Supervisor on duty:

Dr. Melke Tumboimbela, SpS

Residents on duty: Sekplin Sekeon Juita Mokoginta Ansye Momole Seilly Jehosua

STATISTICS
New patient:

Mrs. SK / F / 44 y0 / SOL Intracranial ( Susp Meningioma) 2. Mrs. HL / F / 62 yo / CVD Stroke Ischemic 3. Mrs. DP / F / 42 yo / CVD Stroke Hemoragic
1.

Consult: 1. Mr. MS / M / 76 yo / Ensefalopati Metabolik dd Sepsis (from Internal Med)

History Taking
2 years ago Cronic progresif headache April 2012 going to neurologist and have a Brain CT Scan impresion sfenoid wing meningioma dekstra with perifocal edema and left herniasi subfalcin 3 weeks ago Weak of right limbs going slowly Only bed activity 3 days ago Unconciousness slowly She look sleepy and not talk Intake eat and drink Seizure (-), fever (-)

PHYSICAL EXAMINATION
General status: General condition: severe. Consciousness: somnolen BP: 110/70, HR: 74x / reg, RR: 20 x/ , T: 36.7 C Head: anemic conj (-), icteric sclera (-) Neck: enlarged lymph node (-), trachea positioned in the middle Thorax: Cor: S1-2 N, HR 74 x / min, reg, murmur (-) Pulmo: vesiculer breathing, Rh -/-, wheezing (-) Abdomen: flat supple, bowel sound N, liver/spleen N Extremity: warm acral (+), oedema (-)

PHYSICAL EXAMINATION
Neurologic status: GCS E3M5V4, pupil: round isocor, 3 mm, direct & consentual light reflex: +|+ Meningeal Sign: Nuchal rigidity (-), Laseque (-) | (-), Kerniq (-) | (-) Cranial Nerves: impresion paresis of the right N7 (central)

Physical Examination
Motoric status: impression of hemiparesis dekstra MT: | N

RF: +|+++ RP -||N +|+++ -| Sensoric status: not evaluated Autonomic status: incontinence uri

LABORATORY INVESTIGATION 29th October 2012

Wbc: 10,900 Erythocyte: 4.48 x 106 Hb: 13.5 Hct: 41 Plt: 261,000 Random Blood Glucose (RBG): 110 Ur: 20 Cr: 0.8 Na: 137 K: 2,6 Cl: 98

Wdx: SOL Intracranial ( Susp Meningioma ) Hipokalemia

Therapy & Planning

Head elevation 30

Right-left mobilization every 2 hours

O2 2-4 l / min nasal kanul NGT and kateter

Intake fluids 1500 cc /day

IVFD NaCl 0.9% drip every 8 hours Dexametason 5 mg 2 amp IV bolus, and six hours later

4 x 1 amp IV Ranitidin 2 x 1 amp IV Ketorolac 1 amp IV if necessary