Documente Academic
Documente Profesional
Documente Cultură
Department of Neurology
5.02.2016
F23
Identity
Name: Mr. Kasmiin
Age: 60 yo
Address: gedangan, lamongan
Pekerjaan: farmer
Date examination: 5/02/2016
Anamnesis
PHYSICAL EXAMINATION
VITAL SIGN :
GCS
: 3x6
BP
: 163/96 mmHg
PULSE RATE
: 36.5x / minutes regular
TEMP
: 36,5oC
RR
: 20x / minutes
Primary Survey
A: clear, gargling (-), snoring (-), speak
Secondary Survey
GCS 3x6 afasia motorik
H/N: aicd
Tho: sim, ret -/-
Neurology Status
1. Head :
Position
: Normal,
middle
Mass: Shape | size
: normal | normal
2. Nervus Cranialis :
N.I (Olfaktorius)
N. III (Okulomotorius)
slit eye
: Ptosis
: -| -
Exoftalmus
: -| Movement of eye ball : sde
Pupil
: Pupil round isokor 3 / 3 mm
Light perception : direct : + | +
non-direct
:+|+
nistagmus : - | N.IV (Troklearis)
Position of eye ball : normal | normal
movement of eye ball : sde
N.VI (Abdusen)
N.VII (Fasialis)
Motorik:
m. frontalis
: sde
m. orbikularis okuli : sde
m. oblik oris
: sde
sulcus nasolabialis : dextra
tertarik/mendatar
taster of 2/3 front tongue : not evaluated
N.VIII (Vestibulokoklearis)
watch
: hard to evaluated
whispered voice : hard to evaluated
Tes weber : not evaluated
Tes Rinne : not evaluated
N.IX (Glossofaringeus)
: not evaluated
sensibilitas faring
: not evaluated
N.X (Vagus)
the arc of arcus faring: hard to evaluated
Reflek swallow/vomit : hard to evaluated
N.XI (Acsessorius)
Shruging
: not evaluated
Looked away
N.XII (Hipoglossus)
: not evaluated
Tongue deviation
: hard to evaluated
Fasiculation, Tremor, Atrofi : hard to
evaluated
Neck
Sign of Menigeal infection:
Kaku kuduk
: negative
Brudzinski I dan II : negative,
negative
Kernig
: negative
Kelenjar lymphe : bulge (-)
Kelenjar gondok : bulge (-)
Abdomen
Reflek kulit dinding perut:
+
++ +
++ +
Ekstremitas
Motorik
Movement
Strength
Tonus
:
:
:
:
lateralisasi dextra
normal
hard to evaluated
normal
Reflek fisiologis
BPR
: +2 | +2
TPR
: +2 | +2
KPR
: +2 | +2
APR
: +2 | +2
Reflek patologis
Hoffman-tromner
Babinski
Chaddock
Gordon
Schaefer
Oppenheim
:
:
:
:
:
:
:
|
|
|
|
|
|
Trofi
: -|Sensibilitas
Eksteroseptif
Pain
: not evaluated
Temperature
: not evaluated
Rasa raba halus
: not evaluated
Proprioseptif
Rasa sikap
: not evaluated
Rasa nyeri dalam : not evaluated
Fungsi kortikol
Discrimination function
Stereognosis
: not evaluated
: not evaluated
Barognosis
Abnormal spontan
: not evaluated
: not evaluated
Impaired coordination
Tes finger nose
: not evaluated
not evaluated
: not evaluated
Planning Diagnose
Random Blood Glucosa
Complete bood count
SGOT/SGPT
SE
Urea/Creatinin
LP bila tanda peningkatan TIK (-)
CT Scan kepala tanpa kontras
Thoraks AP
Lab.
Exam
Tampak lesi
hiperdens di
brain
parenchym
pons uk
19x15x20
mm
kesimpulan:
ich pons
Assesment
Dx. Klinis:
Therapy
O2 nasal 3lpm
Head up 30
Pasang DC
Inf. asering 1500 cc/24jam
Loading manitol 200 cc 6x100 cc
Inj. Metamizole 3x1 gr
Inj. Ranitidin 2x50 mg
Inj. Ceftriaxon 2x1 gr
Inj. Citicolin 3x250 mg
c/Sp.S
Monitoring
General state
Vital sign
Patients complaints
Intrakranial Pressure sign