MORNING REPORT

Thursday, July 11, 2019

SMF NEURO

DM : Elsa Kusumawati / 6120018011

MEDICAL SPECIALIST: Shobiatus Syifak, dr., SP.S
 Patient Identity
• NAME : Mr. S
• AGE : 65 y/o
• GENDER : Man
• MARRIAGE STATUS : Married
• OCCUPATION :
• No RM : 324936
• ADDRESS : Surabaya
• EXAMINATION DATE : July 9, 2019
 ANAMNESIS
• MAIN COMPLAINT
Decrease of Consciousness
• Current history
The patient is brought by his family to the emergency room with complaints of Decrease of Consciousness
since 2 hour ago, the patient cannot talk to the family, weakness in the right side of the body(leg and arm). Complaints
were felt by patients when lifting aqua gallon around at seven pm today (about 3 hour before going to the hospital), and
the eye blurred, suddenly the arm ca not be moved, and paralyse. Weakness is felt in the arm first than the leg. The
patient known that he has ate fried duck after breakfasting. The patient is an active smoker, 1 pack / day. (-) nausea, (+)
vomiting, (-) headache, (-) fever, (-) chest pain, (-) difficulty swallowing. Defecation and urination within normal limits.
• Past medical history :
• Hypertension (-)
• Heart Disease (-)
• Stroke (-)
• Diabetes Melitus (-)
• Family history : There are no family members of patients who experience similar complaints
• History of drug use : -
 OBJECTIVE
• PHYSICAL EXAMINATION
• General state : Decrease of Consciousness
• Awareness : stupor
• GCS : 323
• TTV
BP : 120/60 mmHg
Pulses : 68x/min, regular
RR : 20x/min
Temperature : 36,5°C
 NEUROLOGY EXAMINATION
MMT Right Left
2 3
2 3
NERVUS CRANIALIS
• NI : not evaluated
• N II, III : Ptosis (-), PBI 3/3mm, RCL (+/+), RCTL (+/+)
• N III/ IV/VI : not evaluated, Nistagmus (-)
• NV : not evaluated
• N VII : facial palsy dextra
• N VIII : not evaluted
• N IX/X : not evaluted
• N XI : not evaluted
• N XII : lingual palsy ?
• FISIOLOGI REFLEX PRIMITIF REFLEX
• BPR : +1 / +2
• TPR : +1 / +2 • Refleks palmomental : -/-
• KPR : +1 / +2 • Refleks Glabella : -/-
• APR : +1 / +2
• PATOLOGICAL REFLEX
Refleks Babinski : -/- PEMERIKSAAN SENSORIS PEMERIKSAAN OTONOM :
Refleks Chaddock : -/- Propioseptik : ENEURESIS (-)
NGEBROK (-)
Refleks Oppenheim: -/- • Gerak dan Posisi : Not Evaluated
Refleks Gordon : -/- • Getar : Not Evaluated
Refleks Schaffer : -/-
• Tekan : Not Evaluated
Refleks Gonda : -/-
Ekteroseptik :
Refleks Stransky : -/-
Rosolimo : -/- • Raba : not evaluated
Mendel Bachterew : -/- • Nyeri : not evaluated
Hoffman : -/- • Suhu : Not Evaluated
Tromner : -/-
 Supporting Examination
• Complete Blood
• Rapid Glucose : 122 mg/dL

7
 Hasil Nilai Rujukan
Leukosit 9.28 ribu/uL 3,8–10,6 ribu/uL
Basofil 1.416 % 0–1 %
Neutrofil 73.00 % 39,3–73,7 %
Limfosit 16.000 % 25–40%
Eusinofil 2.249 % 2–4 %
Complete Monosit 7.329 % 2–8 %
Blood
Eritrosit 5.13 juta/uL 4,4–5,9 juta/uL
Hemoglobin 16.48 g/dL 13,2–17,3 g/dL
Hematokrit 49.5 % 40–50 %
Trombosit 252 ribu/uL 150–440 ribu/uL
MPV 6.437 fl 7.2–11.1
MCV 96.5 fl 80–100 fL
MCH 32.1 % 26.0–34.0 pg
MCHC 33.3 % 32–36 % 8
 FUNGSI GINJAL (19/05/2019) FUNGSI HATI
Creatinin 1.36 mg/dL 0.45 – 0.75 mg/dL SGOT 18 mg/dL > 50 mg/dL
BUN 17.3 mg/dL 10-20 mg/dL SGPT 24 mg/dL > 50 mg/dL

SERUM ELEKTROLIT
Natrium 133,80 mEq/L 135 – 147 mEq/L
Kalium 3.68 mEq/L 3.5 – 5.0 mEq/L
Chlorida 114.10 mEq/L 95 – 105 mEq/L
• Tak tampak lesi hypodens maupun
hyperdens abnormal di brain parenkim
• Kalsifikasi basal ganglia kanan dan kirir
• Gambaran penumpukan cairan
serebrospinal di tepi otak (higroma)
• Tak tampak deviasi midline struktur
• Sistem ventrikel normal
• Sulci dan gyri normal
• Mastoid, sinus frontalis, sinus ethmodialis,
sinus sphenoidalis kanan kiri normal
• Tulang tulang calvaria tampak normal, tak
tampak fraktur
• Pons dan cerebellum kesan normal

 Kalsifikasi basal ganglia kanan dan kiri (fehrn

disease)
 EMBOLI sinistra
 Gambaran hygroma
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 0) + (0.1 x 60) – (3 x 0) – 12

= -1,5
 Neurological Diagnosis
• Clinical Diagnosis
- Weakness in the right side of the body
- Decrese of consciounes
- Facial Palsy dextra sentral type
- Lingual Palsy?
• Topic Diagnosis :
Cortical cerebri sinistra lobus frontalis susp. artery cerebri anterior
• Etiology Diagnosis :
Stroke Infark emboli
• Secondary Diagnosis :
 SOAP
Subjective Objective Assesment Planning
• Decrease of Consciounes PHYSICAL EXAMINATION CLINICAL DIAGNOSIS PLANNING DIAGNOSIS
• Weakness in the right side of General State : Decrease - Hemiparese dextra UMN type GDA, DL, SE, BUN SK, OT, PT, EKG,
the body of consciounes - Disatria Foto Thorax, Cholesterol total, LDL,
• Complaints are felt when the Awareness : Stupor - Facial palsy dextra HDL, TG, uric acid, head CT scan
patient lifting the gallon GCS 323 without contrast
• The patient also complained TOPIC DIAGNOSIS
about his speech BP : 120/60 mmHg Cortical cerebri sinistra lobus frontalis PLANNING THERAPHY
Pulses : 68x/min, regular susp. artery cerebri anterior IVFD RL 1000cc dalam 24 jam
RR : 20x/min Ng tube
• (+) Vomitting Temperature : 36.5°C ETIOLOGY DIAGNOSIS Pasang kateter (monitoring
• (-) headache Stroke Infark Thrombotic produksi urine)
• (-) fever MMT : 2/3 , 2/3 Inj. Mecobalamin 2 x 500mcg IV
• (-) Chest pain. SECONDARY DIAGNOSIS Inj. Citicolin 2 x 250 mg IV
• Defecation and urination NERVUS CRANIALIS - Aspilet 1 x 80 mg PO
within normal limits. N VII : facial palsy dextra Inj. Ranitidin 2 x 50 mg IV

DIET
sonde
Calori 30 – 50 kcal/Kg weight

EDUCATION and
COMMUNICATION
Adequate rest, head trunk14up 30
degree, avoid stress, low-salt, low-
JAZAKUMULLOH KHOIRON
KATSIR