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S A T U R D A Y , 2 3 T H A G U S T 2 0 1 4

MORNING REPORT

NEUROLOGIC DEPARTMENT

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Patient identity

Name : Mr Su

Age : 65 years oldSex : Male

Work : Farmer

Address : LamonganExamination date : Agust 23th, 2014

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ANAMNESIS

Chief Complaintloss of consciousness

Present illness History

Patient loss of consciousness 5 hour beforeadmision IGD after fall in bathroom. Seizure 1x,than conscious and can talk normally and

than unconciousness. Vomiting 1x during a tripto Emergency room, contain like sputum,white, half a glass of mineral water.Headacne before (-)

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Previously illnes history

Never like this before

HT (+) since 10 years ago, never taking medication.DM denial.

Family illnes History HT dont know

Medicine taking history

-

Social history

Smoker active 2 packs/day

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Vital Sign

GCS : 112Blood pressure : 195/121 mmHg

Heart Rate : 117x /minutes

RR : 26x /minutesAxilla temperature : 37.8oC

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Head / neck : an (-), ict (-), cy (-), dys (-)

Thorax : Normal chest form, retraction (-),Pulmonary

Pulmo : ves/Ves, Rh-/-, Wh -/-

Cor : S1-S2 single, murmur (-), gallop (-)

Abdomen

I : flat

P : soefl, Liver / Splen not palpable.

P : thimpany A : Bowel sound (+) Normal

Extremity : aie -, warm, dry, CRT < 2

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N. I (Olfactorius): SDE

N. II (Opticus) : SDE, pin point, round isokor 2mm/2mm, RC -/-

N. III (Okulomotorius) : SDEN. IV (Trochlearis) : SDE

N. VI (Abducen) : SDE

N. V (Trigeminus) : SDE

N. VII (Facialis) : SDE

N.VIII (acusticus) : SDEN. IX (Glossofaringeus) : SDE

N. X (Vagus) : SDE

N. XI (Assesorius) : SDE

N. XII (Hipoglossus) : SDE

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Meningeal sign:

Kaku kuduk : -/- brudzinsky 1 :-/-

Kernig : -/-

Kekuatan : sdeTonus muscle : spasticReflek Fisiologis :

BPR : +3/+3 KPR : +3/+3TPR : +2/+2 APR : +2/+2

Reflek Patologis :Babinsky: +/+ Hoffman Trommer : + /+Chaddock: +/+ Gordon : +/ +

Schaefer: +/ + Oppenheim : - / -

sde

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CLUE AND CUE

Male, 65 yo

loss of consciousness

seizure

Vomit History HT, never taking medication

Smoker active 2 packs/day

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LABORATORY FINDING

Diffcount : 1/1/92/4/2

Hematocrit : 40.5

Hb : 14.0

LED : 33/54

Leukosit : 18.000

Trombosit : 324.000

Urea : 25 (10-50 mg/dl)

Creatinin serum : 0,8 (0,7-12 mg/dl)

RBS : 142 PT : 10.3 (10.3-16.3 detik)

APTT : 25.0 (24.2-38.2 detik)

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SIRIRAJ SCORE

(2.5xkesadaran)+(2xvomit)+(2xheadacne)+0.1(TDDiastol)-(3xatheroma)

=(2.5X2)+(2X1)+(2X0)+0.1(12.1)-(3X1)-12

= +4

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CT SCAN SKULL

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THORAX XRAY

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Clinical diagnosis

Fisiologic reflek , Patologic reflek (+), vomite, pupil pin point,GCS 112 (Acute LOC)

Topis diagnosis

A. Cerebri media

Etiologic diagnosis

CVA Bleeding

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MONITORING

GCS

Vital sign

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PLANNING THERAPHY

IVFD Ringer assering 1500/24 hours

Inj ranitidin 2x50mg

Inj phenytoin 3x100cc

Inj metamizol 3x500mg

Manitol loading 200cc6x100cc

Pump Nicardipin 3mg/jamTDS

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PLANNING EDUCATION

Explain to the patients family about the diagnosis,etiology, intervention of therapy, complication, andprognosis.