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August 6 , 2016
th
DEPT OF NEUROLOGY
G26
DAFTAR OB NEURO
Name : Mr. H
Age : 50Th years old
Occupation : farmer
Address : Trepan RT 1 RW 1, babat,
lamongan
Admission : August 6th, 2016 at
03.03 PM
Chief ComplaintHemiparesis Sinistra
Present history
•HT (-)
•DM (-)
•CVA (-)
Family history
Social history : -
Vital Signs
BP
186/112 mmHg
Pulse
75 x/min, strong, reguler
Temp
36,2 C
RR
21x/min
A: clear, gargling (-), snoring (-), speak fluently (+),
potential obstruction (-)
B: spontan, RR 21x/min, ves / ves, rh -/-, wh -/-,
SaO2 99% with O2 support.
C: extremity WDR, CRT <2’, N 75x/min, BP 186/112
mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36,2 C
General condition : good
Awareness : compos mentis
GCS : 456
H/N : 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 -/-
Auscultation
Met -, bowel sound WNL
Palpation
Pain (-)
Percussion
Tymphany
Extremities
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-), edema (-)
Palpation
Cold and wet, CRT <2’
Status Neurologic
GCS: 456 Fisiologic reflex:
Meningeal sign: BPR +2/+2
CBC
ECG
Thorax Photo
Laboratory Findings
Diagnosis:
Siriraj Score: (2,5 x 0) + (1x0) + (1x0) + 99-3 x1= -15
Klinis : Hemihipestesia sinistra, hemiparesis sinistra
Topis: A. cerebri media dextra
Etiologi: CVA
Planning Therapy
Vital Signs
Patient’s complaint
Adverse effect
DL
PLANNING EDUCATION