Morning Report

August 6 , 2016
th

DEPT OF NEUROLOGY
G26

DAFTAR OB NEURO
Tn. kastilan
Ny. sukaini
Ny. Suliyah
Tn. Harjito

cva bleeding
paraparese
cva
cva

Marwah 16

Marwah 12

Identity
Name

: Mr. H
Age
: 50Th years old
Occupation : farmer
Address
: Trepan RT 1 RW 1, babat,
lamongan
Admission : August 6th, 2016 at
03.03 PM

Chief Complaint
Hemiparesis Sinistra

Present history
Patient complained paresis left limb and arm since 12 hours
before admited to hospital. Patient also complained loss of skin
sensitivity on his left limb and arm like tiggling. 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 (-)
DM (-)
CVA (-)

Family history
HT (-). CVA (-). DM (-)

Social history : -

Vital Signs
BP

186/112 mmHg

Pulse

75 x/min, strong, reguler

Temp

36,2 C

RR

21x/min

A: clear, gargling (-), snoring (-), speak fluently (+),

potential obstruction (-)

B: spontan, RR 21x/min, ves / ves, rh -/-, wh -/-,
SaO2 99% with O2 support.
C: extremity WDR, CRT <2, N 75x/min, BP 186/112
mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36,2 C

General condition: good

Awareness
GCS
H/N

: compos mentis
: 456
: 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
Meningeal sign:

Kaku kuduk
Kernig -/Brudzinski 1,2 -/-

Nervus Cranialis:

NII: PRI 3mm/3mm, light

reflex +/+, Visus OD >2/60,
Visus OS > 2/60
N III, IV, VI: Normal/normal
NVII: parese sinistra central
N XI: normal/normal
N XII: normal

Fisiologic reflex:

BPR +2/+2
TPR +2/+2
KPR +2/+2
APR +2/+2

Patologic reflex:

Babinski -/Chaddok -/Hoffman trommer -/-

Motoric: sup 5/2

inf 5/3
Sensoric: Hemihipestesi
sinistra

Planning Diagnosis
CBC
ECG
Thorax Photo

Laboratory Findings
Eritrosit
Hb

5.62

15.2
LED
1
LED2
2
Limposit
23
Basofil
1.0
Eosinopil
6.8
Hematokrit 47.8
Leukosit
5.9

MCH

31.8
MCV
85.10
MCHC
31.80
Monosit
4.7
MPV
4
Neutropil
64.5
RDW
11
Trombosit
239
GDA
102

Diagnosis
Diagnosis:

Siriraj Score: (2,5 x 0) + (1x0) + (1x0) + 99-3 x1= -15

Klinis : Hemihipestesia sinistra, hemiparesis sinistra

Topis: A. cerebri media dextra
Etiologi: CVA

Planning Therapy
O2 nasal kanul 3-4 lpm
IVFD asering 1500cc/24 hours
Inj. antrain
3 x 1gr iv
Inj. citicolin 3x250mg
Inj. Ranitidin
2x50mg
Inj. Ceteron
3x 8 mg

PLANNING MONITORING
Vital Signs
Patients complaint
Adverse effect
DL

PLANNING EDUCATION
Explain to the patient and his family about the

disease, cause, complication, intervention of the

therapy and prognosis.

Thank You