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1. MORNING
REPORT
Juli, 2023

2. IDENTITY
● Name : Tn.K
● Age : 60 years old
● Gender : Male
● Address : Batu
● Arrival Date : 02 Juni 2023
● Patient Type : Non-Trauma

3. ANAMNESIS
Main Complaint: Right Weak half body
The patient was found sitting on the floor with complaints of weakness in half
of the body. weakness accompanied by back pain since this morning and the
complaint is accompanied by a squint on the right face. In the past, the patient
had never experienced this kind of complaint. The patient will then be getting
ready to go to work. Nausea (+) Vomiting (+) 1x, convulsions (-), last meal last
night (approximately 5 hours ago).
Past Medical History: The patient has a history of HT (+) and has never been in
control
Family History: In the patient's family there is a history of hypertension (+)
Medicine History: -

4. GENERALIST
STATUS
Consciousness : CM
GCS : 456
BP :205/114mmHg
HR : 64/minute
RR : 24/minute
SpO2 : 100% on NC
Tax : 37.6 c

5. PHYSICAL
EXAMINATION
HEAD/NECK:
Head
Eyes: Anemic conjunctiva (-/-), icteric
sclera (-), Isochor pupil diameter
3mm/3mm, Light reflex direct and
indirect +/+
Ears : bloody Otorea (-/-)
Nose : epistaksis (-/-)
Neck :
Inspection: tracheal deviation (-)
Palpation: enlarged lymph nodes (-)
Auscultation : Bruits (-)
THORAX :
Cor:
Inspection: ictus cordis invisible
Palpation: ictus cordis palpable at ICS 5 MCL S
Percussion: Right heart border at ICS 4 PSL D, Left
heart border at ICS 5 MCL S
Auscultation: S1 S2 single, regular, murmur (-),
gallop (-)
Pulmo:
Inspection: normal chest wall shape, retraction (-)
Palpation: symmetrical D/S chest wall movement
Percussion: sonor
Auscultation:
R
h
-
-
-
-
-
-
Wh -
-
-
-
-
-
Ves +
+
+
+
+
+

6. PHYSICAL EXAMINATION
Abdomen
Inspection: Flat, inflammation (-) scar (-) eritem (-)
Auscultation : Bowel Sounds (+) 8x/minute
Abdominal Percussion: Timpany
Abdominal Palpation: Defans (-) Superficial and
profundus pain (-)
Extremity:
Dry red warm akral +/+/+/+, CRT< 2, Pitting oedem
(-)
Neurological Status:
GCS 456CM
Stiff neck (-)
Kernig's sign (-)
Physiological Reflexes
Biceps +1 / +2
Triceps +1 / +2
Patella +1 / +2
Achilles +1 / +2
Reflek patologis
Babinski +/+
Chaddock -/-
Hoffman -/-
Tromner -/-
Lateralized Extremity Motor Test (D)

7. PROBLEM LIST & PLANNING
Problem list Devinitive
Diagnosis
Planning
Diagnosis
Planning Therapy
Main Complaint:
• Right Weak half body
• Weakness accompanied by back pain since
this morning and the complaint is accompanied
by a squint on the right face
• The patient will then be getting ready to go to
work
• Nausea (+) Vomiting (+) 1x, convulsions (-),
last meal last night (approximately 5 hours
ago).
CT Scan
Terdapat gambaran hiperdens pada ventrikel kiri
dengan perkiraan Volume = (8 x 4 x 4)/ 4 = 32 cc
- IVH (S) - - IVFD NS Maintanance
IVFD Ringer Lactate
Maintain DoseHolliday-
segar formula
(Weight=55 Kg)=10 (Kg)
x 100 ml + 10 (Kg) x 50
ml + (55-20 Kg) x 20 ml
= 1000 ml + 500 ml +
700 ml= 2200 ml/24
Hours
- Inj. Ranitidin 50 mg
- Inj. Metamizol 500 mg
- Inj. Sitikolin 250 mg
- Inj. Piracetam 3 gram
- Drip Nicardipin 15 mg
per jam target tensi
<160/90

9. THANK YOU