Morning report

Friday 8th January 2016

ER

: dr. Betsi

Consultant

: dr. Diah

Stroke unit

: dr. Daniel-dr.Theo

Ward

: dr. Runi-dr. Nanik

PATIENTS IDENTITY
Name

: Mrs. W

Age

: 56 years old

Gender

: Female

Occupation

: Housewives

MR Number

: C529514

Hospital admission

: 8th January 2016

HISTORY (autoanamnesis)
Chief complaint
Onset

: Unconscious

: 1 hour before hospital

admission

Quality
pain
Quantity

: only can awake with

stimulation
: ADL independently

HISTORY
Chronology :

1 hour before hospital admission, family

said that patient suddenly unconscious.
Family said she was sleep at that moment.
Family said patient Cant communicate.
Weakness (+) all extremity,slurred speech
(-), vomit(-), headache (-), seizures (-),
fever(-). Family than brought her to BPJS
Clinic, and suggested transferred to dr
Kariadi Hospital

HISTORY
Aggravated Factors : Extenuated Factors : Concomitant Symptoms :
- Weakness in all extremity

HISTORY
Past Medical History
- Stroke, 1 year ago. Hospitalized in Tugu Hospital for
four days, she permitted to go home and Family said
that she had weakness in right part of body, slurred
speech (+),
Family Disease History : no family history had the
same illness
Social Economic-Status And Personal History :
housewives

CLINICAL FINDINGS
Present States
GCS
: E3M5Vsusp afasia
Vital signs
:
BP 150/80 mmHg
HR
49x/min
RR 20x/min
Temp 36.5 (axilla)
Eye : pupil round, isocor 3/3 mm,light reflex +/+
Thorax : normal breathing, Rh-/-, Wh -/normal heart sound, murmur (-),gallop (-)
Abdomen : unpalpable liver and spleen, ascites (-)

CLINICAL FINDINGS
Cranial Nerves : difficult to assest
Motoric

Sup Inf

Movement /
Strength
Tonus

cant be assest, hemiparese bilateral spastik

hipertonus/hipertonus hipertonus/hipertonus

TrophyE/E E/E
FR

++/++

PR -/--/+(B,C)
Clonus

-/-

++/++

CLINICAL FINDINGS
Sensibility : cant be assest
Vegetative : normal

Laboratorium

Osm : 2(138+4.0)+ (163:18)+(30:6)=298.5

FD : 298.5-295 xO,6x6O= 0.3 L
295

ECG

Thorax
No Tuberculosis
imaging,
Cor is normal

MRI LUMBAL

Impression
Spondilolistesis L4-5
HNP L3-4,L4-5, L5-S1
Spondilosis Lumbal
Buldging L2-3

DIAGNOSIS
I. Clinical Diagnosis
unconsciousness
Hemiparese Bilateral Spastic
Topical Diagnosis
Corona radiata
Etiologic Diagnosis :
Reccurent Stroke Infarction
II. HT Stg II
III. Sinus Bradicardia

INITIAL PLANS &

THERAPY

1. Consult to Cardiologist,
Ophtalmologist,Physical Medicine and
Rehabilitation
2. Therapy :
1. O2 Nasal canul 3 lpm, head up 30 degree
IVFD : RL 20 drop per minutes

Inj Ranitidine 50 mg/12 ho IV

Aspilet 80 mg/24 h.o p.o
Vitamin B1B6B12 1 tab/8 hours p.o

 MONITORING :
GCS, vital signs, neurologic deficits, fluid
balance
EDUCATION :
diagnosis, management, complications,
prognosis

THANK YOU