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    Lapjag Ke 9

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    andisty
    The document summarizes a patient's morning report. It includes details of the patient's complaint of sudden seizure, physical examination findings of severe condition and hemiparesis, and diagnosis of unconsciousness due to cerebral hemorrhage and hypertension. Laboratory tests showed elevated leukocyte count. A CT scan and ECG were performed. The patient was given IV fluids, medications, and admitted to the neurology intensive care unit.

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    Lapjag Ke 9

    Uploaded by

    andisty
    16 views20 pages
    The document summarizes a patient's morning report. It includes details of the patient's complaint of sudden seizure, physical examination findings of severe condition and hemiparesis, and diagnosis of unconsciousness due to cerebral hemorrhage and hypertension. Laboratory tests showed elevated leukocyte count. A CT scan and ECG were performed. The patient was given IV fluids, medications, and admitted to the neurology intensive care unit.

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    Laporan jaga

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    lapjag ke 9

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    The document summarizes a patient's morning report. It includes details of the patient's complaint of sudden seizure, physical examination findings of severe condition and hemiparesis, and diagnosis of unconsciousness due to cerebral hemorrhage and hypertension. Laboratory tests showed elevated leukocyte count. A CT scan and ECG were performed. The patient was given IV fluids, medications, and admitted to the neurology intensive care unit.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    16 views20 pages

    Lapjag Ke 9

    Uploaded by

    andisty
    The document summarizes a patient's morning report. It includes details of the patient's complaint of sudden seizure, physical examination findings of severe condition and hemiparesis, and diagnosis of unconsciousness due to cerebral hemorrhage and hypertension. Laboratory tests showed elevated leukocyte count. A CT scan and ECG were performed. The patient was given IV fluids, medications, and admitted to the neurology intensive care unit.

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    © All Rights Reserved
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    Download as ppt, pdf, or txt
    of 20

    Morning Report th

    30 October 2017
    On Duty :
    dr. Andisty
    dr. Milani
    dr. Riko
    dr. Ricky
    dr. Rivan
    dr. Windi
    dr. Dennis
    dr. Joanita

    DPJP :
    DR. dr Junita Maja P.S, Sp.S(K)
    Statistic
    Mr. FA / 12 yo/ TTH
    Mrs. ML / 17 yo / mild head injury
    Mr. AH / 27 yo/ Cephalgia post trauma
    Mrs KM / 70 yo/ Neuralgia trigeminal
    Mr. LC / 20 yo / severe head injur
    Mrs. NM / 28 yo / Susp Sol Intrakranial
    Mrs. PK / 77 yo / Moderate head injury
    Mr. TM / 8 yo / Moderate head injury
    Mr. MR / 30 yo / Reattack cerebral infarct
    Mr. RR / 20 yo / moderate severe injury
    Mrs. HL / 87 yo / cerebral infarction onset
    day 1
    Mr. MA / 50 yo / Unsconsciousness ec Sol
    Intracranial dd oligodendroglia
    Chief Complaint
    Seizure
    History Taking
    The patient came with the complain of sudden seizure 6 hours before admission.
    The seizure happened when the patient was asleep at night.

    Pre-ictal: no complain

    Ictal : seizure happened 8 times, with the interval 10 times, the patient was
    unconcious between seizure. The head was turned to the right, eyes turned
    upwards, right limbs was raised with the same movement as the left limb, mouth
    was foaming, tounge was bitten, the patient was wetting the bed, with duration
    less than 3 minutes.

    Post ictal: patient was unconcious

    The patient complained of headache for the past two weeks. It happened
    everyday and worsened when the patient coughed and strained. The patient had
    taken pain killer but 4 hours after that the pain resurfaced. History of seizure
    before was denied, family history of seizure was denied. Blurry vision, double
    vision, history of trauma (-)
    History of past illnes
    Hypertension (-).
    History of diabetes mellitus (-), Cholesterol (-),
    heart disease (-), kidney disease (-), stroke (-).
    Physical Examination
    General examination:
    General condition: severe, consciousness :
    sopor
    BP: 150/90 mmHg, HR: 110x/m reg, RR: 24x/m
    T: 36C MABP 110
    Conjunctiva: pale (-/-), sclera ikteric (-/-)
    Thorax: rale -/-, wh -/-, heart sound I/II normal,
    gallop -, murmur -
    Abdomen : flat, normal turgor, peristaltic normal
    Extremities : warm acral
    Neurological Examination
    GCS : E3M5V1, PERRL +/+ 4 mm/ 4mm
    Meningeal Sign : nuchal rigidity (+), Lasegue (>70/>70),
    Kernig (>135/>135)
    Cranial Nerves : paraesis impresion N VII UMN D
    Funduscopy ODS : papil (round), cupping disc (+), A:V (2:3)
    orange
    Motoric State : hemiparesis impresion D
    MT: Phy R: Path R:
    N +/+/+ ++/++/++ - -

    N +/+ ++/++ + +

    Babinski
    Sensoric State : cannot be evaluated
    AGM Cerebral Hemoragic

    SSS (2.5x1) + (2x0) + (2x0) + (0.1x90) (3x1)


    12 = -2.5 Cerebral hemoragic
    Diagnosis
    Unsconsciousness ec susp Cerebral
    Hemoragic.
    Hypertension Grade II
    Secondary general seizure
    Planning
    Communication, information, education
    02 2-4 /Lpm
    Bed Rest + Head elevation 30
    Oral Hygiene + chest phisiotherapy
    Pro NGT + cateter
    Lab
    ECG and expertise
    Chest X-Ray
    Brain CT Scan
    Obs GCS, TTV, Pupil
    IVFD NaCl 0.9% 500cc/8 hours
    Paracetamol 3x500 mg PO
    Ranitidine 2x50mg IV
    Lactulax syrup 0-0-CII NGT
    Diazepam 10 mg max 20 mg IV prn
    Laboratory Examination
    Leucocyte 17.200
    Erythrocyte 3.67
    Hb 16.6
    Hematocryte 47.5
    Trombocyte 288.000
    SGOT / SGPT 17 / 23
    Ureum 25
    Creatinine 0.7
    RBG 443
    Chloride 102
    Kalium 4.6
    Natrium 142
    ECG
    Sinus Tarcicardya
    THORAX
    BRAIN CT SCAN
    Working Diagnosis
    Unsconsciousness ec Cerebral infarct regio temporoparietal
    sinistra.
    Hypertension Grade II
    Epileptic focal symptomatik
    DM type II
    Additional Planning
    Diazepam 10 mg prn
    Consult div Epileptic
    Consult Internist
    Pro IMC Neuro

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