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.