MORNING REPORT

18-02-2013 E-17

PATIENT IDENTITY
Name Sex Age Address Religion Id : : : : : : M r. S Male 6 1 Yo L o p a n g RT 5 RW 1 K e m b a n g b a h u L a m o n g a n Islam 009573

ANAMNESIS
Chief Complaint : weakness of right hand and leg Present illnes : patients complained weakness of right hand

and leg since a day before hospitalized. Actually, it happened for about 2 months ago, but it got worse today. Besides that, patient also complained headache since 2 months ago. It was felt continously everyday but it was only as a mild headache. He had already gone to neurological doctor and got treated, but he forgot the name of medicine. His appettite was good. Nausea (-).Vomit (-). Shiver (-) Past illnes : HT (+) since some years ago and was treated by comsuming a medicine everyday DM (-) Family history: HT in other family member (+)

Patients status

Vital signs General appearence, awareness, GCS Blood Pressure Pulse Rate Temperature Weak , CM, 456 184/88 mmHg 71x/mnt 36,1 C

Respiratory Rate

20X/mnt

Physical Examination

KL:

anemis -/-, icteric -/-, cyanosis -/-, dysp

Thoraks :
I : chest wall movement simetric (+), retraction (-), P : fremitus (+) simetric P : sonor/sonor A : cor : reguler , additional sound () pulmo : simetric (+), ves /ves, rh -/-, wh -/

Abdomen :
I : flat A : BU (+) N P : soefl, pain (-) P : thympani

Ekstremity :Acral warm and dry to touch, CRT

5 1

<2 sec, motoric power

Lab finding
Diff: 0/0/83/14/3 Hct: 33,3 Hb: 12,1 Leko: 8.800

Tromb:252.000
SGOT 15 SGPT 31 Cl serum: 99 K serum: 4,1 Serum creatinin 0,8 Urea 25 Uric acid 4,3 Gda: 200

Clue and cue

- Mr. S, 61 yo - Weakness of right hand and leg - Headache - Nausea (-) - Vomit (-)

Problem list
- Weakness of right hand and leg - Headache

Initial dx
S. tumor cerebri

Plan dx
CT scan

Plan tx
O2 nasal canul 3 lpm Foley Catheter Ivfd ring as 1500 cc/24 hours

Inj ketorolac 3x30 mg iv

Inj ranitidin 2x50 mg Inj fenitoin 3x100mg iv Consul dr SpBS

Prognosis
Dubia ad bonam

PLANNING MONITORING
General appearance Vital sign Other complaint

Education
Explain diagnosis, planning diagnosis, planning

teraphy, complication and prognosis of the patient to his family

Thank you