Professional Documents
Culture Documents
Case Report Febriena Amalia
Case Report Febriena Amalia
Case Report Febriena Amalia
Febriena Amalia
030.11.097
Mentor :
Dr. Ronny Yoes Sp.S
Identity
Name : Mr. RB
Gender : Male
Age : 50 years old
Address : Cileduk
Date of hospital admission: May 26 th, 2016
Marital Status : Married
Education : Senior High School
Room : Numfor Island (May 29th 2016)
Main complaint
Unconscious 2 hours before admitted
to the hospital
Family history
Cancer (-), hypertension (+) father,
diabetes (-), lung and heart problems (-)
tumor (-)
Social-economy and personal history
Good. Smoking (-) coffee (-)
Objectives
General condition
: somnolence
Level of consciousness : E3, M6, V5
(GCS = 14)
Vital sign
Localized Status
Head
1 post operation wounds on right side
of the posterior temporal region.
Stitches condition are good, dry, blood
(-), pus (-), drainage (-)
Neurological examination
Meningeal sign
Cranial Nerves
NI
:N II
: hard to evaluate
N III, IV, VI : hard to evaluate, direct/indirect
light reflexes +/+ , pupils isocoria 2mm/2mm
NV
: hard to evaluate
N VII
: within normal limits
N VIII
:N IX, X
:N XI
: hard to evaluate
N XII
: hard to evaluate
Laboratory Findings
29/5/2016
Diff count
WBC
: 17.100/L
Basophils
:0
RBC
: 5. 04 mil/dL
Eosinophils : 1
Hb
: 14,7 g/dL
Neutrophils
Ht
: 44 %
rod
:2
Platelets : 259.000 /L
segment : 69
Lymphocytes : 25
Monocyte
:3
Electrolytes
Natrium : 138
Kalium : 3.00
Cloride: 103
30/5/2015
Renal function
Ureum : 39
creatinine : 1.0 mg/dL
Radiology Findings
Diagnose
Dx 1
Clinical
: Unconsiousness,
hydrocephalus post VP shunt
Ethiological : Hemorrhagic Stroke
Topical : Intra Ventricular
Pathological : Hemorrhage
Dx 2
Hypertension
Dx 3
hypokalemia
Treatment
Head 30
elevation
NGT
Urine catheter
Resume
Prognosis
Ad vitam
: dubia ad malam
Ad functionam : dubia ad malam
Ad sanationam : dubia ad malam
Poor prognosis
Thank you