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August 25 , 2016
th
DEPT OF NEUROLOGY
G26
DAFTAR OB NEURO
Name : Mr. A
Age : 49 years old
Occupation : farmer
Address : Kadiren Kalitegah, Lamongan
Admission : August 2th, 2016 at
18.28 PM
Chief ComplaintHemiparesis Sinistra
Present history
Family history
BP
192/99 mmHg
Pulse
89 x/min, strong, reguler
Temp
36,7 C
RR
34x/min
A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
B: spontan, RR 24x/min, ves / ves, rh -/-, wh -/-,
SaO2 98% without O2 support.
C: extremity WDR, CRT <2’, N 97x/min, BP 192/99
mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36,7 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 -/-
Auscultation
Met -, bowel sound WNL
Palpation
Pain (-)
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
CBC
ECG
Thorax Photo
Laboratory Findings
Diagnosis:
Siriraj Score: (2,5 x 0) + (1x0) + (1x0) + 99-3 x1= -15
Klinis : Hemihipoestesia dextra, hemiparesis dextra
Topis: A. cerebri anterior sinistra
Etiologi: CVA Infark
Planning Therapy
O2 nasal 3lpm
IVFD RL 1000cc/24 hours
Inj. antrain 3 x 1gr iv prn nyeri
Inj. citicolin 3x250mg
Inj. Ranitidin 2x50mg
Po. Aspilet 1x1 tab
PLANNING MONITORING
Vital Signs
Patient’s complaint
Adverse effect
DL
PLANNING EDUCATION