Morning Report

August 25 , 2016
th

DEPT OF NEUROLOGY
G26

DAFTAR OB NEURO
Ny. Yamu
Tn. A. Dain
Tn. Asram
Ny. Lasmiyat

cva
cva bleeding
cva infark
cva infark

Marwah 14
Marwah 12
Marwah 9
Marwah 5.1

Identity
Name

: Mr. A
Age
: 49 years old
Occupation : farmer
Address
: Kadiren Kalitegah, Lamongan
Admission : August 2th, 2016 at
18.28 PM

Chief Complaint
Hemiparesis Sinistra

Present history
Patient complained paresis righ limb since 12 hours before
admited to hospital. Patient also complained loss of skin
sensitivity on his righ leg. 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 (+)
CVA (-)

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

Social history : drinks coffee 3 glass a day

Vital Signs
BP

192/99 mmHg

Pulse

89 x/min, strong, reguler

Temp

36,7 C

RR

34x/min

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

potential obstruction (-)

B: spontan, RR 24x/min, ves / ves, rh -/-, wh -/-,
SaO2 98% without O2 support.
C: extremity WDR, CRT <2, N 97x/min, BP 192/99
mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36,7 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 dextra central
N XI: normal/normal
N XII: parese dextra

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 5/4
Sensoric: Hemihipoestesia
dextra

Planning Diagnosis
CBC
ECG
Thorax Photo

Laboratory Findings
Eritrosit
Hb

4.84

13.1
LED
52
LED2
81
Limposit
33
Basofil
1.9
Eosinopil
3.7
Hematokrit 40.1
Leukosit
7

MCH 27.10
MCV 82.90
MCHC 32.70
Monosit 4.6
MPV 3
Neutropil

56.8

RDW 12
Trombosit 342
HDL cholestrol

37.3

LDL cholestrol 67.0

Cholesterol

364
50

Urea
Serum creatinin

1,7

Pemeriksaan EKG

Diagnosis
Diagnosis:

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

Klinis : Hemihipoestesia dextra, hemiparesis dextra

Topis: A. cerebri anterior sinistra
Etiologi: CVA Infark

Planning Therapy
O2 nasal
3lpm
IVFD RL
1000cc/24 hours
Inj. antrain
3 x 1gr iv prn nyeri
Inj. citicolin 3x250mg
Inj. Ranitidin
2x50mg
Po. Aspilet
1x1 tab

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