MORNING

REPORT
Monday, 12 December 2022
IDENTITY

● Name : Mr. I
● Age : 52 years old
● Gender : Male
● Address : Batu
● Arrival Date : 11th December 2022 at 01.30 WIB
● Patient Type : Nontrauma
 ANAMNESIS

Main Complaint:
Vomiting and headache

History of Present Illness: Patient complained of vomiting and headache with VAS score 8. The patient also vomited twice at the inn and once at the
emergency room. Complaints were followed by weakness in the left half of the body. Frowning (+) towards the left side, seizure (-), difficulty swallowing
(+)
Past Medical History: HT uncontrolled
Family History: -
Medicine History: amlodipine 5mg but not regularly
Alergic History: -
 GENERALIST STATUS
General Condition : Weak
Consciousness : Composmentis
GCS : 456
BP : 221/119 mmHg
HR : 78x/minutes
RR : 22x/minutes
SpO2 : 97% on room air
Tax : 36,7°C
 PHYSICAL
EXAMINATION
THORAX :
HEAD/NECK:
Cor:
Head:
Inspection: ictus cordis invisible
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), PBI 2mm|
Palpation: ictus cordis palpable at ICS 5 MCL S
3mm (pupil isocor), direct light reflex +/+, indirect light reflex
Percussion: D heart border at ICS 4 PSL D, heart border S
+/+
at ICS 5 MCL S
Ears: otorrhea (-/-)
Auscultation: S1 S2 single, irregular, murmur (-), gallop (-)
Nose: flaring breath (-) deformity (-)
Mouth: trismus (-), cyanosis (-)
Pulmo:
Inspection: normal chest wall shape, retraction (-)
Neck :
Palpation: symmetrical D/S chest wall movement
Inspection: tracheal deviation (-)
Percussion: sonor
Palpation: enlarged lymph nodes (-)
Auscultation:
Auscultation : Bruit (-)
Ves + + Wh - - Rh - -
+ + - - - -
+ + - - - -
 PHYSICAL EXAMINATION

Abdomen:
Inspection : Distended (-), scar (-)
Auscultation : BU (+) 12x/minutes
Palpation: defans muscular (-)
Superficial tenderness: Deep tenderness:
- - - - - -
- - - - - -
- - - - - -

Percussion: tympanic
Ekstremitas:
Dry red warm akral +/+/+/+, oedema -/-/-/-, CRT<2
 PHYSICAL EXAMINATION
Neurological status:
N. Cranialis :
Nervus I : sde
Nervus II : dbn
Nervus III, IV, VI : PBI 2mm/3mm, RCL +/+, RCTL +/+, eyeball movement normal
Nervus V : corneal reflex +/+
Nervus VII : Parese N. VII sinistra
Nervus VIII : sde
Nervus IX : sde
Nervus X : disfagia
Nervus XI : sde
Nervus XII : Parese N. XII sinistra
Patologis reflex :Hoffman (-/-), Tromner (-/-), Babinski (-/-), Chaddock (-/-), Oppenheim (-/-), gordon (-/-), gonda (-/-), schaeffer (-/-),
stransky (-/-)
Fisiologis reflex: Bisep (+2/+2), Trisep (+2/+2), Patella (+2/+2), Achilles (+2/+2)
Motorik : Lateralisasi sinistra
5|3
5|3
Sensorik : normal
Siriraj score: (2,5x0) + (2x1) +(2x1)+ (0,1x119)-(3x0)-12: 3,9
SUPPORTING EXAMINATION LABORATORY (11/12/22)
CT Scan(11/12/22)

Lesi hiperdens di thalamus

Edem serebri
 PROBLEM LIST & PLANNING
Problem list Initial Diagnosis Planning Diagnosis Planning Therapy
Patient complained of vomiting and headache with VAS score 8. The patient also ICH + HT emergency - • Head up 30o
vomited twice at the inn and once at the emergency room. Complaints were • Nasal Canul O2 3lpm
followed by weakness in the left half of the body. Frowning (+) towards the left • IVFD NS 20 tpm
side, seizure (-), difficulty swallowing (+) • Inj tramadol 2x1amp
• Inj OMZ 1x1amp
Physical Examination: • Inj citicolin 2x500mg
Neurological status: • Inf totilac 150ml runs
Nervus VII : Parese N. VII sinistra out in 20 mnt
Nervus X : disfagia • IV ondansetron 4mg
Nervus XII : Parese N. XII sinistra • IV Phenitoin 100mg
Motorik : Lateralisasi sinistra • Drip Nicardipin
5|3 1mcg/kgbb/gr
5|3 • IV santagesik 1gr
Siriraj score: (2,5x0) + (2x1) +(2x1)+ (0,1x119)-(3x0)-12: 3,9

CT scan:
Lesi hiperdens di thalamus
Edem serebri
THANK YOU