Ob Syaraf (4-8-16)

• Tn. A.Afandi Eko meningitis  marwah

15.2
• Tn. Islan 58 th  CVA  marwah11.6
 MORNING REPORT
Department of Neurology
 Ob Syaraf (3-8-16)
• Ny. Sukaesih 90 th> CVA bleeding >
marwah 15
• Tn. Asram 55th > CVA infark > Marwah 9
IDENTITY

• Name : Ny. S
• Age: 90 y.o
• Sex : female
• Address : lamongan
• Date :July, 3 August 2016 20.29
 SUMMARY OF DATABASE
• Chief of complaint:
• Loss of feel half of her body ( Right side )
 SUMMARY OF DATABASE
• Present history:
• Loss of feel was felt 2 hours before go to hospital.
She complained that cant move her right arm and
feet.She felt headache before weakness and vomit
once after half of her body felt weak. First she felt
weak in the arm, and then spread to the leg. Patient
cant be evaluated because she cant communicated-
well. Her daily activity is a massager.
• History of past illness:
• HT (+) uncontrolled
• DM is denied
• History of family illness:-
• History of social ilness: -
PRIMARY SURVEY
• A : clear, gargling (-), snoring (-), speak
fluently (+), potential obstruction (-)
• B : spontan, RR 24x/mnt, ves/ves, rh-/-, wh-
/-, SaO2 100% with NRM 10 lpm support
• C : Acral WDR, CRT < 2 sec, Pulse 81x/mnt,
BP 155/95 mmHg
• D : GCS 456, lateralitation dextra, LR +/+,
pbi 3mm/3mm
• E : temp 36.4 C,
 Secondary survey
• GCS: 456
• Head and Neck :
Anemic (-/-), Icteric (-/-), Cyanosis (-), Dyspneu (-),

Thoraks:
 Inspection: symmetrical, retraction ( -/-), lession -
 Palpation ; thorax expansion is symmetrical
 Percussion:
P: sonor/ sonor
C: deaf sound
 Auscultation :
P  Ves/Ves, rh -/-, wh -/-,
C  S1S2 single, murmur-, gallop-
Abd :
 Inspection: flat, lession-
 Palpation ; H/L unpalpable
 Auscultation : BU + N
 Percussion: tympani
• Ext : aie -, acral WDR
• Neurological Examination

Meningeal sign (-)

R. Physiology
• BPR +2/+2 APR +2/+2
• KPR +2/+2 KPR +2/+2
R. Patholgy
Hoffman -/- Babinski -/-
Trommer -/- Chaddock -/-
Motorik 3/5
2/5
N. Cranialis
N.II : pbi 3mm/3mm LR +/+
N.III, IV, VI : dbn
N.V : dbn
N.VII : dbn
N.XII : dbn
Sensorik : Hemihipoestesi dextra
CLUE AND CUE
• Female, 90 y.o
• Hypertention
• Loss of feel right extremity
• Hemiparese Dextra
• Vomit (+)
• Cephalgia (+)
• Decrease of Right motoric
Assesment
• CVA
Planning Diagnose
•CT scan of the head
•Siriraj score
•(2,5 x 0)+(2x1)+(2x1)+(0,1x95)-(3x0)-12
4+9,5-12= 1,5 (CVA Hemorragic)
 Lab. Exam
 Eritrosit 4,57(3.80 – 5.30)  MCV 84,3 (87.00-100.00)
 Hemoglobin 13.3(13-18)  RDW 11 (10-16,5)
 LED 1 27 (0-1)  Trombosit 187 (150-450)
 LED 2 50 (1-5)  GDA 150
 Limfosit 18.4 (25.0-33)  Ureum : 69 (10-50)
 Basofil 0.8 (0-1)  Creatinin : 0.9 ( 0.7-1.2)
 Eosinofil 1.4 (1.0-2.0)  SGOT :31 (0-31)
 Hematokrit 38.8(40.0-54)  SGPT : 15 (0-31)
 Leukosit 6.3( 4.0-11.0)
 Neutropil 76.2 (49,0-67,0)
 Monosit 3.2 (3.0-7.0)
 MCH 28 (28.00-36.00)
 MCHC 33.40 (31.00-37.00)
Dx Klinis
Hypertention
Hemiparase dextra
Hemihipoestesi detra
vomit
cephalgia
Dx Topis
a. cerebri media
Dx Etiologis
CVA Bleeding
Education
• Explaine to the family about the disease,
about its theraphy and intervention will be
done, and also about complication and
prognosis.
RE-ASSESSMENT
• ICH
• CVA Bleeding
TREATMENT
• Nasal O2 3 lpm
• Inf Asering 1500cc/24jam
• Inf Manitol loading 200cc
• Inj santagesic 3 x 1 gr iv
• Inj Acran 2x50mg iv
• Inj incellin 3x250mg iv
• Amlodipin 10mg 1x1
• Konsul Sp.s
MONITORING
• Vital sign
• GCS