Morep Neuro 1 | Human Anatomy | Animal Anatomy

Medical Report Friday, April 05th 2013

Patient Identity
Name Age Sex Address Number of ID : Mrs. SMS : 38 YO : Women : Lamongan :-

insomnia (+).Chief Complaint : Headache Unilateral Present Illnes : Patient came to the hospital with complaints of headache half. headache half since 10 days before entering the hospital. fever (-). Felt increasing everyday. the pain is felt on the left side of the head. patient feel pain throughout the head and headache decreased when she gotbsome drug.before. vomiting (-). trauma (-). Nausea (-). .

Previous Illness History • Hypertension: declined • DM: declined • asthma (-) • cardiac disease (-) • drugs allergy (-) Family History of Disease None of family have the same illness .

5 °C RR: 20x/minutes .General Physical Examination • • • • • Status Present Awareness : 456 BP: 102/60 mmHg pulse: 64x/minutes Temp: 36.

the left boundary of mid clavicula sin ICS V . ICS II upper left parasternal Auscultation: S2 S1 single murmur (-) Gallop (-) .Thorax • Inspection: symmetrical chest wall movement Palpation: fremitus + / + Lung: Percussion: sonor / sonor Auscultation: vesicular / vesicular heart: Percussion: ICS V parasternal right limit dex.

tenderness (-) Percussion: Tympani Auscultation: BU (+) N Liver: no palpable Lien: no palpable .Abdomen • Inspection: flat Palpation: soepel.

Psychological Status  Affective and emotional: within normal limits The process of thought: within normal limits Intelligence: within normal limits Absorption: within normal limits Willpower: within normal limits Psychomotor: within normal limits .

Neurological Status • head: Position: normocephali Protrusion: (-) Shape / size: normal impression Auscultation: bruit (-) .

Cranial Nerve • N.II (optic) Visual acuity: within normal limits / within normal limits Field of view: within normal limits / within normal limits Funduscopic: not evaluated .I (olfactory) Smelling: within normal limits • N.

/ Eye movements: well in all directions / well in all directions Size: 3mm/3mm. isokor Light reflex: + / + N.N./ Eksoftalmus: .IV (trokhlearis) The position of the eye: ortoforia / ortoforia Eye movements: well in all directions / well in all directions N.VI (abduscen) eye ball movement : well in all directions / well in all directions .III (okulomotorius) Ptosis: .

• N.V (trigeminal) sensibility: V1: wnl / wnl V2: wnl / wnl V3: wnl / wnl motor: Inspection: wnl / wnl Palpation: wnl / wnl Chewing: wnl / wnl Biting: wnl / wnl Reflex chin / masseter: wnl Corneal reflexes: + / + .

VII (fascialis) Sensorik : within normal limits Motorik : M. oblique oris : within normal limits  N.IX (glossofaringeus) Taste: wnl .VIII Seconds watches: wnl / wnl Voice whispered test: wnl / wnl Test weber: not evaluated Rinne test: not evaluated  N. N. Oblique oculi : within normal limits M. Frontalis : within normal limits M.

/ - ./ Atrophy: .X (vagus) Pharyngeal arch Position: wnl Vomiting reflex: + N./ Tremor: .XII (hipoglosus) Devisasi tongue: -/ Fasciculations: .N.XI (accessory) Shrug: + / + Turning heads: + / + N.

/ - .Neck • Inflammatory markers meninges Stiff neck: Kernig's sign: Carotid Artery: + / + Palpation: Strong palpable / palpable strong Auscultation: bruit (-) / bruit (-) Thyroid: .

Abdomen • Abdominal wall skin reflexes + + + + + + vertebral column Inspection: wnl Palpation: wnl Movement: wnl Percussion: wnl .

/ Klonus knee: .extremity • motor Movement: wnl/wnl – Strength : 5 5 5 5 – Muscle tone: Spastic: ./ Rigidity: ./ - ./ Klonus Achilles: .

/ ./ ./ Babinzki: ./ .Rossolimo: .Gordon: .• Physiological reflex: BPR: N / N TPR: N / N KPR: N / N APR: N / N pathological reflexes Hoffman tromer: ./ Chaddock :-/ ./ - ./ Mendel B: .Schaefer: .Oppenheim: .

• sensibility Eksteroseptif: Pain: wnl / wnl Temperature: not evaluated Touch: wnl / wnl proprioceptive Shakes: wnl / wnl Position: wnl / wnl Flavor combinations (combine sensation) Stereognosis: not evaluated Barognosis: not evaluated .

38 years old Cephalgia (+) unilateral Nausea (-) Vomit (-) .• • • • Female.

HR 64 x/mnt.• Female. nausea (-) and vomit (-).38years old. GCS 456. admission to Muhammadiyah Lamongan hospital with unilateral headache. From neurological examination normal . found BP 102/62mmHg. From physical examination.

Clinical diagnosis • Unilateral headache Topis diagnosis • cerebrum Etiologic diagnosis • Migrain without aura .

• - .

• • • • • • LABORATORY OF RESULTS Diffcount: 0/0/61/35/5 Hct: 40.000 .0 mg/dL LED: 69/78 Lekosit: 8100 Trombosit: 294.2 % Hb: 13.

IVFD Asering 1500 cc / 24 hr Inj.S . Ketolorac 3x30mg Inj mecobolamin 2x1 Consult  Sp.

Vital sign. about its therapy and intervention will be done. subjective complaints of patients -Explain to the family about the disease of the family. .

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