MORNING

REPORT
Monday, 10th of July 2023
IDENTITY

● Name : Mr. S
● Age : 64 years old
● Gender : Male
● Address : Batu
● Arrival Date : Friday, 7th of July 2023
● Patient Type : Non Trauma
 ANAMNESIS
Chief Complaint
Patient complains of worsening headache.

History of Illness:
The patient was referred from Baptis Hospital with a diagnosis of Cerebral Tumor. The patient experiences
dizziness (+) and headache for the past 5 days. Patient also complaints of leaning towards the right side of the
body during activities such as walking, holding objects, and driving a car.

Past Medical History:

• One month ago, the patient experienced a similar condition with leaning towards the left side, but for the
past two weeks, the leaning has been towards the right side. The complaint is accompanied by intermittent
heat sensation for the past month, originating from the parietal region and extending to the frontal region.
• Hypertension (+), irregular medication adherence.
• History of BPH surgery on June 21st, 2023.

Family History:
Denied.

Social History:
Non-smoker, consumes 1 cup of coffee per day.
 PRESENT STATUS
Consciousness : Composmentis
GCS : 456
BP : 143/90 mmHg
HR : 81 x/minute
RR : 20x/minute
SpO2 : 97% on RA
Tax : 36.0 °C
 GENERAL STATUS

HEAD/NECK: THORAX :
Head: Cor:
Eyes: pupils are equal in size, 2mm miosis, light reflex Inspection: Normal
intact (+/+) Palpation: Normal
Ears: Normal Auscultation: Normal
Nose: Normal
Mouth: Normal Pulmo:
Inspection: Normal chest wall shape
Neck : Palpation: Symmetrical D/S chest wall movement
Normal Percussion: Sonor
Auscultation:

Ves + + Wh - - Rh - -
+ + - - - -
+ + - - - -
 PHYSICAL
EXAMINATION
Abdomen: Extremity:
Inspection : Normal Dry red warm akral
Lateral Tenderness (-)
Auscultation : Bowel Sounds (+) 10x/minute
Edema (-), CRT <2
Palpation: no lateralization
Superficial tenderness:
- - - Neurologic Status
Physiological Reflexes:
- - - Biceps Reflex: +2 on both sides
- - - Triceps Reflex: +2 on both sides
Patellar Reflex: +2 on both sides
Achilles Reflex: +2 on both sides
Deep tenderness:
- - - Cranial Nerves:
Nerves III, IV, VI: Pupils are equal in size, 2mm miosis, light reflex
- - -
intact (+/+), normal extraocular movements
- - - Nerve VII, VIII, IX, X, XI, XII: Normal

Pathological Reflexes:
Percussion : tympanic
Normal

Motor Function Test:

5/5
5/5
 INITIAL DIAGNOSIS &
Problem list PLANNING
Initial diagnosis Planning Diagnosis Planning Therapy

Problem: • Susp. Vertigo dd Migraine- • Complete Blood Count • Monitor the patient's vital
• Anamnesis Associated Vertigo dd • Head CT-Scan signs Intravenous Ringer's
o The patient experiences dizziness (+) and headache for the Benign Paroxysmal lactate at 20 drops per
past 5 days. Positional Vertigo (BPPV) minute Dexamethasone
o Patient also complaints of leaning towards the right side of the (steroid) Pain control
• Susp. Tumor Cerebri
body during activities such as walking, holding objects, and • Controlled Hypertension therapy Phenytoin
driving a car. (anticonvulsant) Ranitidine
o One month ago, the patient experienced a similar condition. (anti-stress ulcer) Observe
o Controlled Hypertension (+) GCS, intracranial pressure,
seizures, neurological
deficits, complaints, and
• Physical Examination clinical symptoms
o BP : 143/90 mmHg Consultation with a
Neurosurgeon for
operative procedures such
as biopsy to determine the
appropriate management
Pre and post-operative
contrast MRI
LAB (03/07/2023)
 Head CT Scan (July 5th, 2023)

Conclusion:
Cerebral tumor in the right
temporo-parietal lobe,
Suspect Glioblastoma.
 PROBLEM LIST & DIAGNOSIS
Problem list Definitive diagnosis Planning Diagnosis Planning Therapy

• Cephalgia ec Cerebral tumor • Biopsy • Monitor the patient's vital signs

Problem: regio temporo-parietal lobe, Intravenous
CT-Scan: Susp. Glioblastoma • Ringer's lactate at 20 drops per
• Cerebral tumor in the right temporo-parietal lobe, Suspect Glioblastoma. minute
• Dexamethasone (steroid)
• Pain control therapy
• Phenytoin (anticonvulsant)
• Ranitidine (anti-stress ulcer
• Observe GCS, intracranial
pressure, seizures, neurological
deficits, complaints, and clinical
symptoms
• Consultation with a
Neurosurgeon for operative
procedures such as biopsy to
determine the appropriate
management
• Pre and post-operative contrast
MRI
THANK YOU