MORNING REPORT

Department of Neurology
5.02.2016
F23

Identity
Name: Mr. Kasmiin
Age: 60 yo
Address: gedangan, lamongan
Pekerjaan: farmer
Date examination: 5/02/2016

Anamnesis

Chief complain: loss of consciousness

Present Illness History: patients referral from pku

parengan coming to the emergency room RSML with loss

of consciousness since 13.00 ( 4 hours SMRS ) . Initially
patients after clean the house complained of headaches
and vomiting . 5x vomiting food contents . seizures - ,
loss of speech Previous Illness History:
- never like this before
- History of hypertension one year ago is not routine
control and take medication
- history of dibates melitus denied
Familly Illness History = his mother have hypertension +
Social Illness History: patients do not smoke . daily
consumption of coffee

PHYSICAL EXAMINATION
VITAL SIGN :
GCS
: 3x6
BP
: 163/96 mmHg
PULSE RATE
: 36.5x / minutes regular
TEMP
: 36,5oC
RR
: 20x / minutes

Primary Survey
A: clear, gargling (-), snoring (-), speak

fluently (+), potential obstruction (-)

B: spontan, RR 20x/mnt, ves/ves, Rh -/-, Wh
-/-, SaO2 99% without O2 support
C: akral warm dry red, CRT <2, PR
106x/mnt, BP 163/96 mmHg
D: GCS 3x6, lateralisasi -, PBI 3mm/3mm
E: temp 36,8 C

Secondary Survey
GCS 3x6 afasia motorik
H/N: aicd
Tho: sim, ret -/-

P: ves/ves; rh -/-, wh -/C: S1S2 single, murmur -, gallop

Abd: Soepel, met -, H/L not palpaple,
BU+N, pressing pain: sde
Ext: aie -, akral warm dry red

Neurology Status
1. Head :
Position
: Normal,
middle
Mass: Shape | size
: normal | normal
2. Nervus Cranialis :
N.I (Olfaktorius)

Penghidu : not evaluated

N.II (Optikus)

Visual acuity : hard to evaluated

Field of vision : hard to evaluated
Funduscopy
: not evaluated

 N. III (Okulomotorius)

slit eye

: Ptosis

: -| -

Exoftalmus
: -| Movement of eye ball : sde
Pupil
: Pupil round isokor 3 / 3 mm
Light perception : direct : + | +
non-direct
:+|+
nistagmus : - | N.IV (Troklearis)
Position of eye ball : normal | normal
movement of eye ball : sde

 N.VI (Abdusen)

movement of eye ball

: sde
N.V (Trigeminus)
Sensibility:
N. V. 1
: sde
N. V.2
: sde
N. V.3
: sde
Motorik :
Inspeksi : symmetris
chewing : sde
Bitting
: sde
Reflek masseter
: not evaluated
Reflek cornea : sde

 N.VII (Fasialis)

Motorik:
m. frontalis
: sde
m. orbikularis okuli : sde
m. oblik oris
: sde
sulcus nasolabialis : dextra
tertarik/mendatar
taster of 2/3 front tongue : not evaluated
N.VIII (Vestibulokoklearis)
watch
: hard to evaluated
whispered voice : hard to evaluated
Tes weber : not evaluated
Tes Rinne : not evaluated

N.IX (Glossofaringeus)

taster 1/3 (back side)

: not evaluated

sensibilitas faring
: not evaluated
N.X (Vagus)
the arc of arcus faring: hard to evaluated
Reflek swallow/vomit : hard to evaluated
N.XI (Acsessorius)
Shruging

: not evaluated

Looked away
N.XII (Hipoglossus)

: not evaluated

Tongue deviation
: hard to evaluated
Fasiculation, Tremor, Atrofi : hard to
evaluated

 Neck
Sign of Menigeal infection:
Kaku kuduk
: negative
Brudzinski I dan II : negative,
negative
Kernig
: negative
Kelenjar lymphe : bulge (-)
Kelenjar gondok : bulge (-)
Abdomen
Reflek kulit dinding perut:
+
++ +
++ +

Ekstremitas
Motorik
Movement
Strength
Tonus

:
:
:
:

lateralisasi dextra
normal
hard to evaluated
normal

Reflek fisiologis
BPR
: +2 | +2
TPR
: +2 | +2
KPR
: +2 | +2
APR
: +2 | +2

Reflek patologis
Hoffman-tromner
Babinski
Chaddock
Gordon
Schaefer
Oppenheim

:
:
:
:
:
:
:

|
|
|
|
|
|

Trofi
: -|Sensibilitas
Eksteroseptif
Pain
: not evaluated
Temperature
: not evaluated
Rasa raba halus
: not evaluated
Proprioseptif
Rasa sikap
: not evaluated
Rasa nyeri dalam : not evaluated

Fungsi kortikol
Discrimination function
Stereognosis

: not evaluated
: not evaluated

Barognosis
Abnormal spontan

: not evaluated

: not evaluated

Impaired coordination
Tes finger nose
: not evaluated

not evaluated
: not evaluated

Tes pronasi supinasi :

Tes knee to toe

Siriraj score: (2,5x1) + (2x1) +

(2x1) + (0,1x96) (3x1) 12 = 1,1
(>1 cva bleeding)

Planning Diagnose
Random Blood Glucosa
Complete bood count
SGOT/SGPT
SE
Urea/Creatinin
LP bila tanda peningkatan TIK (-)
CT Scan kepala tanpa kontras
Thoraks AP

Lab.
Exam

Eritrosit 5,06 (3.80

5.30)
Hemoglobin 15,6 (1418)
LED 1 117 (0-1)
LED 2 25 (1-5)
Limfosit 12,9 (25.0-33)
Basofil 1,7 (0-1)
Eosinofil 4,8 (1.0-2.0)
Hematokrit 47,1 (40.054)
Leukosit 21,6 ( 4.011.0)
Neutropil 81,7 (49,0-

MCV 87.60 (87.00100.00)

RDW 11 (10-16,5)
Trombosit 299 (150450)
Monosit 4,3 (3.0-7.0)
MPV 3 (5-10)
GDA 151
Urea 29 (10-50)
SC 1,3 (0,8-1,5)
OT/PT: 31/32 (37-41)
Clorida serum 108
(70-108)
Kalium serum 4,0
(3,6-5,5)

Tampak lesi
hiperdens di
brain
parenchym
pons uk
19x15x20
mm
kesimpulan:
ich pons

Assesment
Dx. Klinis:

hemiparese dextra, parese n7 dextra type

central
Dx. Topis:
pons
Dx. Etiologis:
Dx Utama: CVA bleeding
DD: intracranial hemoraghe
subarachnoid hemoraghe

Therapy
O2 nasal 3lpm
Head up 30
Pasang DC
Inf. asering 1500 cc/24jam
Loading manitol 200 cc 6x100 cc
Inj. Metamizole 3x1 gr
Inj. Ranitidin 2x50 mg
Inj. Ceftriaxon 2x1 gr
Inj. Citicolin 3x250 mg
c/Sp.S

Monitoring
General state
Vital sign
Patients complaints
Intrakranial Pressure sign