MORNING REPORT

FRIDAY 14RD AUGUST 2015

ER
: dr. Maria
Consultant : dr. Marthin
Stroke unit : dr. Putri
Ward
: dr. April dan dr. Harris
Tandem : dr. Fathul dan dr.
Ramon

PATIENTS IDENTITY
Name
: Ms. S
Age
: 20 yo
Gender
: Female
Occupation
: Student
MR Number
: C547116
Hospital admission : 14th August 2015

HISTORY

Chief complaint

Onset

: Headache

: 5 years before hospital

admission

Quality

: headache such as

punctured

Quantity

: ADL partly assisted family

HISTORY

Chronolgy :

5 years before entering the hospital, the patient complained of

headache such as punctured, headache felt intermittent, with a duration
of 2 times a week for 1 hour. The longer the headache heavier and more
frequent. Patient had been treated at Mardi Rahayu hospital for 3 days
and is said to be chronic headache, and go home with make up, patient
are advised to control, but because the patient moved to Borneo then the
patient does not control routine
2 Months before entering the hospital patient complain of headache is
felt increasingly become heavy compared to 5 years ago. With a duration
of 1 times a day for 1-2 hours, disappeared at rest and taking medication.
Arises when patients feel stress and fatigue. When the attack patients are
unable to perform activities of moderate to severe. The location of the
perceived pain radiating to the back of the head forward head.
Complaints accompanied by nausea, back feels strained neck.
3 days complaints increasingly become heavy, the patient can not
perform light activities, can not concentrate on attack. Patient often feel
anxious, because the complaint was taken to Kariadi hospital

HISTORY

Aggravated Factors : Stress and fatique

Extenuated Factors : Rest and medicine

Concomitant Symptoms : Nausea

HISTORY

Past Medical History

5 years ago complained of the same complaints
Family Disease History : none
Social Economic-Status And Personal History :
pt is college student, live in dormitory, Medication
supported by his parents.

CLINICAL FINDINGS
Present States
GCS
: E4M6V5
VAS
: 3-4
Vital signs
:

BP 120/80 mmHg
HR
80x/min
RR 20x/min
Temp 36.5 (axilla)
Eye : pupil round, isocor 3/3 mm,light reflex +/+,
Thorax : normal breathing, Rh-/-, Wh -/normal heart sound, murmur (-),gallop (-)
Abdomen : unpalpable liver and spleen, ascites (-)

CLINICAL FINDINGS

Cranial Nerves: in normal state

Motoric Sup Inf

Movement +/+ +/+

Strength
555/555
555/555
Tonus N/N N/N
TrophyE/E E/E
FR
++/++
+++/+++
PR -/--/Clonus -/-

CLINICAL FINDINGS

Sensibility : normal
Vegetative : normal
Chvosteck test : +
Trouseau sign : +

LABORATORY FINDINGS
LABORATORY
EXAMINATION

14rd August 2015

Hb

13,2

12.00 16.00

Ht

39,4

35 47

4,5

4.4 5.9

MCH

29,1

27 32

MCV

87,0

76 96

MCHC

33,5

29 36

Red blood cell

White blood cells

Platelet

5,6

3.6 11 x103

273.0

150 400 x103

Blood glucose

98

80 140

Ureum

16

15 39

LABORATORY FINDINGS
LABORATORY
EXAMINATION

14rd August 2015

Electrolyte
Sodium

141

136-145

Potassium

3,2

3.5-5.1

Chloride

111

98-107

CT SCAN

X-Ray
Thorak

DIAGNOSIS
I. Clinical Diagnosis
Cephalgia chronic
Topical Diagnosis
Perichranial Musculus
Etiologic Diagnosis :
Tension Type Headche
dd Spasmoflia
II. Hipokalemia

INITIAL PLANS &

THERAPY
1.
2.

EMG Spasmofilia
Therapy :
IVFD : RL 20 dpm

Inj Ranitidin 50 mg/12 hours (IV line)

Paracetamol 1 tab/8 hours (orally)
Diazepam 2 mg/12 hours (orally)
Amitriptilin 12,5 mg/24 hours (orally)
Vit B1B6B12 tab 1 tab/24 hours (orally)

MONITORING :
GCS, vital signs, neurologic deficits
EDUCATION :
diagnosis, management, complications,
prognosis