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Morning Report

August 25 , 2016
th

DEPT OF NEUROLOGY
G26
DAFTAR OB NEURO

 Ny. Yamu cva Marwah 14


 Tn. A. Dain cva bleeding Marwah 12
 Tn. Asram cva infark Marwah 9
 Ny. Lasmiyat cva infark 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 ComplaintHemiparesis 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.
 Past history of Illness

•HT (+) since 10 years non regularly taking medication,


•DM (+)
•CVA (-)

 Family history

HT (+). CVA (+). DM (-)

 Social history : drinks coffee 3 glass a day


Vital Signs

 BP
 192/99 mmHg

 Pulse
 89 x/min, strong, reguler

 Temp
 36,7 C

 RR
 34x/min
 A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
 B: spontan, RR 24x/min, ves / ves, rh -/-, wh -/-,
SaO2 98% without O2 support.
 C: extremity WDR, CRT <2’, N 97x/min, BP 192/99
mmHg
 D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
 E: temp 36,7 C
 General condition : good
 Awareness : compos mentis
 GCS : 456
 H/N : a -/i-/c-/d -
lymph node enlargement at neck (-)
JVP within normal limit
Thorax
 Inspection
 Symmetrical, retraction -

 Palpation
 Thrill (-), fremitus WNL

 Percussion
 Lungs: sonor / sonor

 Cor: N

 Auscultation
 Lungs: ves /ves, rh -/-, wh -/-

 Cor: S1S2 single, M -, gallop -


Abdomen
 Inspection
 flat

 Auscultation
 Met -, bowel sound WNL

 Palpation
 Pain (-)

 Liver/Spleen within normal limit

 Percussion
 Tymphany
Extremities

 Inspection
 Clubbing fingers (-), icteric (-), cyanosis (-), edema (-)

 Palpation
 Cold and wet, CRT <2’
Status Neurologic
 GCS: 456  Fisiologic reflex:
 Meningeal sign:  BPR +2/+2

 Kaku kuduk –  TPR +2/+2

 Kernig -/-  KPR +2/+2

 Brudzinski 1,2 -/-  APR +2/+2

 Nervus Cranialis:  Patologic reflex:


 NII: PRI 3mm/3mm, light  Babinski -/-
reflex +/+, Visus OD >2/60,  Chaddok -/-
Visus OS > 2/60  Hoffman trommer -/-
 N III, IV, VI: Normal/normal
 Motoric: sup 5/-5
 NVII: parese dextra central
inf 5/4
 N XI: normal/normal
 N XII: parese dextra
 Sensoric: Hemihipoestesia
dextra
Planning Diagnosis

 CBC
 ECG
 Thorax Photo
Laboratory Findings

 Eritrosit 4.84  MCH 27.10


 MCV 82.90
 Hb 13.1
 MCHC 32.70
 LED 52  Monosit 4.6
 LED2 81  MPV 3
 Limposit 33  Neutropil 56.8
 RDW 12
 Basofil 1.9  Trombosit 342
 Eosinopil 3.7  HDL cholestrol 37.3
• LDL cholestrol 67.0
 Hematokrit 40.1 • Cholesterol 364
 Leukosit 7
 Urea 50
 Serum creatinin 1,7
Pemeriksaan EKG
Diagnosis

 Diagnosis:
Siriraj Score: (2,5 x 0) + (1x0) + (1x0) + 99-3 x1= -15
 Klinis : Hemihipoestesia dextra, hemiparesis dextra
 Topis: A. cerebri anterior sinistra
 Etiologi: CVA Infark
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
 Patient’s complaint
 Adverse effect
 DL
PLANNING EDUCATION

 Explain to the patient and his family about the


disease, cause, complication, intervention of the
therapy and prognosis.