Neurology Departement

April, 07 th 2014

Identify Patient
Name : Mrs. S
Age : 69 years old
Sex : Female
Address: Lamongan

Anamnese
Chief complain: weakness the right part of body
Present illness history
the weakness has been felt since 2 hour before take
to the hospital, suddenly when activity. Headace
(-),Nausea (-), vomit (-), seizure (-), fever (-).
Defecation and miction normal. Disathria +
Past illness history
HT (+) with sistolic blood pressure 170 incontrolled,
DM (-),history of stroke attack (-).
Family illness history
None of family have the same illness
Social illness history : (-)

Vital sign :
BP : 154/84 mmHg
HR : 87 x/mnt
RR : 22 x/mnt
T : 35,6 C
General examination :
Head-neck
: a/i/c/d -/-/-/Thorax :
simetris (+), retraction (-), sonor/sonor, vesikuler/vesikuler,
S1 S2 solitary, murmur (-), gallop (-)
Abdomen :
flat, soefl, intestinal sounds (+) normal, Liver and spleen are
not palpable.
Extremitas : Warm, dry, and red, edema (-)

Affect and emotion

: within normal limit

Thinking process

: within normal limit

Intelligence

: within normal limit

Willingness

: within normal limit

Psychomotor

: within normal limit

Neurological Examination

N. I (Olfactorius)

: within normal limit

N. II (Opticus)
Visus
Visual field
Funduscopy

:
: within normal limit
: within normal limit
: cannot be evaluated

N. III (Okulomotorius)
Ptosis
exoftalmus
eye movement
Pupil
Light reflect
N. IV (Trochlearis)
eye position
eye movement
N. VI (Abducen)
eye movement

:
:-/:-/: within normal limit
: 3mm/3mm, rounded, isokor
: +/+
:
: ortoforia
: within normal limit
:
: within normal limit

N. V (Trigeminus)
Sensibility
: N V1
N V2
N V3
Motorik

:
: within normal limit
: within normal limit
: within normal limit

Inspection
Palpation
chewing
bite

: within normal limit

: within normal limit
: within normal limit
: within normal limit

N. VII (Facialis) :
Sensorik
: not evaluated
Motorik
:
M. Frontalis
M. Oblique oculi
M. oblique oris

: within normal limit

: parese N. VII central dextra
: parese N. VII central dextra

N.VIII (acusticus) :
within normal limit

N. IX, X (GLOSSOFARINGEUS, VAGUS):

sensory 1/3 posterior : not evaluated
arcus pharynk position : central
reflek muntah
: not evaluated
N.XI (accecorius) : not evaluated
N. XII (Hipoglossus) : Parese N XII central dextra

Affect and emotion

Language ability
Memories
Visuospatial
Intellegence

: within normal limit

: within normal limit
: within normal limit
: within normal limit
: within normal limit

Clue and Cue

Female,69 yr
paralyze half of body (right part)
Parese N VII Central dextra
Parese N XII Central dextra
acut onset
BP 154/84 mmHg
Past history illness : Hipertension (+) DM (-) Stroke (-)
Siriraj score

(2,5x0)+(2x0)+(2x0)+(0.1x84)-(3x0)-12= -3,6

Assessment
Clinical Diagnose
Hemiparesis dextra, acute onset when activity,
parese n.VII and XII central dextra, HT (+).
Topic Diagnose
Hemisfer sinistra

Etiologic Diagnose
CVA Bleeding

Planning Diagnose
DL
ECG
Lipid Profile
X-Ray Thorax
CT-Scan

CT SCAN

FOTO THORAX

 Diffcount 3/0/70/22/5
Hct 37,0
LED 21/46
Hb 12,4 g/dl

Laboratorium Result

Lekosit
4.800
Trombosit 180.000
SGOT
SGPT

15
12
Urea
31
Serum creatinin0,7
GDA
89
Cholesterol
173
HDL
47,3
LDL 100,6
TG 73

5B!!
Planning
Therapy

O2 nasal 4 lpm
Foley cathether
IVFD asering 1000 cc / 24 hr
Inj Santagesic 3x1 amp
Inj. Acran 2x1 amp
Inj. Brain act 3x1 amp
C/ Sp.S

Vital sign
Neurologic disorders

Explain to the family about the disease of the

family, about its therapy and intervention will
be done, and also about its complication and
prognosis dubia at bonam