Morning Report

August 6 , 2016
th

DEPT OF NEUROLOGY
G26
 DAFTAR OB NEURO

 Tn. kastilan cva bleeding Marwah 16

 Ny. sukaini paraparese
 Ny. Suliyah cva
 Tn. Harjito cva Marwah 12
 Identity

 Name : Mr. H
 Age : 50Th years old
 Occupation : farmer
 Address : Trepan RT 1 RW 1, babat,
lamongan
 Admission : August 6th, 2016 at
03.03 PM
 Chief ComplaintHemiparesis Sinistra

 Present history

Patient complained paresis left limb and arm since 12 hours

before admited to hospital. Patient also complained loss of skin
sensitivity on his left limb and arm like tiggling. 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 (-)
•DM (-)
•CVA (-)

 Family history

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

 Social history : -
 Vital Signs

 BP
 186/112 mmHg

 Pulse
 75 x/min, strong, reguler

 Temp
 36,2 C

 RR
 21x/min
 A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
 B: spontan, RR 21x/min, ves / ves, rh -/-, wh -/-,
SaO2 99% with O2 support.
 C: extremity WDR, CRT <2’, N 75x/min, BP 186/112
mmHg
 D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
 E: temp 36,2 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 5/2
 NVII: parese sinistra central
inf 5/3
 N XI: normal/normal
 N XII: normal
 Sensoric: Hemihipestesi
sinistra
 Planning Diagnosis

 CBC
 ECG
 Thorax Photo
 Laboratory Findings

 Eritrosit 5.62  MCH 31.8

 Hb 15.2  MCV 85.10
 LED 1
 MCHC 31.80
 LED2 2
 Monosit 4.7
 Limposit 23
 MPV 4
 Basofil 1.0
 Eosinopil 6.8  Neutropil 64.5
 Hematokrit 47.8  RDW 11
 Leukosit 5.9  Trombosit 239
 GDA 102
 Diagnosis

 Diagnosis:
Siriraj Score: (2,5 x 0) + (1x0) + (1x0) + 99-3 x1= -15
 Klinis : Hemihipestesia sinistra, hemiparesis sinistra
 Topis: A. cerebri media dextra
 Etiologi: CVA
 Planning Therapy

O2 nasal kanul 3-4 lpm

IVFD asering 1500cc/24 hours
Inj. antrain 3 x 1gr iv
Inj. citicolin 3x250mg
Inj. Ranitidin 2x50mg
Inj. Ceteron 3x 8 mg
 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.