morning report 07 april

7/21/2019 Morning Report 07 APRIL

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Neurology Departement

April, 07 th 2014



Identify PatientName : Mrs !

Age : "# years old

!e$ : %emaleAddress: &amongan



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 : ./



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 +(-



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



Neurologi(al $amination



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'



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



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



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



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



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



'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 (!"



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



Planning DiagnoseD&

'8

&ipid Pro9le6/ay 3hora$

'3/!(an



CT SCAN



FOTO THORAX



&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<



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!



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

morning report 07 april

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