Morning Report

Departement of Neurology
H27 Muhammadiyah Lamongan Hospital
LIST OB

Ny. N CVA Not specified as haemorrhage or infark Marwah 17

Tn P CVA Not specified as haemorrhage or infark Zam-zam
Tn. D CVA bleeding, IVH, ICH dengan hidrocephalus OK
Identity

Name : Tn. D
Age : 60 y.o 2 months 7 days
Address :Lamongan
Religion : Moslem
Admission : March, 8th 2017
Anamnesis

Chief Complain : loss of consiousness

Present illness History :
the patients family complain: Patient brought by his family to
RSML with loss of consiousness suddelny since 5 hours before
addmision. He found in farm by his family and cant wake up till
now. Then patients brought by his family to BP Sugiyo 3 hours
before admission to RSML. Then patient given Antrain, Ranitidin
and NSB drip by BP Sugiyo. Headache Naussea- Vommit Cough +
2 since a week ago
 Previous illness history:
uncontrol HT and DM (-), Lung TB, Defecation normal,
urinary normal
Family illness history: (-)
Social History : Farmer
Physical Examination

GCS 113
Vital Sign
BP 166/65mmHg
HR 84x/min
RR 37x/min
Temp 38.1C
Primary survey
A :clear, gargling (-), snoring (-), speak frequently
(-), potential obstruction (-)
B :spontaneous, RR 37x/mnt, ves/ves, rh +/+, wh
-/-, O2 saturation97% with NRM
C :acral dry red warm, CRT < 2, N 84 x/mnt, BP
166/65 mmHg
D : GCS 113, lateralisation (D), PBI 3mm/3 mm, RC +/
+
E : Temp 38,10C
 Secondary Survey
GCS 113
K/L a - / i - / c - / d + , lymph S +
Tho symetris, retraction (-)
P : ves/ves, Rh +/+, Wh -/-
C: S1S2 single, murmur (-), Gallop (-)
Abd flat, met(-) ,H/L unpalpable
Ext Lateralitation + Sinistra
Neurological Examination

Head : Position: Normal, middle

Mass : Left Neck
Shape | size : normal | normal
Auskultation : normal

Nervus Cranialis :
N.I (Olfaktorius)
Smell sensasion : couldnt evaluated
N.II (Optikus)
Visual acuity : couldnt evaluated
Field of vision : couldnt evaluated
Funduscopy : couldnt evaluated
 N. III (Okulomotorius)
slit eye: Ptosis : couldnt evaluated
Exoftalmus : -/-
Movement of eye ball : couldnt evaluated
Pupil : Pupil round isokor 3/ 3 mm
Light perception : direct : + | + non-direct :+|
+
nistagmus : couldnt evaluated

N.IV (Troklearis)
Position of eye ball : sde
movement of eye ball : sde
 N.VI (Abdusen)
movement of eye ball : sde
N.V (Trigeminus)
Sensibility : N. V I : sde
N. V II : sde
N. V III : sde
Motorik :
Inspeksi: couldnt evaluated
Palpasi : couldnt evaluated
chewing : couldnt evaluated
Bitting : couldnt evaluated
Reflek masseter : couldnt evaluated
Reflek cornea : couldnt evaluated
 N.VII (Fasialis)
Motorik:
sde

N.VIII (Vestibulokoklearis)
Tes weber : couldnt evaluated
Tes Rinne : couldnt evaluated
 N.IX (Glossofaringeus)
taster 1/3 (back side): not evaluated
sensibilitas faring : not evaluated
N.X (Vagus)
the arc of arcus faring : not evaluated
Reflek swallow/vomit : not evaluated
N.XI (Acsessorius)
Shruging : not evaluated
Looked away : not evaluated
N.XII (Hipoglossus)
normal
 Meningeal Sign
KK (-), Brudzinski 1,2 (-) kernig -

Physiologic Reflex
BPR : +2 | +2
TPR : +2 | +2
KPR : +2 | +2
APR : +2 | +2

Patologic Reflex
Hoffman : - | -
trommer : - | -
Babinski : -|-
 Motorik
sde /sde
sde /sde
Lateralitation + Sinistra

Sensorik sde
 Laboratorium
Basofil 1.9 (0-1)
GDA 125
Eritrosit 4.39 (3,8-5,3
Kalium serum 3.6(3,6-5,5) Hb 11,6(P 13-18 L 14-18)
Natrium serum 137(135-155) Hct 36 (L 40-54 P 35-47)

Clorida serum 103( 70-108) MCV 82 (87.00-100)

MCH 26,4 (28.00-36.00)

Urea 24 (10-50)
MCHC 32,20(31.00-37.00)
Serum creatinin 0.9 (P 0,7-1,2 L 0,8-1,5) RDW 12 (110-16,5)
SGOT 17 ( L 37-P 31) Trombosit 240(150-450

SGPT 19 (L 41, P 31) MPV 4 (5-10)

LED 1 : 9 (0-1)
Leukosit 127 (4 -11)
LED 2 : 25 (1-7)
Neutropil 88.6 (49-67) PT: 14 (10,3-16,3)
Limfosit 5,2(25-33) APTT: 26,40 (24,2-38,2)

Monosit 2,1 (3-7)

Eosinophil 3,3 (1-2)
Clue and cue

male 60 y.o 2 months 7 days

Loss of consiousness
Lateralisasi sinistra
In activity
Uncontrolly HT
 Diagnosis

Clinical Diagnosis

Diagnosis Topis

Etiological Diagnosis
female 50 y.o Hemisfer CVA
3 months 22 sinistra hemoragic
days
Loss of
consiousness
Lateralisasi
dextra
dizzines
In activity
convulsion
Planning Diagnosis

DL
Head MS CT without contrast
Planning Therapy

General Therapy Spesific Therapy

02 masker 10 lpm

INF Asering 1500cc/24jam

Inj Manitol 200 6
Inj santagesic 3x1 gr IV

Inj acran 2x50mg iv

x 100
Inj ondancentron 3x1

Inj terface 2 gr
Inj Sitikolin 250
Kateter volley

NGT
mg/8jam
Planning Monitoring

Vital sign
GCS
Subjective complaints of patients
Input and output fluid
Planning Education

Explain to the family about diagnose Explain to the family about

planning diagnose CT Scan
Risk Factor
Therapy
Complication
Prognose