• General examination:
• General condition: moderate, Consciousness : somnolen
• BP: 200/110 mmHg, MABP : 140 HR: 93 x/m reg, RR: 24 x/m , T:
36.8 °C, SaO2 : 98%
• Conjunctiva : pale (-/-), sclera ikteric (-/-)
• JVP ; normal
• Thorax : Rale -/-, Wh -/-, heart sound I/II normal, gallop -, murmur –
• Abdomen : Flat, normal turgor, peristaltic normal
• Extremities : warm acral
Neurologic examination
• GCS E4M5V4 (13), PERRL +/+, ø 2 mm2 mm
• Meningeal Sign: nuchal rigidity (-) Laseque >70/>70 Kerniq >135/>135
• Cranial Nerves: paresis N VII UMN D impression
• Motoric State : Hemiparesis D impression
MT : ↓ N PhyR : +/+/+ ++/++/++ PatR : - -
↓N +/+ ++/++ - -
• Sensoric State : can’t be evaluated
• Autonomic State : urine catheter (+)
• GMA : SH
• SSS : (2.5x1)+(2x1)+(2x1)+(0,1x110)-(3x0)-12 = 4.5
(SH)
WDx