Morning Report

Saturday November 15th, 2014

ER: dr. Tony

Consult : dr. Isnawan
Stroke Unit : dr. Windri
Ward: dr. Ega
 Patient Identity
Name : Mr. M

Age : 41 years old

Address : Bangak Kampung, Semarang

Occupation : private

Class : BPJS class III

Room : Rajawali 3B

MRS : Nov 15th 2014

RM no. : C506654
 RECENT HISTORY
Main Problem : Right limbs weakness
Location : Right limbs
Onset : 5 hours before
Quality : Right limb strong enough to
against gravity and mild-moderate pressure
Quantity : ADL helped by family.
 Cronology:

5 hours before hospital admission patient

complains weakness of right limbs suddenly when
patient has a conversation with his friend. He also
complains headache, vomit (+) once time, No
seizures. Theres no periode of unconciousness.
Family of the patient take him to the doctor and was
referred to kariadi hospital.
Aggravating factor : (-)

Relieving factor : (-)

Other Symptom : headache (+),

aphasia (+),
vomit (+).
 PAST MEDICAL HISTORY
- Hipertension (+) + 4 years, no routine control, bad compliance.
- DM (-), angina pectoris (-), heart failure (-).
- Stroke (-)
FAMILY MEDICAL HISTORY
- Stroke, DM, HT (-)
SOCIAL-ECONOMY HISTORY
BPJS Class III
 Physical Examination
GCS E4M6Vaphasia
Vital Sign :
BP: 175/110 mmHg
HR : 80 x /minute
RR : 20x / minute
T : 36,5 C
 NEUROLOGICAL STATUS
Head : Mesocephal, Simetris

Eye : Pupil round, isokhor, 2,5mm / 2,5mm

light reflex +/+

Neck : nuchal rigidity (-)

cranial nerves : right facial nerve palsy(UMN), tongue deviation to the

right

Siriraj score :

2,5x0 + 2x1 +2x1+ 0,1x110 (3x0) - 12 = 3

Haemorrhage Stroke
 Motoric Superior Inferior
Movement /+ /+
Strength of matoric 333/555 4+4+4+/555
Tonus N/N N/N
Trophy E/E E/E
Physiologic Reflex ++/++ ++/++
Pathologic Reflex -/- -/-
Clonus -/-

Sensibility : difficult to assessed

Vegetative : DC (+)
LABORATORIUM and
Additional
examination
 Laboratory Examination
15/11/2014
Examination RESULT Normal Point

Routine Hematology

Hb 14.5 13 - 16 g/dl

Ht 41.3 40 52 %

Erythrocyte 4.8 4.3 - 6.0 mil /ul

Leukocyte 8.9 3.8 10.6/ul

Thrombocyte 286.8 150- 400/ul

MCV 86.6 80 96 fL

MCH 30.4 27 - 32 pg

MCHC 35.1 32 36 g/dL

 Examination RESULT Normal Point

Kimia klinik:

Ureum 20 20 - 50 mg/dl

Creatinine 1.03 0.5 1.5 mg/dl

Random glucose 117 < 140 mg/dl

Natrium 141 135 147 mmol/L

Kalium 3.8 3.5 5.0 mmol/L

Chloride 104 95 105 mmol/L

MSCT SCAN Nov 2014
ICH (Volume 11 cc) in left
putamen with perifocal
edema
RO thorax
Susp Cardiomegali (LV)
infiltrates in the right
paracardial
DIAGNOSIS

I. Clinical Diagnostic : Hemiparese right spastic

Right facial nerve palsy(UMN), tongue deviation to the right

Topis Diagnostic : left capsula interna

Etiology Diagnostic : SH
Stroke Hemmoragic

Lab : GD I/II, Profile lipid,

Program Uric Acid
Consultation to nutritionist,
Consultation to rehabilitation medic

IVFD RL 20 tpm
Mannitol 250 cc/6 hrs
Citicoline 500 mg/12 hrs
Therapy Ranitidine 50 mg/12 hrs
Amlodipine 10 mg/24 hrs
Paracetamol 500 mg/8 hrs(po)
MONITORING Vital sign, GCS,
Neurologic Deficite

EDUCATION Diagnosis, Therapy,

Prognosis