Morning report

Sunday, November 27th 2016

ER
: dr. Mardel
Consultant : dr. Putri
Stroke unit : dr. Ani
Ward
: dr. Ben

Patient Identity
Name
: Mr. W
Age
: 56 years old
Address
: Semarang
Occupation : Class
: I/ national health insurance
Registry.
: C612986

Recent History

Chief Complain : altered consciousness

Location
: Intracranial
Onset : 2 days before admission
Quality
: open eyes with voice stimulation
Quantity
: ADL fully helped by family.

Cronology:
2 days before admission, family found the
patient loss of consciousness in front of
television. Patien can opened eyes with voice
stimulation. Weakness on the left extremity,
Asymmetrical face(+), Slurred speech(-),
previous Headache(+), Vomit(+), Nausea(-),
seizure(-), fever(-). Family brought the
patient to Ungaran hospital and hospitalize
for 1 day, then patien goes to Ken Saras
Hospital for CT Scan. Because of theres no
improvement then patient referred to
Kariadis Hospital. At the ER pts referred to
neurosurgeoun for EVD.

 PAST MEDICAL HISTORY

- Hypertension (+) from 5 years ago, patien consumed amlodipin
5mg/24hr
- Stroke non haemoragic (+) 5 years ago, weakness on left extremity fully
recovered. Sequele (-)
- Heart Disease (-)
- Diabetes Mellitus (-)
- Trauma (-)
FAMILY HISTORY
- No family have the same disease
SOCIAL-ECONOMY HISTORY

I/ national health insurance

Physical Examination
GCS E3M5V4
Vital Sign :
BP : 139/83 mmHg (96)
HR : 71 x /minute
RR : 17x / minute
T : 36,7 C
SaO2 : 100 %

NEUROLOGICAL STATUS
Eye

: Pupil round isokor, 2,5mm / 2,5 mm,

Light reflex +/ +

Neck

: nuchal rigidity (-)

Cranial nerves : central paralysis of left fascial nerve

Motoric
Movement
Strength

Superior

Inferior

Lateralization to the left

Tonus

N/

N/

Trophy

E/E

E/E

Physiologic Reflex

++/+++

++/+++

Pathologic Reflex

-/-

B +/+ B

Clonus
Sensibility
Vegetative

-/: difficult to rate

: applied DC and NGT

LABORATORIUM
and Additional
examination

Laboratory Examination 25/05/2015

Examination

RESULT

Normal Point

Hb

14,7

13 - 16 g/dl

Ht

44,3

40 52 %

Erythrocyte

4,74

4.3 - 6.0 mil /ul

Leukocyte

16600

4800 - 10800/ul

Platelet

285000

150000 - 400000/ul

MCV

93

80 96 fL

MCH

31

27 - 32 pg

MCHC

33,2

32 36 g/dL

Routine Hematology

Examination

RESULT

Normal Point

Ureum

22

20 - 50 mg/dl

Creatinine

0,98

0.5 1.5 mg/dl

Random Glucose level

101

< 140 mg/dl

Sodium

131

135 147 mmol/L

Potassium

4,2

3.5 5.0 mmol/L

Chloride

95

95 105 mmol/L

 Osmolarity : 2 (131+ 4,2) + 101/18 + 22/6

= 270,4 + 5,6 + 3,6
= 279,6

ECG

Normo Sinus Rhtym

MSCT without contrast

ICH
in
Right
thalamus
(vol
23cc), IVH, and
SAH

DIAGNOSIS
1. Clinical Diagnostic : Bilateral spastic

hemiparesis heavier at the left side , Central

left paralysis fascial nerve
Topis Diagnostic :

Right thalamus, ventricle system,

subarachnoid space
Etiology Diagnostic:
Stroke Haemoragic (ICH, IVH, SAH)
2. Hyponatremia (Na 131)
3. Leucosytosis (L 16600)

Program

Thera
py

Rehabilitation Consultation
Nutritionist Consultation
Examine lipid profile, uric acid,
PT/APTT
X Ray Thorax

IVFD Nacl 0,9%20 tpm

Inj As Tranexamat 1gr/8 hr (IV)
Inj Ranitidin 50 mg/ 12 hr (IV)
Inf Manitol 125cc/6hr (IV)
Inj Tramadol 100mg/12hr (IV)
Nimodipin tab 60mg/6jhr (PO)

 Vital sign, GCS ,

MONITORIN Neurologic
G
Deficite

EDUCATIO
N

DIAGNOSIS,
THERAPY,
PROGNOSIS

THANK YOU