Vertigo MR

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Subjective objective Assasment Planning

Dizziness PHYSICAL EXAMINATION CLINICAL DIAGNOSIS PLANNING DIAGNOSIS


Nausea General state: weak Dizzines Observation of TTV,
Awareness: Compos Mentis
History of Vertigo GCS: 456 Nausea clinical manifestatio
VAS: 3 DL, BUN, SC, SE
TTV
BP:124/74 mmHg TOPIC DIAGNOSIS PLANNING THERAPY
Pulse: 57x / minute, regular
RR: 18x / minute Canalis Semisircularis Diphenhidramin 1x1 amp
Temperature: 37 ◦C axillar Posterior Sinistra Ranitidine 1x1 amp
MRC : 5/5 5/5 ETIOLOGY DIAGNOSIS Ondansentron 1x1 amp
NERVUS CRANIALIS
N II : VOD / VOS>
BPPV
1/60, Visual field: dbn DIET
N III : PBI 3/3 mm SECONDARY DIAGNOSIS Balance intake nutrition
N III, IV, VI : normal eye KIE
movements
NV : sensory dbn Bedrest until the
motoric m. masseter simetric complaint gone.
N VII : dbn
N VIII : hearing
lateralitation (-)
N IX, X :
dbn
N XI : simetric
N XII : simetric
PHISIOLOGY REFLEX
BPR : +2 / +2
TPR : +2 / +2
KPR : +2 / +2

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