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August 6 , 2016
th
DEPT OF NEUROLOGY
G26
DAFTAR OB NEURO
Tn. kastilan
Ny. sukaini
Ny. Suliyah
Tn. Harjito
cva bleeding
paraparese
cva
cva
Marwah 16
Marwah 12
Identity
Name
: Mr. H
Age
: 50Th years old
Occupation : farmer
Address
: Trepan RT 1 RW 1, babat,
lamongan
Admission : August 6th, 2016 at
03.03 PM
Chief Complaint
Hemiparesis Sinistra
Present history
Patient complained paresis left limb and arm since 12 hours
before admited to hospital. Patient also complained loss of skin
sensitivity on his left limb and arm like tiggling. Never been like
this before. eating + and drinking + in a normal way, do not choke.
Defecation + and micturition +.
Patient felt weakness (+), vomiting (-), nauseous (-), konvulsi (-),
fever (-), loss of consiousness (-)
Defecation within normal limit and micturition felt normal limit.
Family history
HT (-). CVA (-). DM (-)
Social history : -
Vital Signs
BP
186/112 mmHg
Pulse
Temp
36,2 C
RR
21x/min
: compos mentis
: 456
: a -/i-/c-/d lymph node enlargement at neck (-)
JVP within normal limit
Thorax
Inspection
Symmetrical, retraction -
Palpation
Percussion
Auscultation
Abdomen
Inspection
flat
Auscultation
Palpation
Pain (-)
Liver/Spleen within normal limit
Percussion
Tymphany
Extremities
Inspection
Palpation
Status Neurologic
GCS: 456
Meningeal sign:
Kaku kuduk
Kernig -/Brudzinski 1,2 -/-
Nervus Cranialis:
Fisiologic reflex:
BPR +2/+2
TPR +2/+2
KPR +2/+2
APR +2/+2
Patologic reflex:
inf 5/3
Sensoric: Hemihipestesi
sinistra
Planning Diagnosis
CBC
ECG
Thorax Photo
Laboratory Findings
Eritrosit
Hb
5.62
15.2
LED
1
LED2
2
Limposit
23
Basofil
1.0
Eosinopil
6.8
Hematokrit 47.8
Leukosit
5.9
MCH
31.8
MCV
85.10
MCHC
31.80
Monosit
4.7
MPV
4
Neutropil
64.5
RDW
11
Trombosit
239
GDA
102
Diagnosis
Diagnosis:
Planning Therapy
O2 nasal kanul 3-4 lpm
IVFD asering 1500cc/24 hours
Inj. antrain
3 x 1gr iv
Inj. citicolin 3x250mg
Inj. Ranitidin
2x50mg
Inj. Ceteron
3x 8 mg
PLANNING MONITORING
Vital Signs
Patients complaint
Adverse effect
DL
PLANNING EDUCATION
Explain to the patient and his family about the
Thank You