Morning Report Neuro 10 April 2015

April, 10 2015**

Name:Ny. SHAge:73 years oldSex:FemaleAddress:Solokuro, LamonganExamine date: April, 10th 2015

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Chief complain: Weakness of bodyPresent illnes history : Patient came to RSML escorted by her family with weakness of body since 1 hour ago. This complaint appear sudden when the patient woke up and its accompained with cold sweat. Dizziness -. Chest pain -. Shortness -. Nausea -. Vomiting -. Miction and defecation are normal. The patients family said that the patient has difficult to communicate since 5 year. The patients family also said that the patients legs often feel numb and weak since 1 month. **

Previous illnes history : Complaints like this -, DM + since 5 years ago (not routine control to specialist), HT -, convulsions + Family illnes history: Complaints like this -, DM -, HT -**

AirwayClear, gargling -, snoring -, speak fluently -, potential obstruction -BreathingSpontan, RR 26 x/mnt, ves/ves, Rh -/+, Wh -/-, SpO2 98% with O2 nasal 2 lpmCirculationAkral RDW, CRT < 2 second, HR 105 x/mnt, BP 120/70 mmHg

Generally StatusGCS 3x4 (afasia global)Vital sign: BP 120/70 mmHg, HR 105 x/mnt, temp 36,5 c, RR 26 x/mntH/N :a- i- c- dispneu Thorax: Sim dex/sin, ret -/- Pulmo: ves/ves, rh-/+, wh -/-Cor : s1 s2 single, gallop -, murmur -Abdomen: soefl, met -, BS + N, H/L not palpableExt : aie -, RDW

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N. I (Olfactorius): not be evaluated

N. II (Opticus):Visus: difficult to evaluatedVisual field: difficult to evaluatedFunduscopy: not be evaluated

RBG 223Kalium 2,9Natrium 140Clorida 104Urea 72Kreatinin 0,9SGOT 22SGPT 37Leukosit 27.500Neutrofil 84,4Limfosit 4,6Monosit 6,3Eusinofil 0,3Basofil 4,4Hb 13,6Hct 41,3MCV 106.00MCH 35.00MCHC 32.90RDW 18Trombosit 350.000MPV 5LED 1 25LED 2 55

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Weakness of bodyThe complaint appear sudden when the patient woke upThe patients legs often feel numb and weakPrevious illnes history : DM + since 5 years ago (control irreguler)Afasia globalTakipneuRhonki Hemiparese sinistraLeukositosisHipokalemi**

Clinical DiagnosisHemiparesis sinistraAfasia globalTopical DiagnosisA. cerebri mediaEtiological DiagnosisCVA non specific**

HbA1cProfil Lipid**

O2 3 lpm NCIVFD Trimex 1500 cc/24 hoursDCDrip KCl 50 mEq/24 hoursInj. Ceftriaxone 2x1 gramInj. Metamizol 3x1 gramInj. Ranitidine 2x50 mgInj. Citicolin 3x250 mgInj. Ondansetron 2x8 mg prnKonsul Sp. SKonsul Sp. P**

General statusVital signSubjective complainmentNeurologic status

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Explain about diagnosis patientExplain treatment of the patientExplain about the prognosis patient

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