Morning Report

January 19th, 2015

Resident: Frans F. D. Ismail
Supervisor: dr. E. Marpaung, SpKFR

Anamnese
Identity
Name : Mr. SY
Gender/Age : Male/34 years old
Address : Wusa, Lingk IV, Kec Talawaan,
Minut
Religion : Christian
Occupational : Tractor operator at airport.
Exam date : January 17th, 2013

Referred from Neurology Department with post Stroke.

Chief complain:
Weakness of left limbs.
History of present illness:
Since Jan 2nd, 2015.
Afternoon when doing activity (washing dish).
No headache, No vomit, No history for unconsiousness.
Slurred speech +.
Corner of mouth aim to right side.
No choke when eat/drink.
Some of ADL still help by other people (dressing, bathing,
toileting).
There are some rash on the face.
No history for head trauma.
Defecate and urinate normally.

History of past illness:

No history for hypertension.
History of family:
Patients mother have history for stroke.
History of habitual:
alcohol +
fried food +
hand dexterity: right hand.

History of psycologic:
worried with this condition.
History of socioeconomic:
living with her wife and two children.
Type permanent house, 1 floor, tiled floor,
power source PLN, the source of water from
PAM, 3 stair in the house, using the sit type
water closet.
Monthly fee for family is felt still quite enough.
The cost of treatment using BPJS.
Go to the church once a week.

Physical Examination
Karnofsky Performance Scale: 90 (able to carry on normal
activity; minor signs or symptoms of disease).
Level of consciousness: compos mentis.
Vital sign:
blood pressure : 120/90 mmHg.
pulse : 78 x/m, regular, full fill.
respiratory rate: 20 x/m.
body temperature : afebrile.
Body weight : 52 Kg
Body height : 165 cm
Body mass index: 19.1 (normal).
General status: normal.
Barthel index: 80 (light dependent)
MMSE: 26 (normal).

Cranial nerve:
N. VII: weakness of face expression
muscle on
the left side.
N. XII: tongue deviate to left side.
Motorik:
Upper Extremity

Lower Extremity

Right

Left

Right

Left

Movement

decrease

decrease

Muscle Tones

5/5/5/5

5/5/4/3

5/5/5/5

5/5/4/4

Physiologic reflex

Pathologic reflex

Muscle Strength

Sensibility:
Upper Extremity

Lower Extremity

Right

Left

Right

Left

Sensibility

Extremity circumferences:
Upper Extremity
Right

Left

Upper arm
circumference

22,8 cm

22,5 cm

Lower arm
circumference

22,8 cm

22,5 cm

Lower Extremity
Right

Left

Thigh circumference

41 cm

41 cm

Calf circumference

33 cm

33 cm

Diagnosis
Clinical diagnosis:
Post ischemic stroke with
hemiparese + slurred speech.
Dermatitis on the face.
Topic diagnosis:
Cortical.
Etiological diagnosis:
Ischemic stroke.

left

Functional diagnosis:
Body function: left limbs weakness.
Body structure: no deformity.
Activity & partisipation: limitation of
activity due to disability. Go to church
once per week.
Environment: health services using
BPJS.
Personal: 34 years old, man.

Problem:
weakness of left limbs
slurred speech
limitation of activity
vocational disturbance
worried for illness
Program:
Medicamentosa:
continued
Neurology Department.
consult to dermatologist.

from

Rehabilitation program:
breathing exercise.
infrared on left limbs (duration 20 minutes, everyday (6x).
strengthening exercise for left limbs.
give some activity for increase muscle strength.
give practise for ADL (dressing).
support mental for patient & family.
speech therapy.
Prevocational program.
SM: contemporer subtitution in work place after the
patient get better .
Education:
how to get dress.
how to climb the stairs.