MORNING REPORT

NEUROLOGY F-23

PATIENT IDENTITY

Name
: Mr. Mudhofar
Age
: 53 yo
Religion
: Moslem
Occupation : farmer
Residence
Observe

: gunungsari bojonegoro
: 13 January 2016

ANAMNESIS

Chief complaint

weak of body
Present illness history :

patients complained weak of right body since

22.00 pm, the patient suddenly complained of
weakness after waking. weak body is
accompanied by loss of speech. the patient had
never felt like this. Nausea +, vomiting 2x
contents of food. patients also complain of
headache
Previous Illness History : DM -, HT+

ANAMNESIS

Family History of Disease

(-)

Vital sign:
BP:218/137mmHg
HR: 78 x/mnt
RR: 20 x/mnt
Temp: 36,90C

STATUS PRESENT
Primary survey:
A : clear, gargling (-), snoring (-), speak
frequently (+), potential obstruction (-)
B : spontaneous, RR 20x/mnt, ves/ves, rh
-/-, wh -/-, O2 saturation 99% without
support
C : acral dry red warm, CRT < 2, N 78
x/mnt, BP 218/137 mmHg
D : GCS 3X5, lateralisation (+), PBI 3 mm/3
mm, LR +/+
E : Temp 36,90C

Secondary survey:
GCS 3X5
H/N : a -/ I -/ c -/d-;Enlargement of Lymph
node Tho : simestris, ret -/

P : ves/ves, rh -/-, wh -/C : S1S2 single, murmur (-), gallop (-)

Abd : Soepel, met -, bowel loudness (+) N,

H/L unpalpable,
Extr: aie -, acral dry red warm

NEUROLOGY STATUS
1. Head : Position
Mass
Shape | size
Auskultation

: Normal, middle
:: normal | normal
: bruit a. carotis(-)

2. Nervus Cranialis :

N.I (Olfaktorius)

Penghidu

: Normal

N.II (Optikus)

Visual acuity
: normal
Field of vision
: normal
Funduscopy
: not evaluated

N. III (Okulomotorius)
slit eye: Ptosis
: -| Exoftalmus
: -| Movement of eye ball : normal
Pupil
: Pupil round isokor 3 / 3 mm
Light perception : direct : + | +
non-direct
:+|+
nistagmus : + | +
horizontal

N.IV (Troklearis)
Position of eye ball
movement of eye ball

: normal | normal
: normal

N.VI (Abdusen)

movement of eye ball

N.V (Trigeminus)

Sensibility : N. V I

: normal

: normal

N. V II

: normal

N. V III

: normal

Motorik :
Inspeksi

: symmetris

Palpasi

: normal

chewing

: normal

Bitting

: normal

Reflek masseter: normal | normal

Reflek cornea

:+/+

N.VII (Fasialis)
Motorik:
m. frontalis

: normal

m. oblik okuli

: normal

m. oblik oris

: normal

taster of 2/3 front tongue : not evaluated

N.VIII (Vestibulokoklearis)
wrist watch

: hard to evaluated

whispered voice: hard to evaluated

Tes weber : not evaluated
Tes Rinne

: not evaluated

 N.IX

(Glossofaringeus)
taster 1/3 (back side): not evaluated

sensibilitas faring
: hard to evaluated
N.X (Vagus)
the arc of arcus faring: symmetrical | symmetrical
(rest |AAH)
: hard to evaluated
Reflek swallow/vomit : normal | normal
N.XI (Acsessorius)
Shruging

: hard to evaluated

Looked away
: hard to evaluated
N.XII (Hipoglossus)
Tongue deviation : hard to evaluated
Fasiculation, Tremor, Atrofi, Ataxia: hard to

evaluated

Neck

Sign of Menigeal infection

:
Kaku kuduk
: positive
Brudzinski I dan II : negatif, negatif
Kernig
: negatif
Kelenjar lymphe : bulge (-)
Arteri karotis :

Palpasi
: strong, regular
Auskultasi
: bruit ()

Kelenjar gondok : bulge (-)

Kolumna Vertebralis

Inspeksi

: normal

Palpasi

: normal

Movement

Perkusi

: normal
: normal

Ekstremitas

Motorik : lateralisasi dextra

Reflek fisiologis

BPR

: +2 | +2

TPR

: +2 | +2

KPR

: +2 | +2

APR

: +2 | +2

Reflek patologis
:
Hoffman-tromner : - | Babinski : - | Chaddock
: -| Gordon : - | Schaefer : - | Oppenheim : - | Mendel B: - | Rossolimo
: -|Trofi
: -|Sensibilitas
Eksteroseptif
Pain : hard to evaluated
Temperature
: hard to evaluated
Rasa raba halus
: hard to evaluated
Proprioseptif

Rasa sikap : not evaluated

Rasa nyeri dalam : not evaluated

Fungsi kortikol
Discrimination function : hard to evaluated
Stereognosis
: hard to evaluated
Barognosis
: hard to evaluated
Abnormal spontan movement : Impaired coordination
Tes finger nose
: hard to evaluated
Tes pronasi supinasi
: hard to evaluated
Tes knee to toe
: hard to evaluated

LABORATORIUM

GDA 102
Hct 45,2
Hb 15,0
LED : 5/11
Leukosit 10,5
Trombosit 230.000
Neutrofil 86,8
Limposit 7,2
Monosit 3,2
Eosinofil 1,4
Basofil 1,4
Eritrosit 5,43

MCV 82
MCH 27.90
MCHC 33.50
RDW 12
MPV 5
Urea 24
SC 0.9
OT/PT 20/12

CLUE AND CUE

male, 53 yo
Hemipharese dextra
sudden weakness
Nausea +
Vomiting +
Headache +

 Hemisphere
subcortical

Etiological Diagnosis

Diagnosis Topis

Clinical Diagnosis

Hemipharese
dextra
HT
Nausea +
Vomiting +
Headache +

CVA Bleeding

PLANNING THERAPY
General therapy :
O2 nasal 2-4 lpm
IVFD. Assering 1500cc/24jam
Head up 30 derajat
Inj. santagesik 3x1 gr
Inj. Ranitidin 2x50 mg
Inj. Beclov 3x250 mg
Inj. Manitol 200mg 6x100mg

Consul Sp.S, Sp.BS

PLANNING MONITORING

Vital sign
Subjective complaints of patients
Neurology Examination

PLANNING EDUCATION

Explain to the family about the disease of

the family
Explain the patient about therapy and
intervention,
Explain the patient about its complication
and prognosis.

PROGNOSIS

dubia ad malam