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Morning Report: Unconsciousness Cases

The document summarizes the morning report from a hospital on November 2nd, 2017. It includes the doctors on duty that day and 11 patients being treated, most having been admitted for head injuries or cerebral problems. One patient is described in more detail, a 35 year old male who lost consciousness after complaining of a sudden severe headache and vomiting. His examination revealed cerebral hemorrhaging and he was given diagnoses of unconsciousness from SAH, IVH, hypertension, and suspected pneumonia. His treatment plan involves rest, monitoring, IV fluids and medications.

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Andisty Ate
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41 views19 pages

Morning Report: Unconsciousness Cases

The document summarizes the morning report from a hospital on November 2nd, 2017. It includes the doctors on duty that day and 11 patients being treated, most having been admitted for head injuries or cerebral problems. One patient is described in more detail, a 35 year old male who lost consciousness after complaining of a sudden severe headache and vomiting. His examination revealed cerebral hemorrhaging and he was given diagnoses of unconsciousness from SAH, IVH, hypertension, and suspected pneumonia. His treatment plan involves rest, monitoring, IV fluids and medications.

Uploaded by

Andisty Ate
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd

Morning Report 2th

November2017
 On Duty :
 dr. Andisty

 dr. Johannes

 dr. Milani

 dr. Desy

 dr. Ricky

 dr. Rony

 dr. Adryan

 dr. Riane

 dr. Ronald

 DPJP :
Dr. Melke J Tumboimbela Sp.S
Statistic
Mr. rm / 35 yo/ Moderate Head Injury
Mr. rr / 39 yo / Moderate head injury
Mr. So / 35 yo/ Unconsciousness ec cerebral
hemoragic
Mr. Sh / 42 yo/ Severe head injury
Mr. MA / 41 yo / Cerebral Hemoragic
Mr. KV / 54 yo / Cerebral infarction onset day 1
Mr. NK / 65 yo / Sequelle of cerebral infarction
Mrs PMY / 63 yo / Unsconsciouness ec Sol

intrakranial + susp pneumonia


Mrs. AWY/ 32 yo / commotio cerebri day onset 1

Mr. Hamid / 49 yo / Unsconsciousness ec

metabolic
Mrs. MN / 67 yo/ Unsconciousness ec SAH +

Hypertension stage 2 + Susp Pneumonia


Chief Complaint
Unsconsciousness
History Taking
4 hours before admission At Hospital
A patient came with sudden loss of Unconsciousness
conciousness 4 hours before
admission. Beforehand the patient
complained of headache on the front
part that strechtes to the back with
stabbing-listraining.It happened when
the patient had dinner. headache
become worst when patient straining
and become unsconciousness. The
patient had no history of headache. The
complains happened along with vomit
one time with brownish liquid, non
projectile. Trauma history, limbs
weakness, blurry vission, cough
,double vission, slurred speech, seizure
and fever were denied. Chronic
headache history was also denied.
History of past Illnes
The family stated the patient had history of hypertension
about 10 years ago but didnt take medicine regularly
and the patient didn't know what kind of medicine the
patient took.
History of diabetes mellitus (-), Cholesterol (-), heart disease
(-), kidney disease (-), stroke (-).
Family History Past Ilness
Hypertension (+), Diabetes mellitus (-), Cholesterol (-),
heart disease (-), kidney disease (-), stroke (-).
Physical Examination
General examination:
• General condition: severe, consciousness : sopor
• BP: 170/90 mmHg, HR: 80x/m reg, RR: 20x/m T:
36°C MABP 116.6
• Conjunctiva: pale (-/-), sclera ikteric (-/-)
• Thorax: rale +/+, wh -/-, heart sound I/II normal,
gallop -, murmur -
• Abdomen : flat, normal turgor, peristaltic normal
• Extremities : warm acral
Neurological Examination
•GCS : E3M5V3, PERRL +/+ 4 mm/ 4mm
•FODS: Papil clear border,orange,cupping (+),aa:vv=2:3,
flame shape -/-, exudate -/-
•Meningeal Sign : nuchal rigidity (+), Lasegue (<70/<70),
Kernig (<135/<135)
Cranial Nerves : paraesis impresion (-)
•Motoric State : hemiparesis impresion (-)
MT: Phy R: Path R:
N N ++/++/++ ++/++/++ - -

N N ++/++ ++/++ - -

•Sensoric State : cannot be evaluated


•Autonomic State : retensio urine et alvi via cateter -/-
AGM Cerebral hemoragic

SSS (2.5x2) + (2x1) + (2x1) + (0.1x90) – (3x0) – 12 =


6 Cerebral Hemoragic
Diagnosis
Unconsciousness ec Cerebral Hemoragic onset day 1
Hypertension grade II
Susp Pneumonia
Planning
• Communication, information, education
 Bed rest + head elevation 30°
 Oral hygiene + chest physiotherapy
 Mobilization every 2 hours
 Pro NGT and Cateter
 IVFD NaCl 0.9% 500cc/8 hours
 Paracetamol 3x1000 mg IV
 Ranitidine 50mg bid IV
 Lactulax syrup 0-0-CII
Lab
ECG and expertise
Chest X-Ray
Brain CT Scan
Laboratory Examination
 Leucocyte 14.660
 Erythrocyte 4.35
 Hb 12.6
 Hematocryte 35.4
 Trombocyte 200.000
 SGOT / SGPT 20 / 9
 Ureum 28
 Creatinine 0.7
 RBG 130
 Chloride 100.4
 Kalium 2.8
 Natrium 141
ECG
•Sinus rythm
Brain CT Scan
Thorax
Working Diagnosis
 Unconsciousness ec SAH Non tarumatic onset day 1
 IVH Bilateral
 Hypertension Grade 2
 Hypokalemia
 Susp Pneumonia
Additional Planning
•Tranexamat acid 4x1 gram IV
•Ceftriaxone 2 x 1 gram IV (Skin Test)
•KCL 50 meq + NACL 0.9% 500 cc (24 hour)
•Consult Internist
•Pro IMC Neuro

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