MORNING

REPORT
24 September, 2023
IDENTITY

● Name : Mr. K
● Age : 85 years old
● Gender : Male
● Address : Batu
● Arrival Date : 24 September 2023
● Patient Type : Non-trauma
 ANAMNESIS

Main Complaint:
Decreased of Consiousness

Illness:
The patient experienced a loss of consciousness shortly after breakfast and then fell. The patient
fell while having breakfast at 10.30, after which the patient began to lose consciousness. The
previous day the patient complained of weakness to his family. There is blood coming out of
the ears and from the nose. The patient vomited black twice after waking up from fainting. The
patient also vomited again when he was in the ER. The patient's bowel movements are black.
There was no previous history of sudden falls. Complaints of nausea (-), seizures (-), headache
(-), dizziness (-), nausea, vomiting (-)
History of disease: DM (-), HT (-) denied
Medical history: -
Family History: CVA (-), HT (-)
Allergic history: food allergies – drugs allergies -
 GENERALIST STATUS

Consciousness : Apatis
GCS : 314
TD : 157/106mmHg
HR : 69x/mnt
RR : 20x/mnt
Temperature : 35.1⁰C
SpO2 : 90% on RA
 PHYSICAL
EXAMINATION
THORAX :
HEAD/NECK: Cor:
Inspection: ictus cordis invisible
Head: Palpation: ictus cordis palpable at ICS 5 MCL S
Head/neck: a/i/c/d +/-/-/- 5mm/5mm Midriasis pupils, Percussion: D heart border at ICS 4 PSL D, heart
RCL -/-, RCTL -/- border S at ICS 5 MCL S
Neck : Auscultation: S1S2 single, regular, murmur (-),
Inspection: tracheal deviation (-) gallop (-)
Palpation: enlarged lymph nodes (-)
Auscultation : Bruits (-) Pulmo:
Ear: Inspection: normal chest wall shape, retraction (-)
Bloody otorea (+) Palpation: symmetrical D/S chest wall movement
Nose: Percussion: sonor
Bloody otorea (+) Auscultation:
Ves + + Wh - - Rh - -
+ + - - - -
+ + - - - -
 PHYSICAL
EXAMINATION
Abdomen Status Neurologis
Inspection: GCS E3V1M4
Flat, inflammation (-) scar (-) eritem (-) Kaku kuduk (-)
Auscultation : BU (+) 13x/minute Reflek Fisiologis
Abdominal percussion: timpany Bisep +1 | +1
Abdominal Palpation: Trisep +1 | +1
Tenderness (-) superficial and deep Reflek patologis
--- Babinski +/+
--- Chaddock -/-
Hoffman -/-
--- Tromner -/-
Openheim -/-
Extremity: Gordon -/-
Dry red warm akral ++/+-, CRT<2, edema - - Schaeffer -/-
-- Sensorik SDE
Motorik SDE
Lateralisasi (SDE)
 PROBLEM LIST & PLANNING
Problem list Initial Diagnosis Planning
Diagnosis
• Decreased of Consiousness DOC ec CVA • CT Scan
• Vomited black twice Head Non
• Defecation is black Contrast
• blood coming out of the ears and from the nos • Laboratory
(DL, CBC,
Elecrolyts)
GCS : 314
TD : 157/106 mmHg
Head:
Head/neck: a/i/c/d +/-/-/- 5mm/5mm Midriasis pupils, RCL -/-, RCTL -/-
Ear:
Bloody otorea (+)
Nose:
Bloody otorea (+)
Laboratory Examination
(24/9/2023)
Hb 11.2 L
RBC 3.60 L
HCT 31.9 L
WBC 17.770 H
PLT 125 L
LED 25 H
PPT 11.2
APTT 25.8
Ureum 155.7 mg/dL H
Creatinin P 0.78 mg/dL
SGPT 8.3
SGOT 22.6
GDS 162 mg/dl
Na+ 139 mmol/L
K+ 3.60 mmol/L
Cl 109 mmol/L H
Head CT Scan without contrast
(24/09/2023 RS Baptis Batu)
 PROBLEM LIST & PLANNING
Problem list Definitive Planning Therapy Planning
Diagnosis Monitoring
• Decreased of Consiousness DOC ec CVA • IVFD NS 20tpm • GCS
• Vomited black twice ICH • Inj. citicolin 250mg • Vital sign
• Defecation is black • Inj. OMZ 40mg
• blood coming out of the ears and from the nos • Inj. Piracetam 3gr
• Inj. Ketorolac
GCS : 314
30mg
TD : 157/106 mmHg • Inj. Metoklopramid
Head: 10mg
Head/neck: a/i/c/d +/-/-/- 5mm/5mm Midriasis pupils, RCL -/-, • Pasang NGT
RCTL -/- • Sucralfat 20 cc
Ear: • Inj. Asam
Bloody otorea (+)
Nose:
Traneksamat
Bloody otorea (+) 500mg
CT Scan Head NK: • Drip Amiodaron
Hyperdense lesion in the S frontalis area, 150mg
Hyperdense lesions in the pons area, • Pasang NIV
Midline shift to the right,
THANK YOU