History Taking Female 47 yo referred from Teling Hospital. Chief complaint: suddenly unconsciousness 3 days before admission. 3 days before admission,

Presentasi berjudul: "History Taking Female 47 yo referred from Teling Hospital. Chief complaint: suddenly unconsciousness 3 days before admission. 3 days before admission,"— Transcript presentasi:

1 History Taking Female 47 yo referred from Teling Hospital. Chief complaint: suddenly unconsciousness 3 days before admission. 3 days before admission, the patient suddenly loss of consciousness, got slurred speech and weakness of right extremity while he was working. The patient kept squeezing her head and seemed in pain. After that the patient seemed sleepy, he still responds when his family called but it's getting hard to understand what's being said, then the patient has been difficult to wake up. Then he was admitted to the nearest hospital and perfomed brain ct scan

2 History Taking Previous patients perform routine activities as usual, do not complain of signs and symptoms of a disease Vomit (-), seizure (-), fever (-), and head trauma (-) And then he was referred to Kandou Hospital.

3 History of Past illness History of illness like this before ( - ) Hypertension ± 2 years, uncontrolled DM, Hypercholesterol, Heart Disease, and kidney disease were denied. Smoking habit denied Alcohol habit denied

4 Physical Examination General examination: General condition: moderate, Consciousness : somnolen BP: 200/110 mmHg, MABP : 140 HR: 93 x/m reg, RR: 24 x/m, T: 36.8 °C, SaO2 : 98% 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

5 Neurologic examination GCS E4M5V4 (13), PERRL +/+, ø 2 mm2 mm Meningeal Sign: nuchal rigidity (-) Laseque >70/>70 Kerniq >135/>135 Cranial Nerves: paresis N VII UMN D impression Motoric State : Hemiparesis D impression MT : ↓ N PhyR : +/+/+ ++/++/++ PatR : - - ↓ N +/+ ++/++ - - Sensoric State : can’t be evaluated Autonomic State : urine catheter (+)

6 GMA: SH SSS : (2.5x1)+(2x1)+(2x1)+(0,1x110)-(3x0)-12 = 4.5 (SH)

7 WDx Unconsciousness ec Cerebral hemorrhage onset 3nd day Hypertensive emergency

8 Planning Family education 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 Attach NGT ( Family approval ) IVFD NaCl 0.9% 500cc  21 gtt/mnts (macro) IVFD NS 0.9% 100cc + nicardipine 10mg start 50gtt/min titrates up/down 25gtt every 15 minutes until target BP of 160/90 Paracetamol 3x500mg via NGT Ranitidine 2x50mg iv Lactulose syr 0 – 0 – II C via NGT

9 Lab ECG and expertise Chest X Ray Obs GC/GCS/Pupil/VS/increased ICP every 15 minutes

10 ECG expertise Normal Sinus Rhytm

11 Laboratory Examination Hb: 17.3 g/dl Ht: 49.4 % WBC: 11000/ul PLT : 213.000/ul RBC : 5.53 x 10 6 /ul Blood Sugar: 98 mg/dl Ur: 26 mg/dl Cr: 0.7mg/dl Na : 139mEq/L K : 4.9mEq/L Cl : 105 mEq/L Osm: 297

12 WDx Unconsciousness ec CVD SH (ICH r/ thalamus dextra vol. ± 14cc) onset 3nd day Emergency hypertension

13 THANK YOU