August 25 , 2016
th
DEPT OF NEUROLOGY
G26
DAFTAR OB NEURO
Ny. Yamu
Tn. A. Dain
Tn. Asram
Ny. Lasmiyat
cva
cva bleeding
cva infark
cva infark
Marwah 14
Marwah 12
Marwah 9
Marwah 5.1
Identity
Name
: Mr. A
Age
: 49 years old
Occupation : farmer
Address
: Kadiren Kalitegah, Lamongan
Admission : August 2th, 2016 at
18.28 PM
Chief Complaint
Hemiparesis Sinistra
Present history
Patient complained paresis righ limb since 12 hours before
admited to hospital. Patient also complained loss of skin
sensitivity on his righ leg. Never been like this before. eating +
and drinking + in a normal way, do not choke. Defecation + and
micturition +.
Patient felt weakness (+), vomiting (-), nauseous (-), konvulsi (-),
fever (-), loss of consiousness (-)
Defecation within normal limit and micturition felt normal limit.
Family history
HT (+). CVA (+). DM (-)
Vital Signs
BP
192/99 mmHg
Pulse
Temp
36,7 C
RR
34x/min
: compos mentis
: 456
: a -/i-/c-/d lymph node enlargement at neck (-)
JVP within normal limit
Thorax
Inspection
Symmetrical, retraction -
Palpation
Percussion
Auscultation
Abdomen
Inspection
flat
Auscultation
Palpation
Pain (-)
Liver/Spleen within normal limit
Percussion
Tymphany
Extremities
Inspection
Palpation
Status Neurologic
GCS: 456
Meningeal sign:
Kaku kuduk
Kernig -/Brudzinski 1,2 -/-
Nervus Cranialis:
Fisiologic reflex:
BPR +2/+2
TPR +2/+2
KPR +2/+2
APR +2/+2
Patologic reflex:
inf 5/4
Sensoric: Hemihipoestesia
dextra
Planning Diagnosis
CBC
ECG
Thorax Photo
Laboratory Findings
Eritrosit
Hb
4.84
13.1
LED
52
LED2
81
Limposit
33
Basofil
1.9
Eosinopil
3.7
Hematokrit 40.1
Leukosit
7
MCH 27.10
MCV 82.90
MCHC 32.70
Monosit 4.6
MPV 3
Neutropil
56.8
RDW 12
Trombosit 342
HDL cholestrol
37.3
364
50
Urea
Serum creatinin
1,7
Pemeriksaan EKG
Diagnosis
Diagnosis:
Planning Therapy
O2 nasal
3lpm
IVFD RL
1000cc/24 hours
Inj. antrain
3 x 1gr iv prn nyeri
Inj. citicolin 3x250mg
Inj. Ranitidin
2x50mg
Po. Aspilet
1x1 tab
PLANNING MONITORING
Vital Signs
Patients complaint
Adverse effect
DL
PLANNING EDUCATION
Explain to the patient and his family about the
Thank You