MORNING REPORT

Thursday, June 25, 2019

SMF NEURO
DM : Lintan Kurnia Farziqi / 6120018047
MEDICAL SPECIALIST:Shobihatus syifak, dr., SP.S
 Identitas Pasien
• NAME : Ny R
• AGE : 49 y/o
• GENDER : Women
• MARRIAGE STATUS : Married
• OCCUPATION : factory workers
• No RM :
• ADDRESS : Surabaya
• EXAMINATION DATE : June 25, 2019
 ANAMNESIS
• MAIN COMPLAINT
– Dizziness
• Current history
Patients come with complaints of headache, headache is felt for about 1 week. Location of
headache in all parts of the head and radiating to the eyes as pressed, does not improve at
rest, patients complain of nausea. Patients claim to limp. while having lots of thoughts,
eating and drinking also diminishes. The patient has a history of high blood pressure but
does not consume the drug. The tingling is denied, chest pain is denied. Defecation and
urination within normal limits, ringing is denied, views like rainbows are denied.
• Past medical history :
– Hypertension
• Family history : There are no family members of
patients who experience similar complaints
 OBJECTIVE
• PHYSICAL EXAMINATION
– General state : weak
– Awareness : Compos mentis
– GCS : 456
• TTV
BP : 165/87 mmHg
Pulses : 90x/min, regular
RR : 20x/min
Temperature : 36,5°C
 NEUROLOGY EXAMINATION
• MMT Right Left
5 5
5 5
• NERVUS CRANIALIS
• N I : not evaluated
• N II : VOD/VOS >1/60,lapang pandang normal,tes warna normal
• N III : Ptosis sinistra (-), PBI 3/3mm, RCL (+/+), RCTL (+/+)
• N III/ IV/VI : Normal eye movement, Nistagmus (-)
• N V : Within normal limit
• N VII : Within normal limit
• N VIII : Within normal limit
• N IX/X: Within normal limit
• N XI : Within normal limit
• N XII : Within normal limit
• FISIOLOGI REFLEX PRIMITIF REFLEX
– BPR : +2 / +2
– TPR : +2 / +2 • Refleks palmomental :-
– KPR : +2 / +2 • Refleks Glabella :-
– APR : +2 / +2
• PATOLOGICAL REFLEX Meningeal Sign :
Refleks Babinski : -/-
Refleks Chaddock : -/-
Refleks Oppenheim : -/-
Refleks Gordon : -/-
Refleks Schaffer : -/-
Refleks Gonda : -/-
Refleks Stransky : -/-
Rosolimo : -/-
Mendel Bachterew : -/-
Hoffman : -/-
Tromner : -/-
 Supporting Examination
• Complete Blood
• Serum Electrolit
• Rapid Glucose
• Electrocardiogram

8
 Leukosit 7.46 ribu/uL
3,8-10,6 ribu/uL

Basofil 1.543% 0-1 %

Neutrofil 65.63% 39,3-73,7 %
Limfosit 19.530% 25-40%
Complete Eusinofil 5.324% 2-4 %
Blood Monosit 7.969% 2-8 %
Eritrosit 4.80 juta/uL
4,4-5,9 juta/uL

Hemoglobin 14.38 g/dL

13,2-17,3 g/dL

Hematokrit 44.5 % 40-50 %

Trombosit 277 ribu/uL
150-440 ribu/uL
9
 Neurological Diagnosis
• Clinical Diagnosis • Differential Diagnosis :
Dizziness like pressure, nausea Migrain
• Secondary Diagnosis :
Topic Diagnosis : • Hypertension urgency
pericranial muscle
,craniocervical
• Etiology Diagnosis :
Tension type Headache-TTH
Subjective Objective
SOAPAssesment Planning
• Headache 7 days PHYSICAL EXAMINATION Clinical Diagnosis PLANNING DIAGNOSIS
• As in press, spread to the eye, General State : weak Dizziness like pressure, nausea BUN SK, OT, PT,, Foto Thorax,
• The neck and shoulders feel Awareness :compos Topic Diagnosis : pericranial Cholesterol total, LDL, HDL, TG,
stiff mentis muscle ,craniocervical uric acid,SE
• (+) Nausea GCS 456 Etiology Diagnosis :
• (-) Vomitting TTV Tension type Headache-TTH PLANNING THERAPHY
• (-) headache BP: 165/85 mmHg Differential Diagnosis : Infus RL 14tpm
• (-) fever Pulses: 90x/min, regular Ranitidin 2x1 ampul
Migrain
• (-) Chest pain. RR: 20x/min Ondancentron 2x1 ampul
Secondary Diagnosis
• Defecation and urination Temperature: 36,5°C Amplodipin tab 5mg 0-0-1
within normal limits.
Hypertension urgency Ketoprofen 25mg 3x1tab
MMT : 5 /5 , 5/5 Amitriptilin 25mg 1x1 tablet
• Hypertension Depakote 500 mg 1x1 tablet
NERVUS CRANIALIS:
Within normal limit DIET
Calori 30 – 50 ccal/Kg weight

EDUCATION and
COMMUNICATION
Adequate rest, avoid stress, low-
salt, pemijatan untuk mengurangi
serangan,memperbaiki postur
yang kurang benar 11
JAZAKUMULLOH
KHOIRON KATSIR