Emergency Unit

Night Shift Report

January 27 2014 Non trauma : 1

1. Mr. UA (70 Y.O.) NO MR: 86-23-05--00

Chief complaint : loss of consciousness Additional complaint : -

History of illness :
Patient came to the hospital with unresponsive suddenly since 1- hours before. First patient got hard in seeing and then saying and not in long time he couldnt walk and move his hands. The patient became unresponsive after that. He was working when he suddenly got unresponsive. He never got this before. The patient had hypertension history.

PHYSICAL EXAMINATION
Consciousness : Composmentis Blood pressure : 150/110 mmHg Pulse

: 90 bpm Temperature : 37,1 0C Respiratory Rate: 22x/minute Eyes : Conjunctiva anemic -/-, sclera icteric -/- pupil reflex -/Neck : Lymph glands palpable Thorax : Insp : movement of chest wall symmetric, Pal : movement of chest wall symmetric, vocal fremitus symmetric Per : sonor Aus : Basic breath sound vesicular, rh -/-, wh-/Heart sound I & II regular, murmur (-), gallop (-)

Abdomen : Ins Aus Palp (-) Percusion

: Flat : Bowel sound (+) 8x/min : Muscular defense (-), tenderness

: Timpani

DIAGNOSIS
Unresponsive + Hemiparese dextra Treatment at ER: 1. Goedel 2. Face mask 8 L/m 3. Antibiotic 4. Anti-edema 5. IVFD : RL

TREATMENT
Non Medikamentosa: 1. Pro ICU 2. Diet SV 6 x 250 cc 3. I RL + Analgetic Medikamentosa: 1. H2 blocker 2. Antibiotic 3. Anti-edema