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MORNING REPORTFRIDAY14RDAUGUST 2015

ER : dr. Maria

Cons!"an" : dr. Mar"#in

S"ro$% ni" : dr. P"ri

&ard : dr. A'ri! dan dr. (arris

Tand%) : dr. Fa"#! dan dr.

Ra)on

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PATIENT*S IDENTITY

Name : Ms. S

Age : 20 yo

Gender : Female

Occupation : Student

MR Number : C!"##$

%ospital admission : #!t&August 20#

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(ISTORY

C#i%+ ,o)'!ain" : %eadac&e

Ons%" : years be'ore &ospital

admission

-a!i" : &eadac&e suc& as

punctured

-an"i" : A() partly assisted 'amily

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(ISTORY

C&ronolgy : * years be'ore entering t&e &ospital+ t&e patient complained o'

&eadac&e suc& as punctured+ &eadac&e 'elt intermittent+ ,it& a durationo' 2 times a ,ee- 'or # &our. &e longer t&e &eadac&e &ea/ier and more'reuent. 1atient &ad been treated at Mardi Ra&ayu &ospital 'or daysand is said to be c&ronic &eadac&e+ and go &ome ,it& ma-e up+ patientare ad/ised to control+ but because t&e patient mo/ed to 3orneo t&en t&epatient does not control routine

* 2 Mont&s be'ore entering t&e &ospital patient complain o' &eadac&e is'elt increasingly become &ea/y compared to years ago. 4it& a durationo' # times a day 'or #52 &ours+ disappeared at rest and ta-ing medication.

Arises ,&en patients 'eel stress and 'atigue. 4&en t&e attac- patients areunable to per'orm acti/ities o' moderate to se/ere. &e location o' t&epercei/ed pain radiating to t&e bac- o' t&e &ead 'or,ard &ead.Complaints accompanied by nausea+ bac- 'eels strained nec-.

* days complaints increasingly become &ea/y+ t&e patient can notper'orm lig&t acti/ities+ can not concentrate on attac-. 1atient o'ten 'eel

an6ious+ because t&e complaint ,as ta-en to 7ariadi &ospital

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(ISTORY

Aggra/ated Factors : Stress and 'atiue

86tenuated Factors : Rest and medicine

Concomitant Symptoms : Nausea

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(ISTORY

Past Medical History

years ago complained o' t&e same complaints

Family Disease History : none

Social Economic-Status And Personal History :pt is college student, live in dormitory, Medicationsupported by his parents.

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C/INICA/ FINDINGS

Pr%s%n" S"a"%s GCS : 8!M$9 9AS : 5!

9ital signs :31 #20;0 mm%g %R ;06min

RR 206min emp $. e6 ??+ &ora6 : normal breat&ing+ R&55+ 4& 55

normal &eart sound+ murmur

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C/INICA/ FINDINGS

Cranial Ner/es: in normal state

Motoric Sup @n'

Mo/ement ?? ??Strengt&

onus NN NN

rop&y88 88FR ???? ??????

1R 5555

Clonus 55

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C/INICA/ FINDINGS

Sensibility : normal

9egetati/e : normal

C&/ostec- test : ?

rouseau sign : ?

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/AORATORY FINDINGS

/AORATORYEAMINATION

14rdAs" 2015

%b #+2 #2.00 #$.00

%t B+! !"

Red blood cell !+ !.! .B

MC% 2B+# 2" 2

MC9 ;"+0 "$ B$

MC%C + 2B $4&ite blood cells +$ .$ ## 6#0

1latelet 2".0 #0 !00 6#0

3lood glucose B; ;0 #!0

reum #$ # B

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/AORATORY FINDINGS

/AORATORYEAMINATION

14rdAs" 2015

8lectrolyte

Sodium 141 #$5#!1otassium +2 .5.# )

C&loride 111 B;5#0"

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CT SCAN

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X-Ray

Thorak

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DIAGNOSIS

I. C!ini,a! Dianosis

Cep&algia c&ronic

To'i,a! Dianosis

1eric&ranial MusculusE"io!oi, Dianosis :

ension ype %eadc&e

dd Spasmo>ia

II. (i'o$a!%)ia

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INITIA/ P/ANS 3T(ERAPY

#. 8MG SpasmoDlia

2. &erapy :

@9F( : R) 20 dpm

@nE Ranitidin 0 mg#2 &ours

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MON@OR@NG :

GCS+ /ital signs+ neurologic deDcits

8(CA@ON :diagnosis+ management+ complications+prognosis