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

2. 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

3. 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)

4. 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:

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

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

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

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

9. 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

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

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

12. 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 : = -2
Stroke non hemoragic

13. 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

14. 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

16. 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