Morning report neurology

MORNING REPORTDepartment of Neurology

5.02.2016F23

IdentityName: Mr. Kasmi’inAge: 60 yoAddress: gedangan, lamonganPekerjaan: farmerDate examination: 5/02/2016

AnamnesisChief complain: loss of consciousnessPresent Illness History: patients referral from pku

parengan coming to the emergency room RSML with loss of consciousness since 13.00 ( 4 hours SMRS ) . Initially patients after clean the house complained of headaches and vomiting . 5x vomiting food contents . seizures - , loss of speech -

Previous Illness History: - never like this before - History of hypertension one year ago is not routine control and take medication- history of dibates melitus denied

Familly Illness History = his mother have hypertension +Social Illness History: patients do not smoke . daily

consumption of coffee

VITAL SIGN :GCS : 3x6BP : 163/96 mmHgPULSE RATE : 36.5x / minutes regularTEMP : 36,5oCRR : 20x / minutes

PHYSICAL EXAMINATION

Primary SurveyA: clear, gargling (-), snoring (-), speak

fluently (+), potential obstruction (-)B: spontan, RR 20x/mnt, ves/ves, Rh -/-, Wh

-/-, SaO2 99% without O2 supportC: akral warm dry red, CRT <2”, PR

106x/mnt, BP 163/96 mmHgD: GCS 3x6, lateralisasi -, PBI 3mm/3mmE: temp 36,8 C

Secondary SurveyGCS 3x6 afasia motorikH/N: aicd –Tho: sim, ret -/-

P: ves/ves; rh -/-, wh -/-C: S1S2 single, murmur -, gallop –

Abd: Soepel, met -, H/L not palpaple, BU+N, pressing pain: sde

Ext: aie -, akral warm dry red

Neurology Status1. Head : Position : Normal, middle

Mass: -Shape | size : normal | normal

2. Nervus Cranialis : N.I (Olfaktorius)

Penghidu : not evaluated N.II (Optikus)

Visual acuity : hard to evaluatedField of vision : hard to evaluatedFunduscopy : not evaluated

N. III (Okulomotorius)slit eye : Ptosis : -| -

Exoftalmus : -| -Movement of eye ball : sdePupil : Pupil round isokor 3 / 3 mmLight perception : direct : + | +

non-direct : + | + nistagmus : - | -

N.IV (Troklearis)Position of eye ball : normal | normalmovement of eye ball : sde

N.VI (Abdusen)movement of eye ball : sde

N.V (Trigeminus)Sensibility: N. V. 1 : sdeN. V.2 : sdeN. V.3 : sde

Motorik : Inspeksi : symmetrischewing : sdeBitting : sdeReflek masseter : not evaluatedReflek cornea : sde

N.VII (Fasialis)Motorik: m. frontalis : sdem. orbikularis okuli : sdem. oblik oris : sdesulcus nasolabialis : dextra

tertarik/mendatartaster of 2/3 front tongue : not evaluated

N.VIII (Vestibulokoklearis)watch : hard to evaluatedwhispered voice : hard to evaluatedTes weber: not evaluatedTes Rinne : not evaluated

N.IX (Glossofaringeus)taster 1/3 (back side) : not evaluatedsensibilitas faring : not evaluated

N.X (Vagus)the arc of arcus faring: hard to evaluatedReflek swallow/vomit : hard to evaluated

N.XI (Acsessorius)Shruging : not evaluatedLooked away : not evaluated

N.XII (Hipoglossus)Tongue deviation : hard to evaluatedFasiculation, Tremor, Atrofi : hard to

evaluated

NeckSign of Menigeal infection: Kaku kuduk : negative

Brudzinski I dan II : negative, negativeKernig : negativeKelenjar lymphe : bulge (-)Kelenjar gondok : bulge (-)

AbdomenReflek kulit dinding perut: + +++ + ++ + +

EkstremitasMotorik : lateralisasi dextraMovement : normalStrength : hard to evaluatedTonus : normal

 Reflek fisiologis :BPR : +2 | +2TPR : +2 | +2KPR : +2 | +2APR : +2 | +2

Reflek patologis :Hoffman-tromner : - | -Babinski : - | -Chaddock : - | -Gordon : - | -Schaefer : - | -Oppenheim : - | -

Trofi : - | - SensibilitasEksteroseptifPain : not evaluatedTemperature : not evaluatedRasa raba halus : not evaluatedProprioseptif Rasa sikap : not evaluated Rasa nyeri dalam : not evaluated

Fungsi kortikolDiscrimination function : not evaluatedStereognosis : not evaluatedBarognosis : not evaluatedAbnormal spontan : not evaluatedImpaired coordinationTes finger nose : not evaluatedTes pronasi supinasi : not evaluatedTes knee to toe : not evaluated

Siriraj score: (2,5x1) + (2x1) + (2x1) + (0,1x96) –(3x1) – 12 = 1,1 (>1 cva bleeding)

Random Blood GlucosaComplete bood countSGOT/SGPTSEUrea/CreatininLP bila tanda peningkatan TIK (-)CT Scan kepala tanpa kontrasThoraks AP

Planning Diagnose

Lab. Exam Eritrosit 5,06 (3.80 – 5.30) Hemoglobin 15,6 (14-18) LED 1 117 (0-1) LED 2 25 (1-5) Limfosit 12,9 (25.0-33) Basofil 1,7 (0-1) Eosinofil 4,8 (1.0-2.0) Hematokrit 47,1 (40.0-54) Leukosit 21,6 ( 4.0-11.0) Neutropil 81,7 (49,0-67,0) MCH 29.30 (28.00-36.00) MCHC 33.40 (31.00-37.00)

MCV 87.60 (87.00-100.00) RDW 11 (10-16,5) Trombosit 299 (150-450) Monosit 4,3 (3.0-7.0) MPV 3 (5-10) GDA 151 Urea 29 (10-50) SC 1,3 (0,8-1,5) OT/PT: 31/32 (37-41) Clorida serum 108 (70-108) Kalium serum 4,0 (3,6-5,5) Natrium serum 138 (135-

155)

Tampak lesi hiperdens di brain parenchym pons uk 19x15x20 mmkesimpulan: ich pons

AssesmentDx. Klinis:

hemiparese dextra, parese n7 dextra type central

Dx. Topis:pons

Dx. Etiologis:Dx Utama: CVA bleedingDD: intracranial hemoraghe

subarachnoid hemoraghe

Therapy O2 nasal 3lpmHead up 30Pasang DCInf. asering 1500 cc/24jamLoading manitol 200 cc 6x100 ccInj. Metamizole 3x1 grInj. Ranitidin 2x50 mgInj. Ceftriaxon 2x1 grInj. Citicolin 3x250 mgc/Sp.S

Monitoring General stateVital sign Patients complaintsIntrakranial Pressure sign