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    Morning Report 2th November2017

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    Andisty Ate
    The document summarizes the morning report from a hospital on November 2nd, 2017. It includes the doctors on duty that day and 11 patients being treated, most having been admitted for head injuries or cerebral problems. One patient is described in more detail, a 35 year old male who lost consciousness after complaining of a sudden severe headache and vomiting. His examination revealed cerebral hemorrhaging and he was given diagnoses of unconsciousness from SAH, IVH, hypertension, and suspected pneumonia. His treatment plan involves rest, monitoring, IV fluids and medications.

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    Morning Report 2th November2017

    Uploaded by

    Andisty Ate
    16 views19 pages
    The document summarizes the morning report from a hospital on November 2nd, 2017. It includes the doctors on duty that day and 11 patients being treated, most having been admitted for head injuries or cerebral problems. One patient is described in more detail, a 35 year old male who lost consciousness after complaining of a sudden severe headache and vomiting. His examination revealed cerebral hemorrhaging and he was given diagnoses of unconsciousness from SAH, IVH, hypertension, and suspected pneumonia. His treatment plan involves rest, monitoring, IV fluids and medications.

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    morning report

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    8_Nov_2017

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    The document summarizes the morning report from a hospital on November 2nd, 2017. It includes the doctors on duty that day and 11 patients being treated, most having been admitted for head injuries or cerebral problems. One patient is described in more detail, a 35 year old male who lost consciousness after complaining of a sudden severe headache and vomiting. His examination revealed cerebral hemorrhaging and he was given diagnoses of unconsciousness from SAH, IVH, hypertension, and suspected pneumonia. His treatment plan involves rest, monitoring, IV fluids and medications.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    16 views19 pages

    Morning Report 2th November2017

    Uploaded by

    Andisty Ate
    The document summarizes the morning report from a hospital on November 2nd, 2017. It includes the doctors on duty that day and 11 patients being treated, most having been admitted for head injuries or cerebral problems. One patient is described in more detail, a 35 year old male who lost consciousness after complaining of a sudden severe headache and vomiting. His examination revealed cerebral hemorrhaging and he was given diagnoses of unconsciousness from SAH, IVH, hypertension, and suspected pneumonia. His treatment plan involves rest, monitoring, IV fluids and medications.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 19

    Morning Report 2th

    November2017
     On Duty :
     dr. Andisty

     dr. Johannes

     dr. Milani

     dr. Desy

     dr. Ricky

     dr. Rony

     dr. Adryan

     dr. Riane

     dr. Ronald

     DPJP :
    Dr. Melke J Tumboimbela Sp.S
    Statistic
    Mr. rm / 35 yo/ Moderate Head Injury
    Mr. rr / 39 yo / Moderate head injury
    Mr. So / 35 yo/ Unconsciousness ec cerebral
    hemoragic
    Mr. Sh / 42 yo/ Severe head injury
    Mr. MA / 41 yo / Cerebral Hemoragic
    Mr. KV / 54 yo / Cerebral infarction onset day 1
    Mr. NK / 65 yo / Sequelle of cerebral infarction
    Mrs PMY / 63 yo / Unsconsciouness ec Sol

    intrakranial + susp pneumonia


    Mrs. AWY/ 32 yo / commotio cerebri day onset 1

    Mr. Hamid / 49 yo / Unsconsciousness ec

    metabolic
    Mrs. MN / 67 yo/ Unsconciousness ec SAH +

    Hypertension stage 2 + Susp Pneumonia


    Chief Complaint
    Unsconsciousness
    History Taking
    4 hours before admission At Hospital
    A patient came with sudden loss of Unconsciousness
    conciousness 4 hours before
    admission. Beforehand the patient
    complained of headache on the front
    part that strechtes to the back with
    stabbing-listraining.It happened when
    the patient had dinner. headache
    become worst when patient straining
    and become unsconciousness. The
    patient had no history of headache. The
    complains happened along with vomit
    one time with brownish liquid, non
    projectile. Trauma history, limbs
    weakness, blurry vission, cough
    ,double vission, slurred speech, seizure
    and fever were denied. Chronic
    headache history was also denied.
    History of past Illnes
    The family stated the patient had history of hypertension
    about 10 years ago but didnt take medicine regularly
    and the patient didn't know what kind of medicine the
    patient took.
    History of diabetes mellitus (-), Cholesterol (-), heart disease
    (-), kidney disease (-), stroke (-).
    Family History Past Ilness
    Hypertension (+), Diabetes mellitus (-), Cholesterol (-),
    heart disease (-), kidney disease (-), stroke (-).
    Physical Examination
    General examination:
    • General condition: severe, consciousness : sopor
    • BP: 170/90 mmHg, HR: 80x/m reg, RR: 20x/m T:
    36°C MABP 116.6
    • 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 : E3M5V3, PERRL +/+ 4 mm/ 4mm
    •FODS: Papil clear border,orange,cupping (+),aa:vv=2:3,
    flame shape -/-, exudate -/-
    •Meningeal Sign : nuchal rigidity (+), Lasegue (<70/<70),
    Kernig (<135/<135)
    Cranial Nerves : paraesis impresion (-)
    •Motoric State : hemiparesis impresion (-)
    MT: Phy R: Path R:
    N N ++/++/++ ++/++/++ - -

    N N ++/++ ++/++ - -

    •Sensoric State : cannot be evaluated


    •Autonomic State : retensio urine et alvi via cateter -/-
    AGM Cerebral hemoragic

    SSS (2.5x2) + (2x1) + (2x1) + (0.1x90) – (3x0) – 12 =


    6 Cerebral Hemoragic
    Diagnosis
    Unconsciousness ec Cerebral Hemoragic onset day 1
    Hypertension grade II
    Susp Pneumonia
    Planning
    • Communication, information, education
     Bed rest + head elevation 30°
     Oral hygiene + chest physiotherapy
     Mobilization every 2 hours
     Pro NGT and Cateter
     IVFD NaCl 0.9% 500cc/8 hours
     Paracetamol 3x1000 mg IV
     Ranitidine 50mg bid IV
     Lactulax syrup 0-0-CII
    Lab
    ECG and expertise
    Chest X-Ray
    Brain CT Scan
    Laboratory Examination
     Leucocyte 14.660
     Erythrocyte 4.35
     Hb 12.6
     Hematocryte 35.4
     Trombocyte 200.000
     SGOT / SGPT 20 / 9
     Ureum 28
     Creatinine 0.7
     RBG 130
     Chloride 100.4
     Kalium 2.8
     Natrium 141
    ECG
    •Sinus rythm
    Brain CT Scan
    Thorax
    Working Diagnosis
     Unconsciousness ec SAH Non tarumatic onset day 1
     IVH Bilateral
     Hypertension Grade 2
     Hypokalemia
     Susp Pneumonia
    Additional Planning
    •Tranexamat acid 4x1 gram IV
    •Ceftriaxone 2 x 1 gram IV (Skin Test)
    •KCL 50 meq + NACL 0.9% 500 cc (24 hour)
    •Consult Internist
    •Pro IMC Neuro

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