Morep IGD Ayie 8jan2013

8/12/2019 Morep IGD Ayie 8jan2013

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MORNING REPORT

Neurology D-18

Monday, January 6th

2013


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Patient Identity


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ANAMNESIS

Chief complaint: unconscious

Present illness history: familys complained that

Mr.S had unconscious in his house, because

Mr.S live alone nobody from the familys knowsince when this unconscious has started.

Previously familys told Mr.S had headache, this

complaint arise frequently and more increasingly

day by day. During came to hospital Mr.S hasright half of the body spasm once. Vomiting (-),

nausea (-), fever (-)


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Previous Illness History

Hypertension (+) denied DM (-)

Family History of Disease

None of family have the same illness

Sociality History

Patients is a heavy smoker


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General Physical Examination

Awareness : 2x4(sensory aphasia)

BP: 158/103 mmHg

pulse: 63x/minutes

Temp: 36.2 CRR: 20x

Status Present


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Thorax

Inspection: symmetrical chest wall movementPalpation: fremitus + / +Lung:

Percussion: sonor / sonorAuscultation: vesicular / vesicularheart:Percussion: V ICS parasternal right limit dex,

the left boundary of V mid clavicula sin ICS, ICSII upper left parasternalAuscultation: S2 S1 single murmur (-) Gallop (-)


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Abdomen

Inspection: flatPalpation: soepel, tenderness (-)Percussion: Tympani

Auscultation: BU (+) N

Liver: no palpableLien: no palpable


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Psychological Status

Affective and emotional: within normal limitsThe process of thought: within normal limits

Intelligence: within normal limitsAbsorption: within normal limitsWillpower: within normal limitsPsychomotor: within normal limits


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Neurological Status

head:Position: normocephaliProtrusion: (-)

Shape / size: normal impression Subconjunctival bleeding OD


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Cranial Nerve

N.I (olfactory)Smelling: dte/dte

N.II (optic)

Visual acuity: dte / dteField of view: dte / dteFunduscopic: not evaluated


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N.III (okulomotorius)Ptosis: - / -

Eksoftalmus: - / -Eye movements: dte/ dteSize: 3mm/3mm, isokorLight reflex: + / +

N.IV (trokhlearis)The position of the eye: ortoforia / ortoforiaEye movements: dte / dte

N.VI (abduscen)eye ball movement : dte / dte


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N.V (trigeminal)sensibility:

V1: dte / dteV2: dte / dteV3: dte / dtemotor:

Inspection: dte / dtePalpation: dte / dteChewing: dte / dteBiting: dte / dte

Reflex chin / masseter: dteCorneal reflexes: + / +


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N.VII (fascialis)parese N.VII left central type

N.VIIISeconds watches: dte / dteVoice whispered test: dte / dteTest weber: not evaluated

Rinne test: not evaluated N.IX (glossofaringeus)

Taste: dte

N.X (vagus)

Pharyngeal arch Position: dte / dteVomiting reflex: +


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N.XI (accessory)Shrug: dte / dte

Turning heads: dte / dte N.XII (hipoglosus)

Devisasi tongue: dte / dteFasciculations: dte / dte

Tremor: dte / dteAtrophy: dte / dte


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Neck

Inflammatory markers meningesStiff neck: -Kernig's sign: -

Carotid Artery: + / +Palpation: strong palpable / strong palpableAuscultation: cranial, cervical bruit (-) / cranial,cervical bruit (-)

Thyroid: - / -


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Abdomen

Abdominal wall skin reflexes

vertebral columnInspection: wnl

Palpation: wnl

Movement: wnlPercussion: wnl

+ -

-+

+ -


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extremity

motorMovement: dte (lateratation to left) Strength :dte dte

dte dte Muscle tone:

Spastic: - / -

Rigidity: - / -Klonus knee: - / -Klonus Achilles: - / -


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Physiological reflex:BPR: N/TPR: N/KPR: N/APR: N/

pathological reflexesHoffman tromer: - / + Gordon: - / +Babinzki: - / + Schaefer: - / +Chaddock :-/ + Oppenheim: - / +

Mendel B: - / + Rossolimo: - / +


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sensibilityEksteroseptif:Pain: dte / dteTemperature: dte / dteTouch: dte / dteproprioceptive

Shakes: dte / dtePosition: dte / dteFlavor combinations (combine sensation)Stereognosis: dte / dte

Barognosis: dte / dte


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Male, 61th

unconscious

Nausea (-)

Vomit (-) Hypertension

Heavy smoker

Hemiparese sinistra

Parese N. VII left central type


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Male, 61h, admission to Muhammadiyah Lamongan

hospital unconscious, nausea and vomit (-). From physical

examination, found BP 158/103 mmHg, HR 63 x/mnt.

From neurological examination, hemiparese dextra,

Parese N. VII left central type, increasing of left sidebodys physiology reflect, positively of left side bodys

pathology reflect.

From summary above : SIRIRAJ SCORE (2,5x0) + (2x0) + (2x0) + (0,1x103)

(3x1)12 = -4.7 < -1

CVA infark


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Clinical diagnosis

hemiparese dextra, Parese N. VII left central type,increasing of left side bodys physiology reflect,

positively of left side bodys pathology reflect.

Topis diagnosis

a. Cerebri media

Etiologic diagnosis CVA infark


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Head CT scan without contrast X ray Thorax CBC

Random blood glucose test ECG electrolytes


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RADIOLOGICAL

FINDINGS


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LABORATORY OF RESULTS Diffcount : 6/0/67/21/6 Hct: 43.2% Hb: 15.2 mg/dL LED: 8/17 Leucocytes : 8.300 Trombosite: 171.000

OT / PT: 17/28 U/L Albumin: 3.7 mg% Globulin: 1.9 gr% Total protein: 5.6 mg%

Chloride serum: 105 mol/l Calium serum: 4.0 mmol/l Natrium serum: 136 mmol/l Serum creatinin 0.8 mg/dl Urea: 22 mg/dl

Uric acid: 5.1 mg/dl


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O2 nasal 2 lpmIVFD RL 1500 cc / 24 hrInj. Metamizole 3x1 grInj. Ranitidine 2x 50 mg

Inj. Piracetam 4 x 3 grInj. Citicoline 3x250 mgInj. Arixtra 1x1P.O Plavic 3ddI

Foley cathether

ConsultSp.S


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Vital sign, subjective complaints of patients

Explain to the family about the disease of thefamily, about its therapy and intervention will bedone, and also about its complication andprognosis (dubia ad bonam)

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Morep IGD Ayie 8jan2013