MORNING REPORT

SENIN, 29 NOVEMBER 20
21
•PPDS JAGA: DAN/MIT/NUR/BIM
•SUPERVISOR : dr. Dessika Rahmawati, Sp.S (K), M.Biomed
•MODERATOR : dr. Dessika Rahmawati, Sp.S (K), M.Biomed
RESUME JAGA
OB Sisa :
1. Ny. R/ 62 th/ IRD Reguler --> R. Mahakam (SU)/ CVA Trombosis 2nd Attack OH-2 + HT st I.
2. Ny. N/ 56 th/ IRD InCovit --> IRD Reguler --> R. Kapuas (ICU)/ Status Focal to Bilateral Motor Onset Tonic Clonic Seiz
ure dt Symptomatic Epilepsy dt Withdrawal OAE + Tumor Cerebri Primer dt Susp. Anaplastic Oligodendroglioma + Septi
c Condition + Azotemia Renal dd Prerenal + Transaminitis + Leukositosis + Mild Hypokalemia.

OB Jaga : 
1. Ny. ES/ 67 th/ IRD Reguler/ CVA Trombosis Brainstem OH-26 + HT st II + DM Type 2 ( Pasien KRS, Kontrol Perpolikli
nis).
2. Tn. YM/ 31 th/ R. Pangandaran (R. 27)/ Susp. Obstructive Sleep Apnea pro PSG + Tonsilitis Kronis.
3. Ny. DHS/ 46 th/ IRD Reguler --> R. Kerinci (R. 17)/ Paraparese Inferior UMN Type dt Susp. Tumor Myelum IDEM dt M
etastase dd Primer + Anemia NN + Hiponatremia + Hipokalemia.
4. Ny. K/ 43 th/ IRD Reguler --> R. Parangtritis (R. 28)/ Susp. Conus Medullaris Syndrome dd Cauda Equina Syndrome
+ HT st II + Leukositosis.

Konsulan Sisa :
1. Tn. AS/ 53 th/ IRD Reguler-Bedah Digestive --> R. Cisadane (R. 26 lt 1)/ CVA Trombosis Luas dd Emboli 2nd Attack
OH-8 + Ileus Obstruktif + Susp. Pneumonia HAP + Azotemia Renal dd Prerenal + Moderate Hypoalbuminemia + Leukos
itosis ( Raber).
RESUME JAGA

Konsulan Jaga :
1. Ny. ACH/ 29 th/ IRD Reguler-OBG/ Gradual DOC dt Septic dd Hypovolemic Shock + G3P10000Ab10
0 gr 28-30 mg dengan IUFD + Uterus Bicornu + Ruptur Uteri + Agenesis Renal + Bekas SC + Anemia G
ravis + Hiperkalemia + Leukositosis ( Tidak Raber).
2. Sdr. R/ 17 th/ R. Bengawan Solo (R. 5B)-Cardio/ CVA Emboli dd Trombosis Luas OH-1 + Post ASD C
losure by Surgical + Episodic PVC Bigemini + Susp. Pneumonia + Leukositosis ( Renc. Alih Leader Neu
ro).
3. Ny. W/ 27 th/ R. Parangtritis (R. 28)-IPD/ Paraparese Inferior LMN Type dt CIDP dd Neuropathy SLE
+ SLE Derajat Sedang MEX SLEDAI 9 + Lupus Nefritis WHO Class III-IV + Cushing Syndrome dt Steroi
d Prolonged Consumption + Upper Respiratory Tract Infection + Moderate Hypoalbuminemia + Moderat
e Hypokalemia + Leukositosis ( Raber).

Kematian : -
 PERMASALAHAN SELAMA J
AGA
▪ IRD InCovit: -

▪ IRD Reguler: -

▪ Intensive: -

▪ Ruangan: -
 Identitas Pasien

Nama : Sdr. R
Usia : 17 tahun
Alamat : Malang
Pekerjaan : Pelajar
Tanggal MRS : 27 November 2021
Anamnesis
Keluhan Utama: Lemah setengah badan kanan
• Pasien dikatakan mendadak lemah setengah badan kanan saat sedang duduk, pu
kul 14.00, 6 jam SMRS. Keluhan disertai tidak dapat berkomunikasi namun men
gerti perintah , disertai dengan wajah merot (+).
• Keluhan bicara pelo (-) tabal/ geringgingan setengah badan (-), kejang (-), nyeri k
epala (-), muntah (-), pandangan kabur/ dobel (-), gangguan pendengaran (-), ke
luhan jalan geloyoroan (-), ngompol-ngebrok (-).
• Tidak ada riwayat demam, batuk lama, keluar caran dari telinga (-), gigi berluban
g, penurunan berat badan, sesak nafas (-).
• Pasien tinggal di wilayah transmisi Covid- 19, Riwayat Bepergian Ke Daerah Zona
Merah Covid-19 (-), Kontak Dengan Penderita Covid-19 (-).
Riw. Penyakit Dahulu :
Pasien dengan Riwayat PJB (ASD) diketahui sejak usia 16 tahun  tidak rutin control sejak pandemi
ini.

HT (-), DM (-), Riwayat Infeksi (-), Riwayat kejang (-)

Riwayat Keluarga:
Tidak didapatkan keluhan serupa pada anggota keluarga

Riwayat Pengobatan:
Pasien menjalani ASD Closure by surgical pada tanggal 18/11/2021.
Dorner 3x5mg, concor1x 2.5mg revatio 3x5mg

Lifestyle:
Pasien merupakan seorang pelajar, konsumsi makanan asin (-), Manis (-), merokok (-) alcohol (-), obat
obatan terlarang (-)
 Pemeriksaan Fisik
Status Interna

TD = 111/67; HR = 88 x/m (reguler); RR = 20x/m ; Temp. Ax= 36,7° SaO2 98% on NC

4lpm
K/L Anemis -/- Ikterik -/-
Bruit carotis (-)
Thorax C/ S1S2 single, Murmur (+)

P/ Rhonki -/- Wheezing -/-

Abdomen Flat, soefl, BU (+)

Extremitas Edema -/-

 Pemeriksaan Neurologis
GCS Kuantitatif E4VXM6 Afasia Motorik
Four Score E4 M3 B4 R4

Meningeal Sign Kaku Kuduk (-), Brudzinsky Neck Sign (-), Obscure Cheek Sign (-), Symphyseal Sign (-), Brudzinsky Contralateral
Reflex Sign (-/-), Kernig (-/-)

Fungsi Luhur Afasia Motorik (+)

N. I Sde

N. II Visus ODS: sde

Konfrontasi: tde

N. III, IV, VI Ptosis -/- Pupil: isokor 3mm/3mm

Reflex: reflex Pupil +/+
GBM : dbn

N. V Sensoric : V1, V2, V3: sde

Motorik : tde
Reflex : Reflex kornea (+/+).

N. VII Motorik  slight parese NVII D Umn Type

Sensorik  sde
N. VIII Rinne tde Webber tde
Swabach tde
N. IX, N. X Arcus faring tde, uvula di tengah
N.XII sde
Motoric: Tonus: Power: Sensorik :
Normal | Normal 4+ / 5 - sde
Normal | Normal 4+ / 5
Gerakan Involuntary : - Autonom : cath (+)
Atrophy (-)

Reflex Fisiologis Reflex Patologis Reflex Regresi :

BPR +2 | +2 Hoffman -|- palmomental -/-, snout -/-, sucking -/-,
TPR +2 | +2 Tromner -|- glabela -, grasping -/-.
KPR +3 | +2 Babinski +|-
APR +2 | +2 Chaddock -|-
Openheim -|- SSS : -8.3
Gordon -|- NIHSS: 6
Schaefer -|-
Gonda -|-
Rossolimo -|-
Mendel-Bekhtrew -|-
Clinical Dx:
- Acute hemiparese D UMN type onset saat aktivitas ringan 6 jam SMRS
- Acute afasia motorik
- Slight Parese NVII D UMN Type
- Reflex patologis +/-
- Riwayat ASD
- SSS : -8.3
- NIHSS : 6

Topical Dx : ACM S, Cabang M1

Etiological Dx : CVA Emboli
Differential Dx : CVA Trombosis Luas, CVA ICH
Secondary Dx : ASD Post Surgical closure
 PLANNING DIA
GNOSIS
• CT Scan Kepala tanpa kontras
• Chest X-ray
• ECG
• Lab : DL, GDS, SE, Ur/Cr, OT/PT, Albumin, BGA,
FH/INR, Fibrinogen, Swab Antigen
• GD I/II, As Urat, Lipid Profile.

12
 Hasil Laboratorium

Keterangan 26/11/2021 NORMAL VALUE UNIT

Hb 14.1 13,4-17,7 g/dL
Leukosit 12.550 4.700-11.300 /µL
Hematokrit 42.4% 40-47 %
Platelet 288.000 142.000-420.000 /µL
Na/K/Cl 139/ 4.36/ 107 mmol/L
OT/PT 38/ 47 0-40/0-41 U/L
Ur/Cr 25.2/ 0.54 16,6-48,5/<1,2 mg/dL
GDS 111 <200 mg/dL
PPT 11 9,4-11,3 Detik
INR 1.07 <1,5
APTT 25.9 24,6-30,6 Detik
Albumin 4.3
 ANALISA
NORMAL ANALISA GAS NORMAL
GAS RESULT UNIT RESULT
VALUE DARAH VALUE
DARAH
pH 7.44 7,35-7,45
pCO2 30.9 35-45 mmHg Kolesterol total 105 < 200
pO2 94 80-100 mmHg
Trigliseride 69 < 150
HCO3 21 21-28 Mmol/L
BE -3.4 (-3)-(+3) Mmol/L HDL 31  50
SpO2 97.7 >95 %
LDL 67 < 100
26/11/2021 Normal BGA
Asam urat 3,8 3,4- 7

GDS 86 80-100

14
 EKG (27/11/2021)

Sinus rhythm, HR 75-87x/m, T inverted II, III, aVF, V2-5, PVC bigemini 
CXR (18/11/2021)
Kesimpulan :
- Cardiomegaly
ECHOCARDIOGRAPHY AT
RSSA (DECEMBER 26 TH 202
0)
Conclusion :
- Situs Solitus
- All PV to LA
- AV – VA Concordance
- Dilatation of RA, RV and MPA
- Normal RV function (TAPSE 2.1)
- Normal LV function (EF 62%)
- Diastolic function Pseudonormal (E/A 1.4)
- Large Secundum ASD Bidirectional, Balance shunt (4.8-5.7
cm)
- TR Severe, PR Mild  PH High Probability
 CT SCAN NON KO
NTRAS (27/11/21)

- Infark akut luas pada cortex subcortex lobus

fronto
temporal kiri, nukleus caudatus kiri,
kapsula eksterna kiri, kapsula interna kiri, 
nucleus lentiformis kiri, korteks insula kiri,  
suspek ec emboli sesuai teritori MCA segmen M1
prelenticulostriate kiri  (ASPECT score 3/10)
- Sinusitis sphenoidalis bilateral
ASSESSMENT
1. CVA Emboli dd Trombosi Luas OH-1
2. Post ASD Closure by Surgical
3. Episodic PVC bigemini
4. Susp. Pneumonia 
5. Leukositosis (12.550)
PLANNING THERAPY:

Non farmakoterapi:
• Head of Bed Elevation 300
• O2 2-4 lpm NC

Farmakoterapi:
• IVFD NaCl 0.9% 500cc/24 jam
• inj. Citicoline 3x500 mg
• Inj. Metamizole 3x1g k/p
• inj. Ranitidin 2x50 mg
• Drip nicardipine 5-15mg/jam bila TD > 220/120 target MAP turun 15% 
• PO. Warfarin 0-0-2mg
• PO. Bisoprolol 2.5 – 0 – 0 mg ~ TS Cardio
• PO. sildenafil 3x10 mg ~ TS Cardio
• PO. Dorner 3x10mcg ~ TS Cardio

PMo: S, VS, GCS, Tanda Peningkatan TIK

 TERIMA KASIH

22
M1 Lokasi Segmen Cabang Cabang
perforante cortical
s
Spheno Akhir dari ICA a. a. AP carotid arteriogram showing the
idal/ sampai limen Lenticulost Temporali middle cerebral artery (MCA)
Horizon insulae Reyli, riata s anterior branches. (1), M1 segment
tal/ berjalan di atas lateralis (prebifurca (prebifurcation); (2), M1 segment
Segme substansia tio) (postbifurcation); (3), MCA genu; (4),
n perforata anterior lateral lenticulostriate arteries; (5), M2
proxim 2 bagian: segment; (6), M3 segment; (7), M4
al - Pars pre segment (cortical branches); (8), apex
bifurcatio (atau of sylvian fissure (angiographic sylvian
trifurcatio) point); (9), anterior choroidal artery.
- Pars post (From Osborn AG. Diagnostic Cerebral
bifurcatio Angiography. 2nd ed. Philadelphia:
Lippincott Williams & Wilkins, 1999,
41
with permission.)
M2 Lokasi Segmen Cabang cortical
Insular/ Pada Truncus utama cabang AP carotid arteriogram showing the middle
Truncus/ bifurcation cortical (M4) 1 truncus cerebral artery (MCA) branches. (1), M1
Sylvian M1, pada utama, pada M3 segment (prebifurcation); (2), M1 segment
segment permukaa bercabang menjadi 2-4 (postbifurcation); (3), MCA genu; (4),
n insulae truncus dan masing- lateral lenticulostriate arteries; (5), M2
Reyli masing memberikan 1-5 segment; (6), M3 segment; (7), M4
sampai cabang ramus pada M4 segment (cortical branches); (8), apex of
suilcus sylvian fissure (angiographic sylvian point);
circularis (9), anterior choroidal artery. (From Osborn
insula AG. Diagnostic Cerebral Angiography. 2nd
ed. Philadelphia: Lippincott Williams &
Wilkins, 1999, with permission.)
42
M3 Lokasi Segmen Cabang cortical
Opercula Sulcus Truncus utama cabang AP carotid arteriogram showing the middle
r circularis cortical (M4) 1 truncus cerebral artery (MCA) branches. (1), M1
insula reyli utama, pada M3 segment (prebifurcation); (2), M1 segment
sampai ke bercabang menjadi 2-4 (postbifurcation); (3), MCA genu; (4),
tepi fissura truncus dan masing- lateral lenticulostriate arteries; (5), M2
sylvii di masing memberikan 1-5 segment; (6), M3 segment; (7), M4
cortex cabang ramus pada M4 segment (cortical branches); (8), apex of
permukaa sylvian fissure (angiographic sylvian point);
n lateral (9), anterior choroidal artery. (From Osborn
hemisfer AG. Diagnostic Cerebral Angiography. 2nd
cerebri ed. Philadelphia: Lippincott Williams &
Wilkins, 1999, with permission.)
43
M4 Lokasi Segmen Cabang cortical
Cabang Tepi - Orbitofrontal
cortical permukaa - Prefrontal
n fissura - Precentral
sylvii - Central
sampai - Anterior and
ujung posterior parietal
terminal di - Angular
permukaa - Temporo-occipital
n cortex - Temporal
hemisfer - Temporopolar
cerebri branches
AP carotid arteriogram showing the middle
cerebral artery (MCA) branches. (1), M1
segment (prebifurcation); (2), M1 segment
(postbifurcation); (3), MCA genu; (4),
lateral lenticulostriate arteries; (5), M2
segment; (6), M3 segment; (7), M4
segment (cortical branches); (8), apex of
sylvian fissure (angiographic sylvian point);
(9), anterior choroidal artery. (From Osborn
AG. Diagnostic Cerebral Angiography. 2nd
ed. Philadelphia: Lippincott Williams &
Wilkins, 1999, with permission.) 44
(Adam, 45
2009)
46