Tuesday , November 25nd, 2014

Chief complaint : weakness half of body

Present illness history :

A 56-years-old female, weakness half body

expecially right, suddenly and felt like
tingling when he had activity. Headache (+),
Nausea (-), vomit (+) five times watery,
miction (+)N, defecation (+)N.

Previous Illness History

Hypertension (+) uncontrolled

DM (-)
Stroke (+)
history of heart disease (-)

Family History of Disease

HT (+), DM (-)

Sociality History
Cigarrete (-)

STATUS PRESENT

Head and Neck

Awareness : 456
BP: 174/93 mmHg
A-/i-/c-/dpulse: 89x/minutes
Temp: 36,7 C
RR: 26x/minutes

Inspection: symmetrical chest wall movement

ICS retraction (-)

Palpation:
Lung:
Percussion: sonor / sonor
Auscultation: vesicular / vesicular, rh -/-,
wh -/Heart:
Percussion: within normal limit
Auscultation: S2 S1 single murmur (-) Gallop
(-)

Inspection: flat
Palpation: soepel, tenderness (-)
Percussion: Tympany
Auscultation: bowel sounds normal
Liver: not palpable
Lien: not palpable

Extremity :
Warm, dry , red CRT <2

N.I (olfactory)
Smelling: not to evaluated

N.II (optic)
Visual acuity: not to evaluated
Field of view: not to evaluated
Funduscopic: not evaluated

N.III (okulomotorius)
Ptosis: - / Exophtalmos: - / Eye movements: normal
Size: 3mm/3mm, isokor
Light reflex: + / +
N.IV (trokhlearis)
The position of the eye: normal / normal
Eye movements: normal
N.VI (abduscen)
eye ball movement : normal

N.V (trigeminal)
sensibility:
V1: not to evaluated
V2: not to evaluated
V3: not to evaluated
motor:
Inspection: normal
Palpation: not evaluated
Chewing: not evaluated
Biting: not evaluated
masseter reflex : not evaluated
Corneal reflexes: +/+

N. VII

Obrikularis oris :normal

Orbikularis oculi :normal
Frontalis :normal

N. VIII
Seconds watches: not to evaluated
Voice whispered test: not to evaluated
Test weber: not to evaluated
Rinne test: not to evaluated
N.IX (glossofaringeus)
not evaluated
N.X (vagus)
Pharyngeal arch Position: normal / normal
Vomiting reflex: normal

N.XI (accessory)
Shrug: not to evaluated
Turning heads: not to evaluated

N.XII (hipoglosus)
Devisasi tongue: normal
Fasciculations: negative / negative
Tremor: negative / negative
Atrophy: negative / negative

Meningeal sign
Stiff neck: Kernig's sign: Carotid Artery: + / +
Palpation: strong palpable / strong
palpable
Auscultation: not evaluated
Thyroid: - / -

Motor
Movement:

Strength : 3 / 5
3/5
Physiological reflex:
BPR: +2/+2
TPR: +2/+2
KPR: +2/+2
APR: +2/+2

Pathological reflexes
Hoffman tromer: -/Gordon: -/Babinsky : +/Oppenheim : -/Chaddock : -/Sensibility :normal

Diffcount :
0/2/80/14/4
Hct : 37,9
Hb : 12,5
LED : 53/72
Leukocyte : 12.000
Thrombocyte :
251.000
Urea : 29
Creatinin : 0,7
GDA: 109

SGOT : 20
SGPT : 16
Potassium : 3,6
Sodium : 140
Chloride : 113
Cholesterol : 231
TG: 116

female, 56yo.
right body weakness
Headache (+), nausea (-), vomit (+)
Siriraj score +1,3

Lipid profile

General:
O2 Nasal 4 lpm
IVFD Asering 1500 cc/24 jam
Inj. Methamizole 3x1 gram i.v.
Inj. Ranitidin 2x50 mg
Inj. Ondansentron 3x1 amp
Specific:
Inj. Citikolin 3x1 amp
Loading Clopidogrel 4 tab 1x1 tab
Inj. Fondaparinux (Arixtra) 1x1 amp
CA 1x1 tab
Consulted to neurologist

- Vital sign
-subjective complaints of patients
-Neurology Examination

-Explain to the family about the disease of the family

-Explain the patient about therapy and intervention,
-Explain the patient about its complication and
prognosis.

PROGNOSIS

Dubia ad bonam