Morning report

History Taking
 Male 41 yo with chief complain unconciousness

2 day before admission At admission

• The patient was suddenly unconscious ± 2 • Unconscious
days before admission. At that time, the • Weakness in the left extremity
patient was picking up the goods. Suddenly
he felt a severe headache and fell down • Vomit (-), fever (-), double vision
didn't knock on the floor because he was (-), loss of weight (-), seizure (-),
hold by his family members. cough (-), slurred speak (-)
• He seemed sleepy but still can be awakened
when he called by his family. The left
extremity appears to be less active than the
right extremity.
History of Past illness

 History of stroke (-)

 Hypertension,DM, Heart Disease, and kidney disease were
denied.

Habitual History
 Smoking habit ± 20 years ( 1 pack a day )
 Alcohol habit +
 Physical Examination
 General examination:
 General condition: severe, Consciousness : sopor
 BP: 120/90 mmHg, MABP : 100 HR: 64 x/m reg, RR: 24 x/m , T: 36.8
°C, SaO2 : 99%
 Conjunctiva : pale (-/-), sclera ikteric (-/-)
 JVP ; normal
 Thorax : Rale -/-, Wh -/-, heart sound I/II normal, gallop -, murmur –
 Abdomen : Flat, normal turgor, peristaltic normal
 Extremities : warm acral
 Neurological Examination
 GCS E2M5V3, PERRL +/+, ø 3 mm/3 mm
 Meningeal Sign: nuchal rigidity (+) Laseque >70/>70 Kerniq
>135/>135
 Cranial Nerves: paresis N.VII UMN sinistra impression
 Motoric State : hemiparesis sinistra impression
MT : N ↓ PhyR : ++/++/++ +/+/+ PatR :- -
N↓ ++/++ +/+ - -
 Sensoric State : can’t be evaluated
 Autonomic State : urination via catheter
 GMA : SH (unconscious, headache)
 SSS : (2.5x1)+(2x1)+(2x0)+(0,1x90)-(3x0)-12 =
1.5 (SH)
WDx
 Unconsciousness ec Cerebral hemorrhage onset 2nd day
 Hypertension grade I
 Planning
 Family CIE
 O2 2-4 lpm via canule nasale
 Bed rest + head elevation 30 degree
 Mobilization lean to right/left every 2 hours
 Oral hygiene + chest physiotherapy
 IVFD NaCl 0.9% 500cc  21 gtt/mnts (macro)
 Paracetamol 3x500mg via NGT
 Ranitidine 2x50mg iv
 Lactulose syr 0 – 0 – II C via NGT
Diagnostic Planning
 Blood exam
 ECG
 Chest X ray
 Brain CT Scan
 Laboratory Examination
 Hb : 14.4
 Ht : 46
 WBC : 12.500
 PLT : 248.000
 RBC : 5.37 x 106
 SGOT : 22
 SGPT : 16
 Ureum : 42
 Creatinine : 0.9
 Random Blood sugar : 131
 Na : 146
 K : 3.85
 Cl : 106.2
 OSM : 285.30 mOsm/L
 PT : 0.88x
 INR : 0.90
 APPT : 0.86x
ECG
 Normal sinus rythm
Chest X- Ray
Brain
CT Scan
Brain CT Scan (zoomed)
WDx
 Cerebral infarction transformation haemorrhage onset 2nd
day
 Hypertension grade I
Added Therapy

 Manitol 20% loading dose 300 cc  TD >130/80

mmHg & Osm N
THANK YOU