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July 28 , 2017
th
DEPT OF NEUROLOGY
M28
DAFTAR OB NEURO
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
Family history
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 -/-
Auscultation
Met -, bowel sound + N
Palpation
Pain (-)
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
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
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