Ward Round Report

Friday, 2017, August 25th

 Identity
• Mrs. MR, 70 yo
• Diagnosis :
SOL Intracranial with bleeding
Pneumonia
dislipidemia
• LOS : 11 days
• Chief Complain : unconsciousness
HISTORY TAKING
1 YEARS BEFORE Headache (+)
ADMISSION  Intermitten
 Sharp
 Relieve with pain killer
 Right forehead
 Mainly at night

3 MONTHS BEFORE Headache getting serious but still can be relieve with pain killer
ADMISSION

6 DAYS BEFORE Fall down in sitting position, but didn’t knock her head
ADMISSION Still concious

4 DAYS BEFORE Gradually lost her consciousness

ADMISSION Look sleepy
Lost appetize

DAYS ON Lost of conciousness

ADMISSION
 History Taking
Slurred speech
nausea
vomiting
double vision
seizure
 Past History
• History of uncotrolled hypertension ± 1 years
• History of stroke, heart disease, cholesterol,
kidney disease denied
 Physical Examination first day onset
General Examination
• General condition: severe
• Consciousness: sopor
• BP: 140/80 mmHg, HR 70 times per minute, RR 16 times per
minute , T 36.5˚C, SaO2 94%
• Conjunctiva pale -/-, sclera ikteric -/-
• Thorax : Rh -/-, Wh -/-, heart sound I/II normal, gallop -,
murmur -
• Abdomen : Flat, normal turgor, peristaltic normal
• Extremities : warm acral
 Neurologic Examination
• GCS E2M5V2 (9)
• Pupil round ø 3/3 mm. Direct light Reflex +/+ Indirect Light
Reflex +/+
• Meningeal signs: Nuchal rigidity(-), Lasegue sign >70/>70,
Kerniq sign >135/>135
• Nn. Craniales: paresis N VII UMN Sinistra impression
• Motoric examination: hemiparesis sinistra impression
MT : N N
N N
PhyR : ++/++/++ ++/++/++ PatR : - -
++/++ ++/++ - -
Sensoric examination: not evaluated
• Otonom status: incontinensia urine et alvi -/-
 Physical Examination 10 th day LOS
General Examination
• General condition: moderate
• Consciousness: compos mentis
• BP: 110/60 mmHg, HR 58 times per minute, RR 18 times per
minute , T 36.5˚C, SaO2 96%
• Conjunctiva pale (-/-), sclera ikteric (-/-)
• Thorax : Rh +/+, Wh -/-, heart sound I/II normal, gallop -,
murmur -
• Abdomen : Flat, normal turgor, peristaltic normal
• Extremities : warm acral
 Neurologic Examination
• GCS E4M6V5
• Pupil round ø 3/3 mm. Direct light Reflex +/+ Indirect Light Reflex +/+
• Meningeal signs: Nuchal rigidity(-), Lasegue sign >70/>70, Kerniq sign
>135/>135
• Nn. Craniales: paresis N VII UMN Sinistra
• Motoric examination:
MS : 5555 3333
5555 3333
MT : N N
N N
PhyR : ++/++/++ +++/+++/+++ PatR : - -
++/++ +++/+++ - +
• Sensoric examination: Exteroceptive  normoestesia
Propioseptive  not affected
• Otonom status: urination via catheter
 Laboratory Report (13th August 2017)
• Hb : 12.4% • SGOT : 21 U/L
• Ht : 37.9 % • SGPT : 9 U/L
• WBC : 5.700 /uL • Ureum : 21.9 mg/dL
• PLT : 188.000 /uL • Creatinin : 1.1 mg/dL
• GDS : 119 mg/dL
• RBC : 4.020.000 /uL
• Uric acid : 6 mg/dL
• Na : 138 mEq/L
• Cholesterol: 222 mg/dL
• K : 3.6 mEq/L
• HDL : 49 mg/dL
• Cl : 107.0 mEq/L
• LDL : 191 mg/dL
 Laboratory Report (22th August 2017)
• Hb : 13.8%
• Ht : 39.2 %
• WBC : 17.680 /uL
• PLT : 251.000 /uL
• RBC : 4.510.000 /uL
Chest X-Ray
 EKG
• Normal sinus rhytm
Brain CT SCAN
Brain CT SCan
 Diagnosis
SOL Intracranial with bleeding
Pneumonia
Dislipidemia
 Treatment
• Family education
• Bed rest + head elevation 45˚
• Mobilization right and left side every 2 hours
• Chest physiotherapy + OH
• IVFD NaCl 0.9% 500cc  20 gtt/mnts
• Dexamethasone 2 x 5 mg iv (days 2)
• Ceftriaxone 2 x 1 gr iv (days 7)
• Inj ranitidine 2x50mg IV
• PCT 3x500mg P.O.
• Amlodipine 5 mg 1-0-0
• N acetyl sistein 3 x 200mg
• Simvastatin 10mg 0-0-1

 Consult NS