, RCTL +/+ Palpation: symmetrical D/S chest wall
Neck : movement
Inspection: tracheal deviation (-) Percussion: sonor
Palpation: enlarged lymph nodes (-) Auscultation: Ves + + Wh - - Rh - -
+ + - - - -
Auscultation : Bruits (-) + + - - - -
THORAX : Abdomen
Cor: Inspection: Flat, scar (-)
Inspection: ictus cordis invisible Auscultation : BU (+) 14x/minute
Palpation: ictus cordis palpable at ICS 5 MCL S Palpation: Tenderness superficial and deep (-)
Percussion: D heart border at ICS 4 PSL D, heart Percussion: timpany
border S at ICS 5 MCL S
Auscultation: S1S2 single, regular, murmur (-), Extremity:
gallop (-) Dry red warm akral ++/++, CRT<2, edema (-)
 PHYSICAL
EXAMINATION
Motorik :
- Tonus otot: SDE
Neurological Examination: Lateralisation : (+) kanan
Meningeal sign: neck stiffness (-), laseque Physiological Reflex
(-) Bisep +2 | +2
Trisep+2 | +2
Nervus Cranialis Patela +2 | +2
N.I : tde Achiles +2 | +2
N.II : tde Patological Reflex
N. III, IV, VI: PB isokor 2mm|2mm, RCL Babinski -/-
+/+, RCTL +/+, ptosis (-/-), gerak bola Chaddock -/-
mata (tde) Hoffman -/-
N. VII : tde Tromner -/-
N. XII : deviation (sde) Openheim -/-
Gordon -/-
Schaeffer -/-
 PROBLEM LIST & PLANNING
Problem list Initial Diagnosis Planning
Diagnosis
Anamnesis CVA bleeding • CBC,
• Decreased consciousness, snored, and unable to Respiratory failure BGA, SE,
communicate since (8/9/2023) morning . Pneumonia faal hati,
• History of seizures (10x) and weakness on the left Hypertension st 1 faal
body. ginjal,
• Slurred speech (-), swallowing problems (-), nausea rapid
(-), vomiting (-), headache (-), blurred vision (-), glucose
double vision (-) • CT Scan
• History of disease: DM (-), HT (+) uncontrolled, Head
epilepsy (-), stroke (+) Non
• Medical history: had a history of trepanation in 2014 Contrast
at Baptist Hospital • Rontgen
thorax
• ECG
 PROBLEM LIST & PLANNING
Problem list Initial Diagnosis Planning
Diagnosis
Physical Examination CVA bleeding • CBC,
GCS : E1V1M1 comatose Respiratory failure BGA, SE,
TD : 155/97mmHg Pneumonia faal hati,
HR : 66x/mnt Hypertension st 1 faal
RR : 28x/mnt ginjal,
Temp: 38⁰C rapid
SpO2: 83% on NRBM 15 lpm glucose
Lateralisation (+)  right side • CT Scan
Siriraj Score: Head
= (2.5 x level of consciousness) + (2 x vomiting) + (2 x Non
headache ) + (0.1 x diastolic blood pressure) – (3 x Contrast
atheroma marker) - 12 • Rontgen
= (2.5 x 2)+(2 x 0)+(2 x 0)+(0.1 x 80 ) – (3 x 1) -12 thorax
= 5+0+0+8-3 -12 • ECG
= -3 (cerebral infarction)
ECG (14/9/2023)
 Laboratory Examination
CBC (14/09/2023) Blood Gas Analysis (14/09/2023)
Hb 13.6 L pH H 7.472
WBC 14.14 H PCO2 41.6 mm Hg
PO2 L 44.5 mm Hg
Kimia Darah (14/09/2023) TCO2 26 mmolL
SGPT 15.9 U/L HCO3 H 29.7 mmol/L
SGOT H 46.0 U/L DO2 519.2 mm Hg
Ureum H 101.2 mg/dL BE ecf H 6.1 mmol/L
Creatinin P H 1.40 mg/dL SO2 L 84 %
Rapid glucose 187 mg/dL  Uncompensated metabolic
alkalosis
Electrolyte (14/09/2023)
Na+ H 157.7 mmol/L
K+ L 3.36 mmol/L
Cl- HH 122.4 mmol/L
Head CT Scan without contrast
(14/09/2023 RSKH)
 PROBLEM LIST & PLANNING
Problem list Definitive Planning Therapy Planning
Diagnosis Monitoring
Anamnesis • CVA ICH SpBS • Vital sign
• Decreased consciousness, snored, and unable • Respiratory • Pro trepanation • Symptoms
to communicate since (8/9/2023) morning failure (hematome • ECG
• History of seizures (10x) and weakness on the • Pneumonia evacuation) • Electrolyte
left body. • Hypertension st • Pro ventilator Serum
• Slurred speech (-), swallowing problems (-), 1
nausea (-), vomiting (-), headache (-), blurred • SVT SpPD
vision (-), double vision (-) • Electrolyte • Inj Omeprazole
• History of disease: DM (-), HT (+) uncontrolled, imbalance 1x40mg
epilepsy (-), stroke (+) (hypernatremia, • PO Sucralfat
• Medical history: had a history of trepanation in hypokalemia, 3x1
2014 at Baptist Hospital hyperchloremia)
Physical Examination
• GCS : E1V1M1 comatose
• TD : 155/97mmHg
• HR : 66x/mnt
• RR : 28x/mnt
• Temp: 38⁰C
• SpO2: 83% on NRBM 15 lpm
 PROBLEM LIST & PLANNING
Problem list Definitive Planning Therapy Planning
Diagnosis Monitoring
Lateralisation (+)  right side • CVA ICH SpJP • Vital sign
• Respiratory failure • Inj Furosemide • Symptoms
Siriraj Score: • Pneumonia 2x20mg • ECG
= (2.5 x level of consciousness) + (2 x vomiting) + • Hypertension st 1 • Inj. Ceftriaxone • Electrolyte
(2 x headache ) + (0.1 x diastolic blood pressure) • SVT 2x1gr Serum
– (3 x atheroma marker) - 12 • Electrolyte • PO Amlodipin
= (2.5 x 2)+(2 x 0)+(2 x 0)+(0.1 x 80 ) – (3 x 1) -12 imbalance 1x10mg
= 5+0+0+8-3 -12 (hypernatremia, • PO Captopril
= -3 (cerebral infarction) hypokalemia, 3x25mg
hyperchloremia) • PO PCT
ECG: Sinus tachycardia HR 140x/min, SVT 4x500mg
• PO Digoxin
Xray thorax: pneumonia, aorta dilatation 1x0, 25mg
SpAn
CT head non contrast: • Drip NE
Chronis infarct on temporal sinistra (hypodens 5,25cc/jam
lesion) • Drip Morphin
Hemorrage on temporal dextra (hyperdens lesion) 1mg/jam
THANK YOU