Sociality History
Cigarrete (-)
STATUS PRESENT
Palpation:
Lung:
Percussion: sonor / sonor
Auscultation: vesicular / vesicular, rh -/-,
wh -/Heart:
Percussion: within normal limit
Auscultation: S2 S1 single murmur (-) Gallop
(-)
Inspection: flat
Palpation: soepel, tenderness (-)
Percussion: Tympany
Auscultation: bowel sounds normal
Liver: not palpable
Lien: not palpable
Extremity :
Warm, dry , red CRT <2
N.I (olfactory)
Smelling: not to evaluated
N.II (optic)
Visual acuity: not to evaluated
Field of view: not to evaluated
Funduscopic: not evaluated
N.III (okulomotorius)
Ptosis: - / Exophtalmos: - / Eye movements: normal
Size: 3mm/3mm, isokor
Light reflex: + / +
N.IV (trokhlearis)
The position of the eye: normal / normal
Eye movements: normal
N.VI (abduscen)
eye ball movement : normal
N.V (trigeminal)
sensibility:
V1: not to evaluated
V2: not to evaluated
V3: not to evaluated
motor:
Inspection: normal
Palpation: not evaluated
Chewing: not evaluated
Biting: not evaluated
masseter reflex : not evaluated
Corneal reflexes: +/+
N. VII
N. VIII
Seconds watches: not to evaluated
Voice whispered test: not to evaluated
Test weber: not to evaluated
Rinne test: not to evaluated
N.IX (glossofaringeus)
not evaluated
N.X (vagus)
Pharyngeal arch Position: normal / normal
Vomiting reflex: normal
N.XI (accessory)
Shrug: not to evaluated
Turning heads: not to evaluated
N.XII (hipoglosus)
Devisasi tongue: normal
Fasciculations: negative / negative
Tremor: negative / negative
Atrophy: negative / negative
Meningeal sign
Stiff neck: Kernig's sign: Carotid Artery: + / +
Palpation: strong palpable / strong
palpable
Auscultation: not evaluated
Thyroid: - / -
Motor
Movement:
Strength : 3 / 5
3/5
Physiological reflex:
BPR: +2/+2
TPR: +2/+2
KPR: +2/+2
APR: +2/+2
Pathological reflexes
Hoffman tromer: -/Gordon: -/Babinsky : +/Oppenheim : -/Chaddock : -/Sensibility :normal
Diffcount :
0/2/80/14/4
Hct : 37,9
Hb : 12,5
LED : 53/72
Leukocyte : 12.000
Thrombocyte :
251.000
Urea : 29
Creatinin : 0,7
GDA: 109
SGOT : 20
SGPT : 16
Potassium : 3,6
Sodium : 140
Chloride : 113
Cholesterol : 231
TG: 116
female, 56yo.
right body weakness
Headache (+), nausea (-), vomit (+)
Siriraj score +1,3
Lipid profile
General:
O2 Nasal 4 lpm
IVFD Asering 1500 cc/24 jam
Inj. Methamizole 3x1 gram i.v.
Inj. Ranitidin 2x50 mg
Inj. Ondansentron 3x1 amp
Specific:
Inj. Citikolin 3x1 amp
Loading Clopidogrel 4 tab 1x1 tab
Inj. Fondaparinux (Arixtra) 1x1 amp
CA 1x1 tab
Consulted to neurologist
- Vital sign
-subjective complaints of patients
-Neurology Examination
PROGNOSIS
Dubia ad bonam