morning report 13 januari16
TRANSCRIPT
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7/26/2019 Morning Report 13 Januari16
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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