Ward Round Report

Friday, 2017, August 25th

 Identity
• Mrs. S, 51 yo
• Diagnosis :
CVD SH (ICH R/ Ganglia basalis Sinistra vol
±27 cc)
HT grade II
• LOS : 8 days
• Chief Complain : unconsciousness
HISTORY TAKING
• Female 51 yo admitted to hospital with chief
complain unconsciousness since 3 days before
admission
• The patient complained suddenly feel headache
• According to her family her left side of the body
more active than the right side since 3 days ago.
• Vomit 1 time consist of food and fluid, blood (-)
• Double vision (-),seizure (-), faver (-), trauma (-)
• Patient had been treated in kotamobagu
hospital
 Past History
• History of illness like this before (-)
• Hypertension (+) since 2 years ago when,
doesn’t take medicine regularly.
• Cholesterol, DM, Heart Disease, and kidney
disease were denied.
Physical Examination first day onset
General Examination
– General condition: moderate, Consciousness :
Somnollen
– BP: 190/100 mmHg, MABP : 130 HR: 92 x/m reg, RR:
24x/m , T: 36.6°C
– Conjunctiva : pale (-/-), sclera icteric (-/-)
– JVP ; normal
– Thorax : Rale -/-, Wh -/-, heart sound I/II normal, gallop
-, murmur –
– Abdomen : Flat, normal turgor, peristaltic normal
– Extremities : warm acral
 Neurologic Examination
• GCS E3M5V2 (10) Pupil Isocor ø 3 mm/3 mm
Direct light Reflex +/+ Indirect Light Reflex +/+
• Meningeal Sign: nuchal rigidity (-) Laseque
>70/>70 Kerniq >135/>135
• Cranial Nerves: paresis N VII UMN Dextra
impression, N XII UMN Dextra impression
• Motoric State : hemiparesis Dextra impression
MT ↓ N PhyR : +/+/+ ++/++/++ PatR : - -
↓N +/+ ++/++ - -
• Sensoric State :Not evaluated
• Autonomic State : Incontinentia urine et alvi (-)
• GMA : SH
• SSS : (2.5x1)+(2x0)+(2x1)+(0,1x90)-
(3x0)-12 = 1.5 (SH)
 Physical Examination 8 th day LOS
General Examination
• General condition: moderate
• Consciousness: compos mentis
• BP: 140/100 mmHg, HR 59 times per minute, RR 18 times per
minute , T 36˚C, SaO2 97%
• 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 E4M6Vafasia
• 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 dextra, N XII UMN dextra
• Motoric examination:
MS : 1111 5555
1111 5555
MT : ↓ N
↓ N
PhyR : ++/++/++ ++/++/++ PatR : - -
++/++ ++/++ - -
• Sensoric examination: Not evaluated
• Otonom status: urination via catheter
 Laboratory Report (18th August 2017)
• Hb : 13.1% • SGOT : 12 U/L
• Ht : 39.5 % • SGPT : 17U/L
• WBC : 10.700 /uL • Ureum : 35 mg/dL
• PLT : 187.000 /uL • Creatinin : 0.8 mg/dL
• RBC : 5.690.000 /uL • GDS : 99 mg/dL
• Na : 138 mEq/L
• K : 3.7 mEq/L
• Cl : 105.0 mEq/L
 Laboratory Report (22th August 2017)

• Fasting Blood sugar : 129 mg/dL

• Uric acid : 5.6 mg/dL
• Cholesterol : 186 mg/dL
• HDL : 33 mg/dL
• LDL : 135 mg/dL
• Trigliseride : 92 mg/dL
• Albumin : 3.74 g/dL
Chest X-Ray
Brain CT
Brain CT
 EKG
• Normal sinus rhytm
 Diagnosis
• unconsciousness ec CVD SI (ICH Ganglia
basalis vol 27 cc ) 10th day onset
• Hypertension grade II
 Treatment
• Family education
• Bed rest + head elevation 30˚
• Mobilization right and left side every 2 hours
• Chest physiotherapy + OH
• IVFD NaCl 0.9% 500cc  20 gtt/mnts
• Simvastatin 20mg 0-0-1
• Amlodipine 10mg 1-0-0
• Valsartan 80mg 0-0-1
• Inj ranitidine 2x50mg IV
• PCT 3x500mg P.O.
• Lactulac syr 0-0-CII