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    Ward Round Report

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    lie anto
    A 25-year-old man was admitted to the hospital with a headache after a motorcycle accident where he was not wearing a helmet and lost control of his bike. On examination, he had lacerations on his forehead and cheek but was conscious. Brain CT showed subdural hemorrhage. He was treated conservatively with bed rest, IV fluids, antibiotics, and vitamins.

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    Ward Round Report

    Uploaded by

    lie anto
    141 views13 pages
    A 25-year-old man was admitted to the hospital with a headache after a motorcycle accident where he was not wearing a helmet and lost control of his bike. On examination, he had lacerations on his forehead and cheek but was conscious. Brain CT showed subdural hemorrhage. He was treated conservatively with bed rest, IV fluids, antibiotics, and vitamins.

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    A 25-year-old man was admitted to the hospital with a headache after a motorcycle accident where he was not wearing a helmet and lost control of his bike. On examination, he had lacerations on his forehead and cheek but was conscious. Brain CT showed subdural hemorrhage. He was treated conservatively with bed rest, IV fluids, antibiotics, and vitamins.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    141 views13 pages

    Ward Round Report

    Uploaded by

    lie anto
    A 25-year-old man was admitted to the hospital with a headache after a motorcycle accident where he was not wearing a helmet and lost control of his bike. On examination, he had lacerations on his forehead and cheek but was conscious. Brain CT showed subdural hemorrhage. He was treated conservatively with bed rest, IV fluids, antibiotics, and vitamins.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 13

    Ward Round Report

    History Taking
    A man, 25years old, admitted to hospital with a
    chief complaint: a headache after an accident.
    5 hours before admission, the patient was riding a
    motorcycle and he was not wearing a helmet. The
    rider rode the motorcycle with high-speed and
    loses control and the patient fell down, head
    bumped asphalt road. Temporarily loss of
    consciousness that the patient didn’t know how
    long it is.
    Vomit (-), Blood from nose (-), blood from ears(-),
    alkocol (+), helmet (-), seizure (-)
    Past History
    • History of hypertension, stroke, DM, heart
    disease, cholesterol, kidney disease, stroke 
    denied
    Physical Examination first day onset
    • General condition: moderate
    • Consciousness: compos mentis
    • T: 110/80 mmHg, pulse 82, resp 18, temp 36.7
    vas 5
    • GCS E4M6V5 (15)
    • PERRL +/+, diameter 3/3 mm.
    • Meningeal signs: nuchal rigidity can’t evaluated.
    Lasegue sign >70°/>70°, Kerniq sign >135°/>135°
    • Nn. Craniales: N. II – N. XII intak
    Physical Examination
    • Motoric examination:
    MS: 5555 5555
    5555 5555
    MT : N N
    N N
    PhyR : ++/++/++ ++/++/++ PatR : - -
    ++/++ ++/++ - -
    • Sensoric examination: normoesthesia
    • Otonom status: incontinensia uri et alvi -/-
    • Status Localis : rhinore -/-
    otorrhea -/-
    Batlle sign -/-
    Racoon eyes -/-
    Vulnus laceratum regio Frontal 1x1cm
    Vulnus laceratum regio Nasoabial Sinistra 1x3
    cm
    Physical Examination 9th day onset
    • General condition: moderate sickness
    • Consciousness: compos mentis
    • T: 110/70 mmHg, pulse 72, resp 20, temp 36.6
    • GCS E4M6V5
    • PERRL +/+, diameter 3/3 mm.
    • Meningeal signs: nuchal rigidity can’t evaluated.
    Lasegue sign >70°/>70°, Kerniq sign >135°/>135°
    • Nn. Craniales: n.II-n.XII intak
    Physical Examination
    • Motoric examination:
    MS: 5555 5555
    5555 5555
    MT : N N
    N N
    PhyR : ++/++/++ ++/++/++ PatR : - -
    ++/++ ++/++ - -
    • Sensoric examination: normoesthesia
    • Otonom status: incontinensia uri et alvi -/-
    • Status Localis : rhinore -/-
    otorrhea -/-
    Batlle sign -/-
    Racoon eyes -/-
    Vulnus laceratum regio Frontal 1x1cm
    Vulnus laceratum regio Nasoabial Sinistra 1x3
    cm
    Laboratory Report (2th Nov 2017)
    • Leucocyte 13900
    • Erythrocyte 5.81 x 10^6
    • Hb 17.1
    • Thrombocyte 305.000
    • Random blood sugar 82
    • ureum 27
    • Creatinin 0.6
    • Natrium 134
    • kalium 4.00
    • Clorida 103
    • SGOT 37
    • SGPT 22
    Brain CT
    EKG
    Normo sinus rythm
    Diagnosis
    Subdural Hemorrhage regio transtentorial
    onset 9th day
    Treatment
    • Family communication information education
    • Bed rest + head elevation 30°
    • Observation GCS, VS, increase ICP
    • IVFD NaCL 0,9% 500cc  21 gtt/mnt
    • PCT 3x500mg P.O.
    • Zinc 2x20 mg p.o
    • Vit C 2x 200 mg p.o
    • Lactulac syr. 0-0-CII P.O.

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