Morning Report

July 25 , 2016
th

DEPT OF NEUROLOGY
G26
 DAFTAR OB NEURO

 Tn. Dadi Prayitno cva infark Zamzam 07

 Identity

 Name : Mr. D
 Age : 46 years old
 Occupation : farmer
 Address : Jagul RT1 RW 1
Sendanggrejo, Lamongan
 Admission : July 25 th, 2016 at
10.30 PM
 Chief ComplaintHemiparesis Sinistra

 Present history

Patient complained Hemiparesis sinistra since 2 hours before

admited to hospital. This hemiparesis spread to left shoulder.
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 (-)

 Family history

HT (+). CVA (+)

 Social history : (-)

 Vital Signs

 BP
 181/99 mmHg

 Pulse
 97 x/min, strong, reguler

 Temp
 36,5 C

 RR
 20x/min
 A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
 B: spontan, RR 20x/min, ves / ves, rh -/-, wh -/-,
SaO2 98% without O2 support.
 C: extremity WDR, CRT <2’, N 97x/min, BP 181/99
mmHg
 D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
 E: temp 36,5 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: normal/normal
inf 5/2
 N IX: normal/normal
 N XII: abnormal/normal
 Sensoric: Hemihipoestesia
Sinistra
 Planning Diagnosis

 CBC
 ECG
 Thorax photo
 CT-Scan
 Laboratory Findings

 Eritrosit 5.67  MCH 19.10

 MCV 88.70
 Hb 16.5
 MCHC 32.80
 LED 6  Monosit 5.6
 LED2 11  MPV 5
 Limposit 15.6  Neutropil 70.6
 RDW 11
 Basofil 1.5  Trombosit 233
 Eosinopil 6.7  SGOT 19
 SGPT 16
 Hematokrit 50.3  Urea 35
 Leukosit 12.2  Serum creatinin 0,9
 Diagnosis

 Diagnosis:
 Klinis : Hemihipoestesia Sinistra

 Topis: Serebri dextra

 Etiologi: CVA Infark

 Hypertension Essential
 Planning Therapy

IVFD PZ 1500cc/24 hours

Inj. antrain 1gr iv prn nyeri
Inj. citicolin 3x500mg
Inj. Ranitidin 2x50mg
 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.