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MORNING REPORT

NEUROLOGY F-23

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PATIENT IDENTITY Name : Mr. Mudhofar

Age : 53 yo

Religion : Moslem

Occupation : farmer

Residence : gunungsari bojonegoro

Observe : 3 !anuary "#$

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ANAMNESIS

Chief complai! :%ea& of body

P"e#e! ille## hi#!o"$:

patients complained %ea& of right bodysince

"".## pm' the patient suddenly complained of%ea&ness after %a&ing. %ea& body is

accompanied by loss of speech. the patient had

never felt li&e this. Nausea (' vomiting ")

contents of food. patients also complain ofheadache

P"e%io Ille## 'i#!o"$ :*M +' ,-(

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ANAMNESIS amily ,istory of *isease

/+0

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1ital sign:

2:"436mm,g

,R: 64 )mnt

RR: "# )mnt -emp: 3$'7#8

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STATUS PRESENT

rimary survey:

A : clear' gargling /+0' snoring /+0' spea&

fre9uently /(0' potential obstruction /+0

2 : spontaneous' RR "#)mnt' vesves' rh++' %h ++' O" saturation 77 %ithout

support

8 : acral dry red %arm' 8R- ; "

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>econdary survey:

=8> 3?5

,N : a + @ + c +d+CBnlargement of ymph

node + -ho : simestris' ret ++

: vesves' rh ++' %h ++

8 : >>" single' murmur /+0' gallop /+0

Abd : >oepel' met +' bo%el loudness /(0 N'

, unpalpable'

B)tr: aie +' acral dry red %arm

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NEUROLOGY STATUS. ,ead : osition : Normal' middle

Mass : +

>hape D siEe : normal D normal

Aus&ultation : bruit a. carotis/+0

". Nervus 8ranialis :

N.@ /Olfa&torius0

enghidu : Normal

N.@@ /Opti&us0

1isual acuity : normal

ield of vision : normal

unduscopy : not evaluated

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N. @@@ /O&ulomotorius0

slit eye: tosis : +D +

B)oftalmus : +D +

Movement of eye ball : normal

upil : upil round iso&or 3 3 mm

ight perception : direct : ( D (

non+direct : ( D (

nistagmus : ( D (

horiEontal

N.@1 /-ro&learis0

osition of eye ball : normal D normal

movement of eye ball :normal

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N()I *A+,e

movement of eye ball : normal

N() *T"i.emi

>ensibility : N. 1 @ : normal

N. 1 @@ : normal

N. 1 @@@ : normal

Motori& :

@nspe&si : symmetris

alpasi : normal

che%ing : normal

2itting : normal

Refle& masseter: normal D normalRefle& cornea : ( (

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N.1@@ /asialis0

Motori&:

m. frontalis : normal

m. obli& o&uli : normal

m. obli& oris : normal

taster of "3 front tongue : not evaluated

N()III *)e#!i+&lo/o/lea"i#

%rist %atch : hard to evaluated

%hispered voice: hard to evaluated

-es %eber : not evaluated-es Rinne : not evaluated

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N.@? /=lossofaringeus0

taster 3 /bac& side0: not evaluated

sensibilitas faring : hard to evaluated N.? /1agus0

the arc of arcus faring: symmetrical D symmetrical

/rest DAA,0 : hard to evaluated

Refle& s%allo%vomit : normal D normal N.?@ /Acsessorius0

>hruging : hard to evaluated

oo&ed a%ay : hard to evaluated N.?@@ /,ipoglossus0

-ongue deviation : hard to evaluated

asiculation' -remor' Atrofi' Ata)ia: hard to

evaluated

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Nec/

>ign of Menigeal infection :

Fa&u &udu& : positive

2rudEins&i @ dan @@ : negatif' negatif

Fernig : negatif

Felenjar lymphe : bulge /+0

Arteri &arotis : alpasi : strong' regular

Aus&ultasi : bruit /G0

Felenjar gondo& : bulge /+0

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Folumna 1ertebralis

@nspe&si : normal

alpasi : normal

Movement : normal

er&usi : normal

B&stremitas

Motori& : lateralisasi de)tra

Refle& fisiologis :

2R : (" D ("

-R : (" D ("

FR : (" D ("

AR : (" D ("

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Refle& patologis :

,offman+tromner : + D +

2abins&i : + D +

8haddoc& : + D +

=ordon : + D +

>chaefer : + D +

Oppenheim : + D +

Mendel 2: + D +

Rossolimo : + D +

-rofi : + D +

>ensibilitas

B&steroseptif

ain : hard to evaluated -emperature : hard to evaluated

Rasa raba halus : hard to evaluated

roprioseptif

Rasa si&ap : not evaluated

Rasa nyeri dalam : not evaluated

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ungsi &orti&ol

*iscrimination function : hard to evaluated

>tereognosis : hard to evaluated 2arognosis : hard to evaluated

Abnormal spontan movement : +

@mpaired coordination

-es finger nose : hard to evaluated

-es pronasi supinasi : hard to evaluated

-es &nee to toe : hard to evaluated

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LA0ORATORIUM =*A #"

,ct I5'"

,b 5'#

B* J: 5

eu&osit #'5 -rombosit "3#.###

Neutrofil 4$'4

imposit 6'"

Monosit 3'" Bosinofil 'I

2asofil 'I

Britrosit 5'I3

M81 4"

M8, "6.7#

M8,8 33.5#

R*K " M1 5

Lrea "I

>8 #.7 O-- "#"

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CLUE AND CUE male' 53 yo

,emipharese de)tra

sudden %ea&ness

Nausea ( 1omiting (

,eadache (

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8linica

l*iagnosis

,emipharesede)tra

,- Nausea ( 1omiting (

,eadache (

*iag

nosis-opis

,emispheresubcortical

Btiologica

l*iagnosis

81A 2leeding

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PLANNING T'ERAPY

=eneral therapy :

O" nasal "+I lpm

@1*. Assering 5##cc"Ijam

,ead up 3# derajat @nj. santagesi& 3) gr

@nj. Ranitidin ")5# mg

@nj. 2eclov 3)"5# mg

@nj. Manitol "##mg $)##mg

8onsul >p.>' >p.2>

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PLANNING MONITORING 1ital sign >ubjective complaints of patients Neurology B)amination

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PLANNING EDUCATION B)plain to the family about the disease of

the family B)plain the patient about therapy and

intervention' B)plain the patient about its complication

and prognosis.

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PROGNOSIS dubia ad malam