MORNING

REPORT
Juli, 2023
IDENTITY

● Name : Tn.K
● Age : 60 years old
● Gender : Male
● Address : Batu
● Arrival Date : 02 Juni 2023
● Patient Type : Non-Trauma
 ANAMNESIS

Main Complaint: Right Weak half body

The patient was found sitting on the floor with complaints of weakness in half
of the body. weakness accompanied by back pain since this morning and the
complaint is accompanied by a squint on the right face. In the past, the patient
had never experienced this kind of complaint. The patient will then be getting
ready to go to work. Nausea (+) Vomiting (+) 1x, convulsions (-), last meal last
night (approximately 5 hours ago).
Past Medical History: The patient has a history of HT (+) and has never been in
control
Family History: In the patient's family there is a history of hypertension (+)
Medicine History: -
 GENERALIST
STATUS
Consciousness
: CM
GCS : 456

BP :205/114mmHg

HR : 64/minute
RR : 24/minute
SpO2 : 100% on NC
Tax : 37.6 c
 PHYSICAL
EXAMINATION
THORAX :
HEAD/NECK: Cor:
Head Inspection: ictus cordis invisible
Eyes: Anemic conjunctiva (-/-), icteric Palpation: ictus cordis palpable at ICS 5 MCL S
Percussion: Right heart border at ICS 4 PSL D, Left
sclera (-), Isochor pupil diameter heart border at ICS 5 MCL S
3mm/3mm, Light reflex direct and Auscultation: S1 S2 single, regular, murmur (-),
indirect +/+ gallop (-)

Ears : bloody Otorea (-/-) Pulmo:

Nose : epistaksis (-/-) Inspection: normal chest wall shape, retraction (-)
Palpation: symmetrical D/S chest wall movement
Percussion: sonor
Neck : Auscultation:
Inspection: tracheal deviation (-)
Ves + + Wh - - Rh - -
Palpation: enlarged lymph nodes (-) + + - - - -
Auscultation : Bruits (-) + + - - - -
 PHYSICAL
EXAMINATION
Abdomen Physiological Reflexes
Inspection: Flat, inflammation (-) scar (-) eritem (-) Biceps +1 / +2
Auscultation : Bowel Sounds (+) 8x/minute Triceps +1 / +2
Abdominal Percussion: Timpany Patella +1 / +2
Abdominal Palpation: Defans (-) Superficial and Achilles +1 / +2
profundus pain (-)

Extremity:
Dry red warm akral +/+/+/+, CRT< 2, Pitting oedem Reflek patologis
(-) Babinski +/+
Chaddock -/-
Neurological Status: Hoffman -/-
GCS 456CM Tromner -/-
Stiff neck (-)
Kernig's sign (-)
Lateralized Extremity Motor Test (D)
 PROBLEM LIST & PLANNING
Problem list Devinitive Planning Planning Therapy
Diagnosis Diagnosis
Main Complaint: - IVH (S) - - IVFD NS Maintanance
• Right Weak half body IVFD Ringer Lactate
• Weakness accompanied by back pain since Maintain DoseHolliday-
this morning and the complaint is accompanied segar formula
by a squint on the right face (Weight=55 Kg)=10 (Kg)
• The patient will then be getting ready to go to x 100 ml + 10 (Kg) x 50
work ml + (55-20 Kg) x 20 ml
• Nausea (+) Vomiting (+) 1x, convulsions (-),
= 1000 ml + 500 ml +
last meal last night (approximately 5 hours
ago). 700 ml= 2200 ml/24
Hours
CT Scan
- Inj. Ranitidin 50 mg
Terdapat gambaran hiperdens pada ventrikel kiri
- Inj. Metamizol 500 mg
dengan perkiraan Volume = (8 x 4 x 4)/ 4 = 32 cc
- Inj. Sitikolin 250 mg
- Inj. Piracetam 3 gram
- Drip Nicardipin 15 mg
per jam target tensi
<160/90
THANK YOU