Morning Report

NIGHT SHIFT’S MORNING REPORT

GROUP THREE
Thursday, 11th of October 2018
• Name : Ny. K
• Age : 46yo

Chief complain : unconscious

Additional complain : headache, feels like trobbing

S/ a women came to the ER with chief complain unconscious, twice, around 2

hours before came to the ER. After she woke up, she had a headache, throbbing
on the front of her head. Numbness on half of her body was denied. Weakness
on half of her body was denied. Slurred speech was denied. Tingling was felt on
all of her extremities and pain on her toes. History of the same complain around
2 years ago. History of TB around 2 years ago, was declared healed with 6 months
of medication. Coughing with sputum around 1 month ago. History of DM,
controlled with metformin 2x500mg.
 Physical examination
Vital Sign :

• GCS : E4M6V5
• BP : 140/80mmhg
• P : 80x/mnt
• T : 36,0C
• RR : 20X/mnt
HEAD Normocephaly

EYE CA -/-, SI -/-, Pupil Isokor, RCL +/+, RCTL +/+, centered pupil 3mm/3mm

NECK JVP distended (-)

Enlarged lymph nodes (-)

THORAKS I : Symetrical respiratory movements

P : Symetrical voca fremitus
P : Sonor sounds all over lung platform
A : Lung sounds vesikular, rh -/-, wh -/-,
Heart Sound I &II regular Murmur -/-, Gallop -/-

ABDOMEN I : Appeared flat

A : Intestinal sounds (+) 4x/min
P : Timpanis, percussion oain (+)
P : Pressure pain (+) epigastrica area, release pain (-), defense muscular (-)

EKSTREMITAS Warm extermities

, CRT <2”, edema (-)
 Neurological examination

N.I (Olfactory)
Meningeal signs
• Normosmia
• Neck Stiffness : -
• Brudzinski I : - N.II (Optic)
• Brudzinski II : -/- • Visus : >3/60 / >3/60
• Color blind :-
• Kerniq : -/-
• FOV : same with
• Laseque examiner
:>70º/>70º • Funduscopy : not performed
 Neurological examination
N.III, IV, VI :
• Eye position : Normal • Eye movement : Normal
• Ptosis : -/+ • Pupil round, isocor 3mm/3mm,
• Strabismus : -/- in the middle, flat edge
• Enophtalmus : -/- • DLR : +/+
• Exophtalmus : -/- • ILR : +/+
• Diplopia :- • Accommodation reflex: +/+
• conjugate deviation : -
Neurological Exam
N.V (Trigeminal)
Motoric
Open-close mouth : deviation (-)
Jaw Movement : +/+
Chewing : m.maseter +/+, m.temporalis +/+
Sensory : Pain sense : pain on both legs (knee
and foot)
Touch sense : normal
Temp. sense : no act
Reflex : Corneal Reflex : +/+
Maseter Reflex :+
 Neurological Exam
N.VII(Fascialis)
• Face Expression : Normal
• Eyebrow lift : +/+
• Forehead wrinkle : +/+
• Bloated cheeks : +/+
• Lagophthalmos : -/-
• Grinning : +/+
• Taste of 2/3 anterior : Not performed
• Chovstek sign :-
Neurological Exam

N. VIII(Vestibulo kokhlearis)
• Nystagmus : -/-
• Vertigo :-
• Whispering : not performed
• Finger Friction : +/+
• Rinne : +/+
• Weber : No lateralization
• Swabach : same with examiner
Neurological Exam
N. IX, X (Glossofaringeus, Vagus)
• Pharyngeal arches : symetric
• Palatum molle : intact
• Uvula : in the middle
• Rhinolalia :-
• Dysfagia :-
• Dysfonia :-
• Cough reflex :+
• Swallowing reflex :+
• Pharying Reflex : Not performed
• Occulocardiac Reflex : Not performed
• Sinus caroticus Reflex : Not performed
Neurological Exam
N. XI(Accessorius)
• Raise Shoulders : +/+
• Turned neck : +/+

N. XII(Hypoglossal)
• Tounge position in mouth : Symetric
• Tounge protruding : symetric, deviation (-)
• Atrophy :-
• Tremor :-
• Fasiculation :-
• Tongue muscle strength : Normal, symetric
Status Neurologi
MOTORIC
Abnormal Spontaneous Movement : -
Muscle Trophy : Arms: eutrophy/eutrophy; legs:
eutrophy/eutrophy
Muscle Tone : normotonus/normotonus
DKO :5555/555
5555/5555

Physiological Reflex :
Biceps ++/++
Triceps ++/++
Brachioradialis ++/++
Brachioulnaris ++/++
KPR ++/++
APR ++/++
Pathological Reflex
• Babinski -/-
• Chaddock -/-
• Oppenheim -/-
• Gordon -/-
• Schaeffer -/-
• Rossolimo -/-
• Mendel bechterew -/-
• Gonda -/-
• Hoffman trommer -/-
• Genu Clonus -/-
• Ankle Clonus -/-
Coordination
Static
Sit : Good
Stand : Not performed
Romberg Test
Not performed
Sharpened Romberg
Not performed
Dynamic
Finger to nose : not performed
Finger to finger : not performed
Disdiadokokinesis : not performed
Tremor intention : -/-
Wrting : Fine
Dysmetri :-
Rebound phenomen : -/-
Knee-ankle : Fine
Talk (disatria) :-
 SENSIBILITY VEGETATIVE
Eksteroceptif • Mixie : Normal
• Touch sense : normal • Defecation : Normal
• Pain sense : normal • Salivation : normosalivasi
• Temp sense : Not performed • Hydration : normohidrosis
• Sex Function : Not performed
Propioceptif
• Position sense :Normal, symetric
• Vibratory : Norma, symetric
MENTAL STATUS
• Memory : Fine
• Bahasa : Understandable
• Affect and Emotion : hormonious
 Assesment

Clinical diagnosis : syncope

Topis diagnosis : vertbebrobasilar artery
Etiology diagnosis : TIA vertebrobasilar
 Therapy & Planning
• Inpatient Mm :
• II RL/24h • Ketorolac 3x1 (IV)
• Pro CT Brain non contrast • Ranitidine 2x1 amp (iv)
• Miniaspi 1x80 mg
• Betahistine 3x6mg
• Metformin 2x500mg