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  • LapJag Jeff 4apr MS CVD SH

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    Jeffri Setiawan
    10 vistas15 páginas
    This document summarizes a patient case involving a 42-year-old female admitted to the hospital with sudden decreased consciousness for 19 hours. Her history indicates uncontrolled hypertension and cholesterol for 3 years. Physical examination finds her condition is moderate with awareness in a sopor state, blood pressure is 170/90, and neurological examination finds right hemiparetic impression. Brain CT scan reveals a 30cc intracerebral hemorrhage in the left basal ganglia region. Her diagnosis is concluded to be CVD SH (intracerebral hemorrhage) and hypertension grade II. Her treatment plan involves bed rest, medication, and monitoring.

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    Lapjag Kejang Neuro neurologi

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    LapJag Jeff 4Apr MS CVD SH.pptx

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    This document summarizes a patient case involving a 42-year-old female admitted to the hospital with sudden decreased consciousness for 19 hours. Her history indicates uncontrolled hypertension and cholesterol for 3 years. Physical examination finds her condition is moderate with awareness in a sopor state, blood pressure is 170/90, and neurological examination finds right hemiparetic impression. Brain CT scan reveals a 30cc intracerebral hemorrhage in the left basal ganglia region. Her diagnosis is concluded to be CVD SH (intracerebral hemorrhage) and hypertension grade II. Her treatment plan involves bed rest, medication, and monitoring.

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    © All Rights Reserved
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    10 vistas15 páginas

    LapJag Jeff 4apr MS CVD SH

    Cargado por

    Jeffri Setiawan
    This document summarizes a patient case involving a 42-year-old female admitted to the hospital with sudden decreased consciousness for 19 hours. Her history indicates uncontrolled hypertension and cholesterol for 3 years. Physical examination finds her condition is moderate with awareness in a sopor state, blood pressure is 170/90, and neurological examination finds right hemiparetic impression. Brain CT scan reveals a 30cc intracerebral hemorrhage in the left basal ganglia region. Her diagnosis is concluded to be CVD SH (intracerebral hemorrhage) and hypertension grade II. Her treatment plan involves bed rest, medication, and monitoring.

    Copyright:

    © All Rights Reserved
    Descargue como PPT, PDF, TXT o lea en línea desde Scribd
    Marcar por contenido inapropiado
    de 15

    Team:

    Jeffri
    Aprillia
    Hendy
    Yasinta
    Caroline
    Dennis
    dr. Karema Winifred, Sp.S(K)

    Statistic :
    New Patient :
    1. Mrs MS/42 yo / Unconsciousness ec CVD SH
    2. Mr HP / 17 yo / Severe Head Injury
    3. Mr. SP / 45 yo / Unconsciousness ec CVD SH
    4. Mr. AD / 19 yo / Moderate Head Injury w
    5.
    6.
    7.
    8.

    Alcoholism
    Mr. FP / 20 yo / Severe Head Injuey w alcoholism
    Mr. FH / 30 yo / Simple Head Injury
    Mr. PM / 45 yo / Mild Head Injury + Alcoholism
    Ms. VA / 16 yo / Simple Head Injury

    History taking
    Female, 42 y0 admitted to hospital with

    suddently decreassed of consiousness about


    19 hours before admitted to hospital

    History taking

    History of Pass Illness


    Hypertension (+) about 3 years ago

    uncontrolled
    Cholesterol (+) about 3 years ago
    uncontrolled
    DM, Uric acid, Heart and kidney disesases
    were denied

    Physical Examination
    General status:
    General condition: Moderate, awareness: Sopor
    BP: 170/90 mmHg, MABP : 116,67 , HR: 62 x/m
    reg,
    RR: 18 x/m , T: 36,8 C ,SO2 : 98% .
    Neck: Deformity (-)
    Thorax: Simetric Dextra=Sinistra, Rh-/-, Wh -/-,
    sign of injury (-)
    Abdomen : soepel, normal turgor, normal
    peristaltic
    Extremities : warm acral

    Neurologic examination
    GCS : E3M5V1 (9) PERRL +/+, 3 mm/3

    mm,
    Meningeal Sign: Nuchal rigidity(-),Laseque
    (-/-) ,Kernig(-)
    Cranial Nerves : Paretic right N. 7 UMN
    Impression
    Motoric State : Right hemiparetic
    impression
    TO : / N RF : + / ++ RP : - / / N
    + / ++
    +/Sensoric State : no yet evaluated
    Autonomic State :
    Inkontinensia Urine et Alvi : -

    Score Stroke
    SSS : (2,5x2)+(2x1)+(2x1)+(0,1x90)- (3x0)-

    12 = +6 ( SH )
    GMA : SH

    X foto thorax

    Brain CT Scan

    Brain CT Scan

    Laboratory Examination
    Leukosit = 7.280
    - ECG : normal
    Eritrosit = 4,39
    Hb
    = 13,0 gr/dl
    Ht
    = 37,7%
    Trombosit = 268.000
    Kreatinin = 0,7
    Ureum
    = 12
    Na
    = 140
    K
    = 3,8
    Cl
    = 107
    GDS
    = 118

    WDx
    CVD SH ( ICH region Ganglia Basal Sinistra

    with estimated volume 30 cc )


    Hipertension grade II

    Planning
    Bed rest, Head elevation 30
    Chest fisioterapy + oral higiene
    Mobilitation left and right per 2 hour
    IVFD : NaCl 0,9% 500 cc 14 gtt/m
    Inj Citicholin 2 x 500 mg (iv)
    Inj Ranitidine 50 mg 2x1 amp (iv)
    Paracetamol Tab 500 mg 3x1 via NGT
    NGT and catheter ( family approvel )
    CIE family

    THANK YOU

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