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Morning Report

July 28 , 2017
th

DEPT OF NEUROLOGY
M28
DAFTAR OB NEURO

 Mr. Muflihan  CVA not specified


Identity

 Name : Mr. M
 Age : 48 years old
 Address : Sedayulawas, Lamongan
 Admission : July 28 th, 2017 at
10.01 am
SUMMARY OF DATABASE

 Chief of complaint:
 Weak half of extremity
 Chief ComplaintHemiparesis dextra

 Present history

Patient complained weakness on the right foot and right hand


since 10 days before admitted to hospital when activity. No Vomits
. Never been like this before. convulsion (-), fever (-), loss of
consiousnes (-), headache (+). Defecation within normal limit and
micturition felt normal limit.
 Past history of Illness

•HT (+) , DM (-) , Cholesterol [+]

 Family history

Father with hypertension

 Social history : (-)


Vital Signs

 BP
 154/78 mmHg

 Pulse
 88 x/min, strong, reguler

 Temp
 36,8 C

 RR
 20x/min
 A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
 B: spontan, RR 20x/min, ves / ves, rh +/+, wh -/-,
SaO2 99% without O2 support.
 C: CRT <2’, N 88 x/min, BP 154/78 mmHg
 D: GCS 456, lateralisasi dextra, PBI 3mm/ 3mm, LP
+/+
 E: temp 36,8 C
 General condition : good
 Awareness : composmentis
 GCS : 456
 H/N : a -/i-/c-/d -
lymph node enlargement at neck (-)
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 + N

 Palpation
 Pain (-)

 Liver/Spleen within normal limit

 Percussion
 Tymphany
Extremities

 Inspection
 Clubbing fingers (-), icteric (-), cyanosis (-), edema (-),

 Palpation
 Warm, dry and Red, 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:
 NI: not be evaluated  Babinski -/-
 NII: PRI 3mm/3mm, light reflex  Chaddock -/-
+/+,  Hoffman trommer -/-
 N III, IV, VI: normal  Motoric: 3/5
 NVII: Paresis nerve VII Central 3/5
Dextra
 Sensoric: normal
 NVIII: normal
 N IX, X: normal
 N XI: Normal
 N XII: Paresis nerve XII central
Sinistra
Planning Diagnosis

 Complete blood count


Laboratory Findings

 MCH 29.1
 Eritrosit 4,78  MCV 85.1
 MCHC 34.2
 Hb 13,9  Monosit 5.6
 LED1 47  MPV 4
 LED2 88  Neutropil 72,7.
 RDW 12
 Limposit 13,8.  Trombosit 211.000
 Basofil 1,6.  Clorida serum 105
 Kalium serum 3.9
 Eosinopil 6,3.
 Natrium serum 138
 Hematokrit 40,7  GDA 109
 Leukosit 9,9
Diagnosis

 Diagnosis:
 Klinis : hemiparese dextra, parese nerve VII central dextra,
parese Nerve XII sinistra
 Topis: arteri cerebri media sinistra

 Etiologi: suspect CVA Infark


 (Siriraj Score: (2.5x0)+(2x1)+(2x0)+(0.1x80)-(3x1)-12)=-5)
Planning Therapy

O2 nasal 3lpm
Inf PZ 1000cc/24 hours
Inj. Metamizole 3x1 g iv
Inj. Ranitidin 2 x 50mg iv
Inj. Citicolin 3x250mg iv
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.

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