Morep IGD Ayie 8jan2013
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Transcript of Morep IGD Ayie 8jan2013
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MORNING REPORT
Neurology D-18
Monday, January 6th
2013
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Patient Identity
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ANAMNESIS
Chief complaint: unconscious
Present illness history: familys complained that
Mr.S had unconscious in his house, because
Mr.S live alone nobody from the familys knowsince when this unconscious has started.
Previously familys told Mr.S had headache, this
complaint arise frequently and more increasingly
day by day. During came to hospital Mr.S hasright half of the body spasm once. Vomiting (-),
nausea (-), fever (-)
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Previous Illness History
Hypertension (+) denied DM (-)
Family History of Disease
None of family have the same illness
Sociality History
Patients is a heavy smoker
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General Physical Examination
Awareness : 2x4(sensory aphasia)
BP: 158/103 mmHg
pulse: 63x/minutes
Temp: 36.2 CRR: 20x
Status Present
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Thorax
Inspection: symmetrical chest wall movementPalpation: fremitus + / +Lung:
Percussion: sonor / sonorAuscultation: vesicular / vesicularheart:Percussion: V ICS parasternal right limit dex,
the left boundary of V mid clavicula sin ICS, ICSII upper left parasternalAuscultation: S2 S1 single murmur (-) Gallop (-)
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Abdomen
Inspection: flatPalpation: soepel, tenderness (-)Percussion: Tympani
Auscultation: BU (+) N
Liver: no palpableLien: no palpable
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Psychological Status
Affective and emotional: within normal limitsThe process of thought: within normal limits
Intelligence: within normal limitsAbsorption: within normal limitsWillpower: within normal limitsPsychomotor: within normal limits
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Neurological Status
head:Position: normocephaliProtrusion: (-)
Shape / size: normal impression Subconjunctival bleeding OD
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Cranial Nerve
N.I (olfactory)Smelling: dte/dte
N.II (optic)
Visual acuity: dte / dteField of view: dte / dteFunduscopic: not evaluated
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N.III (okulomotorius)Ptosis: - / -
Eksoftalmus: - / -Eye movements: dte/ dteSize: 3mm/3mm, isokorLight reflex: + / +
N.IV (trokhlearis)The position of the eye: ortoforia / ortoforiaEye movements: dte / dte
N.VI (abduscen)eye ball movement : dte / dte
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N.V (trigeminal)sensibility:
V1: dte / dteV2: dte / dteV3: dte / dtemotor:
Inspection: dte / dtePalpation: dte / dteChewing: dte / dteBiting: dte / dte
Reflex chin / masseter: dteCorneal reflexes: + / +
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N.VII (fascialis)parese N.VII left central type
N.VIIISeconds watches: dte / dteVoice whispered test: dte / dteTest weber: not evaluated
Rinne test: not evaluated N.IX (glossofaringeus)
Taste: dte
N.X (vagus)
Pharyngeal arch Position: dte / dteVomiting reflex: +
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N.XI (accessory)Shrug: dte / dte
Turning heads: dte / dte N.XII (hipoglosus)
Devisasi tongue: dte / dteFasciculations: dte / dte
Tremor: dte / dteAtrophy: dte / dte
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Neck
Inflammatory markers meningesStiff neck: -Kernig's sign: -
Carotid Artery: + / +Palpation: strong palpable / strong palpableAuscultation: cranial, cervical bruit (-) / cranial,cervical bruit (-)
Thyroid: - / -
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Abdomen
Abdominal wall skin reflexes
vertebral columnInspection: wnl
Palpation: wnl
Movement: wnlPercussion: wnl
+ -
-+
+ -
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extremity
motorMovement: dte (lateratation to left) Strength :dte dte
dte dte Muscle tone:
Spastic: - / -
Rigidity: - / -Klonus knee: - / -Klonus Achilles: - / -
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Physiological reflex:BPR: N/TPR: N/KPR: N/APR: N/
pathological reflexesHoffman tromer: - / + Gordon: - / +Babinzki: - / + Schaefer: - / +Chaddock :-/ + Oppenheim: - / +
Mendel B: - / + Rossolimo: - / +
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sensibilityEksteroseptif:Pain: dte / dteTemperature: dte / dteTouch: dte / dteproprioceptive
Shakes: dte / dtePosition: dte / dteFlavor combinations (combine sensation)Stereognosis: dte / dte
Barognosis: dte / dte
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Male, 61th
unconscious
Nausea (-)
Vomit (-) Hypertension
Heavy smoker
Hemiparese sinistra
Parese N. VII left central type
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Male, 61h, admission to Muhammadiyah Lamongan
hospital unconscious, nausea and vomit (-). From physical
examination, found BP 158/103 mmHg, HR 63 x/mnt.
From neurological examination, hemiparese dextra,
Parese N. VII left central type, increasing of left sidebodys physiology reflect, positively of left side bodys
pathology reflect.
From summary above : SIRIRAJ SCORE (2,5x0) + (2x0) + (2x0) + (0,1x103)
(3x1)12 = -4.7 < -1
CVA infark
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Clinical diagnosis
hemiparese dextra, Parese N. VII left central type,increasing of left side bodys physiology reflect,
positively of left side bodys pathology reflect.
Topis diagnosis
a. Cerebri media
Etiologic diagnosis CVA infark
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Head CT scan without contrast X ray Thorax CBC
Random blood glucose test ECG electrolytes
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RADIOLOGICAL
FINDINGS
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LABORATORY OF RESULTS Diffcount : 6/0/67/21/6 Hct: 43.2% Hb: 15.2 mg/dL LED: 8/17 Leucocytes : 8.300 Trombosite: 171.000
OT / PT: 17/28 U/L Albumin: 3.7 mg% Globulin: 1.9 gr% Total protein: 5.6 mg%
Chloride serum: 105 mol/l Calium serum: 4.0 mmol/l Natrium serum: 136 mmol/l Serum creatinin 0.8 mg/dl Urea: 22 mg/dl
Uric acid: 5.1 mg/dl
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O2 nasal 2 lpmIVFD RL 1500 cc / 24 hrInj. Metamizole 3x1 grInj. Ranitidine 2x 50 mg
Inj. Piracetam 4 x 3 grInj. Citicoline 3x250 mgInj. Arixtra 1x1P.O Plavic 3ddI
Foley cathether
ConsultSp.S
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Vital sign, subjective complaints of patients
Explain to the family about the disease of thefamily, about its therapy and intervention will bedone, and also about its complication andprognosis (dubia ad bonam)