MORNING REPORT

Sunday , April 22, 2019

SMF NEURO

DM : Sri safariawati maa/ 6120018039

MEDICAL SPECIALIST: Dyah Yuniati, dr., Sp. S
April 14th, 2019 07.00 – March 15th 19.00
2 neurology patient
in patient
1 patient diagnosis with hemiplegic sinistra susp stroke intracranial
hemorrhage
1 patient diagnosis with hemiplegic sinistra susp stroke infark trombotic
 Identitas Pasien
• NAME : Ms. S
• AGE : 50 y/o
• GENDER : Female
• MARRIAGE STATUS : Married
• WORK : Private employee
• No RM : 318247
 ANAMNESIS
• MAIN COMPLAINT
left hand and foot weakness
Speaking difficulties
• Current history
patients come to igd with left hand and foot weakness complaints since 3 hour ago, then patients family also
says that she vomiting 5 time and she also feel a headache, patients also feeling numb in her left hand and
foot, cant walk, and holding pee , she cant speak but she still understand about what people talking.
Patients family also says that she doesn’t have problem with swallowing food. Patients family says there is
no fever, heart problem and diabetes. Patients family just say that she only have hypertention and always
took a hypertention drug and go to doctors.
 ANAMNESIS

Past medical history:

Hipertension

Family history :
None of the family have similliar disorder

History of drug use :

amlodipine 5mg
 OBJECTIVE
• PHYSICAL EXAMINATION
• General state: Weak
• GCS : 346

• TTV
• BP : 210/120 mmHg
• Pulses : 77x/min, regular
• RR : 20x/min
• Temperature : 36.5°C axillar
 NEUROLOGY EXAMINATION
• MRC right left
5 2 Propioceptive
5 2 1.Rasa Gerak
+ -
• NERVUS CRANIALIS
+ -
• NI : not evaluated
• N II : normal 2. Rasa Tekan
• N III : Ptosis: (-) PBI: 3/3mm RCL: +/+ RCTL: +/+ + -
+ -
• N III/ IV/VI : normal
• N V : normal Eksteroseptive
1. Rasa raba + -
• N VII : Facial dan lingual palsy sinistra central type
+ -
• N VIII : normal
• N IX/X : normal 2. Rasa Nyeri + -
• N XI : normal
+ -
• N XII : lingual palsy sinistra central type
 PRIMITIF REFLEX
• FISIOLOGI REFLEX • Refleks palmomental : -/-
• BPR : +2/ +3
• TPR : +2 / +3 KPR : +2 / +3 MENINGEAL SIGN
• APR : +2 / +3 • KAKU LEHER : -
• PATOLOGiCAL REFLEX • KAKU KUDUK : –
Refleks Babinski : -/+ • BRUDZINKY I : –
Refleks Chaddock : - / + • BRUDZINKY II : –
Refleks Oppenheim : - / -
• BRUDZINKY III : –
Refleks Gordon : - / -
• BRUDZINKY IV : _
Refleks Schaffer :-/-
• KERNIG SIGN : –
Refleks Gonda : -/ -
Refleks Stransky : -/ -
Refleks Hoffmann : -/-
Refleks Tromner : - /-
Supporting Examination
• Darah Lengkap
• Lekosit : 11.32ribu/ul
• Eritrosit : 5.00juta/uL
• HB : 14.19 g/dl
• HCT : 43.4 %
• GDA : 174
• EKG : normal, irama sinus
• CTSCAN :
• Lesi hyperdense di area thalamus
sampai capsula interna hemisfer
kanan

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Siriraj Score
(2,5 x awereness) + (2 x vomiting) + (2 x headache) + (0.1 x diastol
preassure) – (3 x atheroma) - 12

Interpretation :
SSS > 1 Hemorrhagic stroke
SSS < -1 Ischemic stroke

(2,5 x 1) + (2 x 1) + (2 x 1) + (0.1 x 120) – (3 x 0) – 12

= 6.5 (Hemorrhagic stroke)
 SOAP
Subjective Objective
patients come to igd with left hand - Hemiplegi sinistra
and foot weakness complaints - Hemipesthesi sinistra
since 3 hour ago, then patients - Disartria
family also says that she vomiting 5 - Facial dan lingual palsy
time and she also feel a headache, sinistra central type
patients also feeling numb in her - Incontinentia urine
left hand and foot, cant walk, and
holding pee , she cant speak but - Weak, GCS : 346
she still understand about what - BP : 210/120
people talking. Patients family says mmHg
there is no fever, heart problem - Pulse : 77x/minute
and diabetes. Patients family just - RR : 20x/minute
say that she only have - Temperature : 36,5 °C
hypertention and always took a
axillar
hypertention drug and go to - VAS : 0 (no pain)
doctors. - MMT : 5/2
- 5/2
BPR : +2/ +3
TPR : +2 / +3 KPR
: +2 / +3
APR : +2 / +3
- N. XII : : Facial and
lingual palsy sinistra
central type (+)
Assesment
CLINICAL DX
- Hemipesthesi sinistra
- Disartria
- Facial dan lingual palsy sinistra
central type
- Incontinentia urine
TOPIC DIAGNOSIS
Cortex cerebri dextra lobus frontal
et parietal susp. artery cerebri
anterior et artery cerebri media
ETIOLOGY DIAGNOSIS
Stroke infarc trombotic
DD :
Stroke hemoragic
SECONDARY DIAGNOSIS
- Hypertension emergency
Planning
PLANNING DIAGNOSIS
blood sugar test 2 hour pp , SE,
BUN SK, OT,PT, Cholesterol total,
LDL, HDL, TG, uric acid, ECG,
head CT scan without contrast
Planning Theraphy
Head up position 30 derajat
O2 nasal 4 lpm
Inf. NaCL 0.9% 14 tpm
Inj Mecobalamin 2 x 500 µg iv
Inj. Ondancentron 3x4mg
Inj Ranitidin 2x 50 mg
Diltiazem pump 10mg/hour
DIET
Calori 30 ccal/kgWeight
Education and communication
Bed rest untill complaints gone
(usually 5-7 days).
Change the right side slant
11 to the
left side every 3 hours
THANK YOU

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