Physical Examination

Vital Sign:
BP
: 130/80 mmHg
HR
: 80 bpm
RR
: 20 tpm
Review system
a. Head
:
normocephali, mouth deviation (-)
anemic conjungtiva (-), icteric sclera (-), pupil isocore
b. Neck
: normal, no rigidity, no palpable lymph nodes
c. Thorax
:
Cor
: S1 S2 regular, murmur -, gallop Lung
: vesicular sound +/+, wheezing -/-, ronchi-/d. Abdomen
:
Flat, abdominal wall//chest wall, normal peristaltic, tympany sound,
tenderness -, mass -, liver, spleen and kidney not papable
e. Extremity
: Warm acral, capp refill <2, edema (-)
Neurogical Examination
Cranial nerves examination:
CN I
CN II
CN III,IV,VI
CN V
CN VII
CN VIII
CN IX
CN X
CN XI
CN XII

: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding
: in normal finding

Pysiological reflex
Upper extremities: biceps reflex (+), triceps reflex (+)
Lower extremities: patella reflex (+), achilles tendon reflex (+)

Pathological reflex
Upper extremities: Hoffman (-), Tromner (-)
Lower extremities: babinski(-), chaddok(-),gordon(-), oppenheim(-),
rossolimo (-)
Motoric examination
Normal movement, good coordination, normal strength
Cranial nerve examination in normal finding

Motorik
Meningeal sign
Physiologic reflex

: Normotonus, good coordination of movement

: negative
: +/+

Patologic reflex

: -/-

Laboratory Examination
February 18, 2016 12.13
Assays
Results
Trigliserid
78 mg/dl
Natrium
146 mmol/L
Chlorida
116,4 mmo/L
Kalium
3,67 mmol/L
Cholesterol
220 mg/dl
Glucose
85 mg/dl
Ureum
14 mg/dl
Creatinine
1,08 mg/dl
Uric Acid
4,03 mg/dl
SGOT
11,1 U/l
SGPT
13,1 U/l

Ref. Range
1 200
135-145
98-108
3,5-5,5
0-220
70-200
10-50
0,9-1,3
3,4-7
0-37
0-42

February 18, 2016 11.09

Assays
Results
WBC
11.42 x 103/ uL
Neutrofil#
8.68 x 103/ uL
Lym#
1,96 x 103/ uL
Mon#
0,54 x 103/ uL
Eos#
0,21 x 103/ uL
Bas#
0,03 x 103/ uL
Neu%
76.0 %
Lym%
17,2 %
Mon%
4.7%
Eos%
1.8%
Bas%
0,3%
RBC
4,65 x 106/uL
HGB
14,4 g/dl
HCT
41,9 %
MCV
90,1 fL
MCH
31 pg
MCHC
34,4 g/dl
RDW-CV
11 %
RDW-SD
36,9 fL
PLT
223 x 103/uL
MPV
7,4 fL
PDW
15,5
PCT
0,165 %
P-LCC
37 x 109/L
P-LCR
16,5 %

Ref. Range
4- 10
2-7
0,8 4
0,12 1,2
0,02 0,5
0 0, 10
50 70
20-40
3-12
0,5-5
0-1
4-5,5
13-18
40-54
80-100
27-34
32-36
11-16
35-56
150-450
6,5 12
9- 17
0,108 0,282
30 90
11 45

Details
Normal
High
High
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Details
High
High
Normal
Normal
Normal
Normal
High
Low
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal

Radiology Examination
- Head CT Scan (February 19, 2016)

Conclusion : Multiple Infark Cerebri (all infark) Regio Nucleus Caudatus

Sinistra et Lobus Temporalis Sinistra