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Neurology Departement
April, 07 th 2014
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Identify PatientName : Mrs !
Age : "# years old
!e$ : %emaleAddress: &amongan
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Anamnese'hief (omplain: )ea*ness the right part of +odyPresent illness historythe )ea*ness has +een felt sin(e 2 hour +efore ta*e
to the hospital, suddenly )hen a(tiity -eada(e./,Nausea ./, omit ./, seiure ./, feer ./Defe(ation and mi(tion normal Disathria
Past illness history-3 . )ith sistoli( +lood pressure 170 in(ontrolled,
DM ./,history of stro*e atta(* ./
%amily illness historyNone of family have the same illness
!o(ial illness history : ./
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Vital sign :Vital sign :
BP : 1BP : 154/8454/84 mmHgmmHg HR :HR : 8787 x/mntx/mnt
RR : 2RR : 222 x/mntx/mnt T :T : 5!"5!" #$#$
%ene&al examination :%ene&al examination :
Hea'(ne)*Hea'(ne)* : a/i/)/': a/i/)/' ((/(/(/(/(/(/(
Tho&ax :Tho&ax :
simet&is +,-! &et&a)tion +(-! sono&/sono&! vesi*.le&/vesi*.le&!simet&is +,-! &et&a)tion +(-! sono&/sono&! vesi*.le&/vesi*.le&!
1 2 solita&y! m.&m.& +(-! gallo0 +(-1 2 solita&y! m.&m.& +(-! gallo0 +(-'omen :'omen :
flat! soefl! intestinal so.n's +,- no&mal! 3ive& an' s0leen a&eflat! soefl! intestinal so.n's +,- no&mal! 3ive& an' s0leen a&e
not 0al0alenot 0al0ale
xt&emitas : 6a&m! '&y! an' &e'! e'ema +(-xt&emitas : 6a&m! '&y! an' &e'! e'ema +(-
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ffe)t an' emotionffe)t an' emotion : ithin no&mal limit: ithin no&mal limit
Thin*ing 0&o)essThin*ing 0&o)ess : ithin no&mal limit: ithin no&mal limitntelligen)entelligen)e : ithin no&mal limit: ithin no&mal limit
6illingness6illingness : ithin no&mal limit: ithin no&mal limit
Psy)homoto&Psy)homoto& : ithin no&mal limit: ithin no&mal limit
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Neurologi(al $amination
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N. I (Olfactorius)N. I (Olfactorius) : ithin no&mal limit: ithin no&mal limit
N. II (Opticus)N. II (Opticus) ::
Vis.sVis.s : ithin no&mal limit: ithin no&mal limit
Vis.al fiel'Vis.al fiel' : ithin no&mal limit: ithin no&mal limit
9.n'.s)o0y9.n'.s)o0y : )annot e eval.ate': )annot e eval.ate'
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N. III (Okulomotorius)N. III (Okulomotorius) ::
PtosisPtosis : ( / (: ( / (
exoftalm.sexoftalm.s : ( / (: ( / (eye movementeye movement : ithin no&mal limit: ithin no&mal limit
P.0ilP.0il : mm/mm! &o.n'e'! iso*o&: mm/mm! &o.n'e'! iso*o&
3ight &efle)t3ight &efle)t : ,/,: ,/,
N. IV (Trochlearis)N. IV (Trochlearis) ::eye 0ositioneye 0osition : o&tofo&ia: o&tofo&ia
eye movementeye movement : ithin no&mal limit: ithin no&mal limit
N. VI (Abducen)N. VI (Abducen) ::
eye movementeye movement : ithin no&mal limit: ithin no&mal limit
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N. V (Trigeminus)N. V (Trigeminus) ::
ensiilityensiility : N V1: N V1 : ithin no&mal limit: ithin no&mal limit N V2N V2 : ithin no&mal limit: ithin no&mal limit
N VN V : ithin no&mal limit: ithin no&mal limit
oto&i*oto&i* ns0e)tion : ithin no&mal limitns0e)tion : ithin no&mal limit
Pal0ation : ithin no&mal limitPal0ation : ithin no&mal limit
)heing : ithin no&mal limit)heing : ithin no&mal limit
iteite : ithin no&mal limit : ithin no&mal limit
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N. VII (Facialis)N. VII (Facialis) ::
enso&i*enso&i* : not eval.ate': not eval.ate'
oto&i*oto&i* :: 9&ontalis 9&ontalis : : ithin no&mal ithin no&mal limitlimit
;li<.e o).li : ;li<.e o).li : 0a&ese N V )ent&al 'ext&a0a&ese N V )ent&al 'ext&a
oli<.e o&is oli<.e o&is :: 0a&ese N V )ent&al 'ext&a0a&ese N V )ent&al 'ext&a
N.VIII (acusticus) :N.VIII (acusticus) :
ithin no&mal limit ithin no&mal limit
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N. I! ("#O$$OFA%IN"&'$! VA"'$)N. I! ("#O$$OFA%IN"&'$! VA"'$) ::
senso&y 1/ 0oste&io&senso&y 1/ 0oste&io& : not eval.ate': not eval.ate'
a&).s 0ha&yn* 0ositiona&).s 0ha&yn* 0osition : )ent&al: )ent&al&efle* m.ntah&efle* m.ntah : not eval.ate': not eval.ate'
N.I (accecorius) :N.I (accecorius) : not eval.ate'not eval.ate'
N. II (ipoglossus)N. II (ipoglossus) :: Pa&ese N = )ent&al 'ext&aPa&ese N = )ent&al 'ext&a
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Affect and emotionAffect and emotion : ithin normal limit: ithin normal limit
#anguage abilit*#anguage abilit* : ithin normal limit: ithin normal limit+emories+emories : ithin normal limit: ithin normal limit
VisuospatialVisuospatial : ithin normal limit: ithin normal limit
IntellegenceIntellegence : ithin normal limit: ithin normal limit
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'lue and 'ue9emale!"> y&
0a&aly?e half of o'y +&ight 0a&t-
Pa&ese N V $ent&al 'ext&a
Pa&ese N = $ent&al 'ext&a
a).t onset
BP 154/84 mmHg
Past histo&y illness : Hi0e&tension +,- @ +(- t&o*e +(-i&i&aA s)o&e
+2!5x-,+2x-,+2x-,+1x84-(+x-(12C (!"
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Assessment'lini(al Diagnose
-emiparesis de$tra, a(ute onset )hen a(tiity,parese n5II and 6II (entral de$tra, -3 .
3opi( Diagnose
-emisfer sinistra
tiologi( Diagnose
'5A leeding
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Planning DiagnoseD&
'8
&ipid Pro9le6/ay 3hora$
'3/!(an
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CT SCAN
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FOTO THORAX
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&a+oratorium esult
• Di;(ount <=0=70=22=>
• -(t <7,0
• &D21=4"
• -+ 12,4 g=dl• &e*osit 4?00
• 3rom+osit 1?0000
• !8@3 1>
• !8P3 12
• rea <1
• !erum (reatinin0,7
8DA ?#'holesterol 17<
-D& 47,<
• &D& 100,"
• 38 7<
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Planning 3herapy
>BB@2 nasal 4 lpm
%oley (athether
I5%D asering 1000 (( = 24 hr
InC !antagesi( <$1 ampInC A(ran 2$1 amp
InC rain a(t <$1 amp
'= !p!
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5ital signNeurologi( disorders
$plain to the family a+out the disease of thefamily, a+out its therapy and interention )ill+e done, and also a+out its (ompli(ation andprognosis du+ia at +onam
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