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Morning reportFriday 18/12/2015

ER : dr. Rustina

Consultant : dr. Marthin

Stroke unit : dr.Christine

ard : dr. !aniel"dr.#heo

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$%#&E'#(S &!E'#&#) 

Name : Mrs. J

Age : 38 years old

Gender : Female

Occupation : Housewives

M Num!er : "#$%&%'Hospital admission: %$(%'( '#%)

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*&S#+R) ,alloana-nesis

Chie o-plaint : decreased consciousness

+nset : * days !e+ore ,ospital

admission

-ocation : intracranial

uality : can !e awaen wit, ,ard

stimulation

uantity : A/- dependent

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*&S#+R) ",ronology :

0 % mont,s !e+ore Hospital Admission +amily said patient

complained ,eadac,e 12continuously4 vomit 124 weaness 154

tingling sensation4 sei6ures15.

0 ' wees !e+ore ,ospital admission4 +amily said t,at4 patient start

to +eel weaness 4patient ,ad di7culty to wal4 s,e need ,elp to

wal ,eadac,e !ecame more severed4 continuously4 vomit 124

Family said s,e started cant understand wit, conversation4 !ut still

can tal uently4 t,en s,e !roug,t to 9etileng Hospital124 s,e ,ad

some pain illers and ,er complaint a!out ,er ,eadac,e decreased4

 

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 0 * days !e+ore ,ospital admission4 +amily said s,e

s,e cant understand wit, any ind o+ conversation4

,er ,eadac,e !ecome more severe didnt relievewit, pain iller. ;,e cant wal4 sei6ures 154 vomit 12.

0 % days !e+ore ,ospital admission4 +amily said t,e

patient loos unconscious4 s,e started not to eat4cant communicate4 s,e cant wal4

sei6ures154+ever15.

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*&S#+R) 

• Aggravated Factors : 5

• <=tenuated Factors : 5

• "oncomitant ;ymptoms : ,eadac,e124

>omit124 weaness

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*&S#+R) • Past Medical History 

5 ;ame complaint !e+ore denied

5 Hypertension denied

5 /M denied

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C&'&C% F&'!&'3S

$resent StatesG"; : <'M*>'>ital signs :

?@ : %'#($# mmHg H : 8#=(min : '#=(min emp 3&.) 1a=illa

<ye : round pupil4 isocor 3(3 mm4lig,t ree= 2(2

 ,ora= : normal !reat,ing4 ,5(54 B, 5(5

  normal ,eart sound4 murmur 154gallop15

A!domen : unpalpa!le liver and spleen4 ascites 15 

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Nn "raniales : di7cult to asses

;ensi!ilitas : di7cult to asses

>egetati+ : di7cult to asses

Motorik Superior &nerior

Movement  +( + +( +

;treng,t -ateralisation 15

 onus N(N N(N

 roC <(< <(<

F 222(222 222(222

@ 2H4(2H4 2?4"(2?4"

9lonus 5(5

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-A?OAOD 1%$5%'5'#%)

a4oratory alue 'or-al alue

*4 %3.% %35%&

*t *%.3E *#5)*

Eritrosit *.)& uta(mm *4*5)4 uta

MC* '4 pg '$53'

MC 8.# $&5&MC*C 3*.3 g(dl '53&

eukosit )&.###(mm 3&##5%%###

#ro-4osit *#'.###(mm %)#5*##ri!u

R! %3.) %%.&5%*.8

M$   $.3* *5%%

Ur 73 mg/dl 15-39

Cr 1.2 mg/dl 0,6-1,3

3!S %38 mg(dl 8#5%&#

Sodiu- %3 mmol(- %3)5%*)

6aliu- 3.$ mmol(- 34)5)4%

$otassiu- %#% mmol(- 85%#$

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   H  e  a   d   M

   ;   "     w   i   t   ,

  o  u   t   "  o  n   t  r  a  s

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   ' 5   '

   #   %   )

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   H  e  a   d

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   t   ,   "  o  n   t  r  a

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mpression

• Hiperdens -esion in -e+t Frontotemporal-o!e wit, peri+ocal edema

• @ro!a!ly ntracere!ral Hemmor,age

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   "   ,  e  s   t   I 5     a  y   A   @

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mpression

• "or : Normal state

• @ulmo : Normal ;tate

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EC3 17/12/2015

Impression : Normo Sinus Rhythm, with Non

Specific ST Changes

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Op,talmologist

• mpression : @apil Oedema O/;

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!&%3'+S&S

  Clinial !iagnose

O!s nconsciousnes

",ronic "ep,algia

  #opis !iagnose-e+t Frontotemporal -o!e

  <tiology /iagnosis

;usp ntratumoural Hemmor,age

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#herapy

%. "onsult : Op,talmologist4 M

'. ,erapy :O' 3l( nasal canul4 ,ead elevation 3# degree

>F/ - 3# dpm

n anitidine )# mg(%' ,ours>

n /esamet,asone %# mg( & ,.o >

>itamin ?%?&?%' % ta!( 8 ,.o  @.O

nrane=amat Acid )## mg( 8 ,.o  >

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• MONONG :

G";4 vital signs4 neurologic deCcits4 uid!alance

</"AON :

diagnosis4 management4 complications4prognosis

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 HAN9 DO