Team:Jeffri

Aprillia Hendy

YasintaCaroline

Dennis

dr. Karema Winifred, Sp.S(K)

Statistic :New Patient :

1. Mrs MS/42 yo / Unconsciousness ec CVD SH2. Mr HP / 17 yo / Severe Head Injury3. Mr. SP / 45 yo / Unconsciousness ec CVD SH4. Mr. AD / 19 yo / Moderate Head Injury w

Alcoholism5. Mr. FP / 20 yo / Severe Head Injuey w

alcoholism6. Mr. FH / 30 yo / Simple Head Injury7. Mr. PM / 45 yo / Mild Head Injury + Alcoholism8. Ms. VA / 16 yo / Simple Head Injury

History takingFemale, 42 y0 admitted to hospital with

suddently decreassed of consiousness about 19 hours before admitted to hospital

History taking

History of Pass IllnessHypertension (+) about 3 years ago

uncontrolledCholesterol (+) about 3 years ago

uncontrolledDM, Uric acid, Heart and kidney disesases

were denied

Physical ExaminationGeneral 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 examinationGCS : E3M5V1 (9) PERRL +/+, ø 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 evaluatedAutonomic State :

Inkontinensia Urine et Alvi : -

Score StrokeSSS : (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 : normalEritrosit = 4,39Hb = 13,0 gr/dlHt = 37,7%Trombosit = 268.000Kreatinin = 0,7Ureum = 12Na = 140K = 3,8Cl = 107GDS = 118

WDxCVD SH ( ICH region Ganglia Basal Sinistra

with estimated volume 30 cc )Hipertension grade II

PlanningBed rest, Head elevation 30° Chest fisioterapy + oral higieneMobilitation left and right per 2 hourIVFD : NaCl 0,9% 500 cc 14 gtt/mInj Citicholin 2 x 500 mg (iv)Inj Ranitidine 50 mg 2x1 amp (iv) Paracetamol Tab 500 mg 3x1 via NGTNGT and catheter ( family approvel )CIE family

THANK YOU