MORNING REPORT ZAAL Ex & Fx Karina Agustin Daniel Banjarnahor Dokter Muda:

Zaal E Zaal F Total Patient: 4 person New Patient: 3 person Tuesday, 7 april 2015 Total Patient: 4 person New Patient: 3 person Old Patient: 1 person Zaal E Total patient : 3 person New Patient : - Old Patient : 3 person Zaal F

PATIENT’S IDENTITY Name : Johnny Lumbantobing Age : 51 years old Occupation : Entrepreneur Religion : Christian Education : Senior High School Ethnic : Batak toba Address : Hutahaean street, Balige Date of admission: 7 april 2015 (17.30 wib)

Past Medical History: Hypertension (+), Previous stroke ANAMNESIS Autoanamnesis √ √ Alloanamnesis CHIEF COMPLAINT : left-sided weakness History of present illness: Patient suffer for the weakness about one week before admission, which occurred suddenly. History of headache (-), History of projectile vomit (-), history of seizure (-). About one month before admission the patient had hospitalized with the same complain, but the weakness was milder. History of hypertension (+), history of DM (-), Hypercholestrolnemia (?), Ciggarette smoker (+) Past Medical History: Hypertension (+), Previous stroke Past Medicine list:

Status Present General condition: CM anemic (-) BP : 150/100 mmHg icterus (-) Pulse : 92x/i dyspnea (-) RR : 20 x/ cyanotic (-) Temp : 36,4 oC edema (-)

Physical Examination Head : WNL Neck : WNL Thorax : WNL Extremities : left sided weakness of extremity

Neurology examination Meningeal signs examination: Nuchal rigidity : (-/-) Brudzinski’s neck sign : (-/-) Brudzinski’s contralateral leg : (-/-) Kernig’s sign : (-/-) Lasegue’s sign : (-/-)

Increase Intracranial Pressure / ICP Sign Vommit : (-/-) Headache : (-/-) Seizure : (-/-)

Cranial nerves N I : difficult to examine N II : Pupil isokor (+/+), light reflex (+/+) N III,IV,VI: pupil isokor (+/+), size 3 mm both side, eye movement (+/+) N V : corne reflex (+/+) N VII : weakness on left side of face N VIII : hearing (+/+) N IX/X : not checked N XI : strenocleidomastoideus and trapezius muscle strength normal N XII : tongue deviate to the left side

Physiologic Reflexes Right left Biceps/Triceps +2 +1 KPR/APR Pathologic Reflexes right left H/T - + Babinski

Motoric System ESD :55555 ESS : 33333 EID : 55555 EIS : 33333

Siriraj Score Consiousness : 2,5 x 0 Vomit : 2 x 0 Headache : 2 x 0 Diastole BP : 0,1 x 100 Ateroma : 3 x 0 Konstanta : -12 Result : 0+0+0+10-0-12= -2 Stroke non hemoragic

Laboratory result April 7, 2015 Hb : 12,8 g/dl Leukosit : 11,7 x 103/uL Eritrosit : 4,41 x 106/uL Trombosit : 479 x 103/uL Hematokrit: 35,6% Blood Sugar level:116 gr/dl

Diagnosis Fungsional diagnosis: Hemiparesis sin + parese sin (N VII, XII) type UMN Etiologic diagnosis: Thrombus Anatomical diagnosis: subcortical Working diagnosis: recurrent stroke ischemic Differential Diagnosis: Recurrent stroke ischemic Recurrent stroke hemoragic

Therapy IVFD R Sol 20 gtt/I Inj citicoline 500 mg/ 12 h Cylostazol 50 mg / 12 h Further examination: Head CT scan Thorax rontgen ECG Lipid profile