Morning Report

July 25 , 2016
th

DEPT OF NEUROLOGY
G26

DAFTAR OB NEURO
Tn. Dadi Prayitno

cva infark

Zamzam 07

Identity
Name

: Mr. D
Age
: 46 years old
Occupation : farmer
Address
: Jagul RT1 RW 1
Sendanggrejo, Lamongan
Admission : July 25 th, 2016 at
10.30 PM

Chief Complaint
Hemiparesis Sinistra

Present history
Patient complained Hemiparesis sinistra since 2 hours before
admited to hospital. This hemiparesis spread to left shoulder.
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 (+) since 10 years non regularly taking medication, DM (-)

Family history
HT (+). CVA (+)

Social history : (-)

Vital Signs
BP

181/99 mmHg

Pulse

97 x/min, strong, reguler

Temp

36,5 C

RR

20x/min

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

potential obstruction (-)

B: spontan, RR 20x/min, ves / ves, rh -/-, wh -/-,
SaO2 98% without O2 support.
C: extremity WDR, CRT <2, N 97x/min, BP 181/99
mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36,5 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: normal/normal
N IX: normal/normal
N XII: abnormal/normal

Fisiologic reflex:

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

Patologic reflex:

Babinski -/Chaddok -/Hoffman trommer -/-

Motoric: sup 5/5

inf 5/2
Sensoric: Hemihipoestesia
Sinistra

Planning Diagnosis
CBC
ECG
Thorax photo
CT-Scan

Laboratory Findings
Eritrosit
Hb

5.67

16.5
LED
6
LED2
11
Limposit
15.6
Basofil
1.5
Eosinopil
6.7
Hematokrit 50.3
Leukosit
12.2

MCH 19.10
MCV 88.70
MCHC 32.80
Monosit 5.6
MPV 5
Neutropil

70.6

RDW 11
Trombosit 233
SGOT 19
SGPT 16
Urea
Serum creatinin

35
0,9

Diagnosis
Diagnosis:

Klinis : Hemihipoestesia Sinistra

Topis: Serebri dextra
Etiologi: CVA Infark
Hypertension Essential

Planning Therapy
IVFD PZ
1500cc/24 hours
Inj. antrain
1gr iv prn nyeri
Inj. citicolin 3x500mg
Inj. Ranitidin
2x50mg

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