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Monday, January 6th 2013

Patient Identity

Chief complaint: unconscious Present illness history: familys complained that Mr.S had unconscious in his house, because Mr.S live alone nobody from the familys know since when this unconscious has started. Previously familys told Mr.S had headache, this complaint arise frequently and more increasingly day by day. During came to hospital Mr.S has right half of the body spasm once. Vomiting (-), nausea (-), fever (-)

Previous Illness History

Hypertension (+) denied DM (-)

Family History of Disease

None of family have the same illness

Sociality History Patients is a heavy smoker

General Physical Examination

Status Present

Awareness : 2x4 (sensory aphasia) BP: 158/103 mmHg pulse: 63x/minutes Temp: 36.2 C RR: 20x

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

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

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 Subconjunctival bleeding OD

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

N.III (okulomotorius) Ptosis: - / Eksoftalmus: - / Eye movements: dte/ dte Size: 3mm/3mm, isokor Light reflex: + / + N.IV (trokhlearis) The position of the eye: ortoforia / ortoforia Eye movements: dte / dte N.VI (abduscen) eye ball movement : dte / dte

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

N.VII (fascialis) parese N.VII left central type N.VIII Seconds watches: dte / dte Voice whispered test: dte / dte Test weber: not evaluated Rinne test: not evaluated N.IX (glossofaringeus) Taste: dte N.X (vagus) Pharyngeal arch Position: dte / dte Vomiting reflex: +

N.XI (accessory) Shrug: dte / dte Turning heads: dte / dte N.XII (hipoglosus) Devisasi tongue: dte / dte Fasciculations: dte / dte Tremor: dte / dte Atrophy: dte / dte

Inflammatory markers meninges Stiff neck: Kernig's sign: Carotid Artery: + / + Palpation: strong palpable / strong palpable Auscultation: cranial, cervical bruit (-) / cranial, cervical bruit (-) Thyroid: - / -

Abdominal wall skin reflexes
+ + + -

vertebral column Inspection: wnl Palpation: wnl Movement: wnl Percussion: wnl

motor Movement: dte (lateratation to left)
Strength :dte dte dte dte Muscle tone: Spastic: - / Rigidity: - / Klonus knee: - / Klonus Achilles: - / -

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

sensibility Eksteroseptif: Pain: dte / dte Temperature: dte / dte Touch: dte / dte proprioceptive Shakes: dte / dte Position: dte / dte Flavor combinations (combine sensation) Stereognosis: dte / dte Barognosis: dte / dte

Male, 61th unconscious Nausea (-) Vomit (-) Hypertension Heavy smoker Hemiparese sinistra Parese N. VII left central type

Male, 61h, admission to Muhammadiyah Lamongan hospital unconscious, nausea and vomit (-). From physical examination, found BP 158/103 mmHg, HR 63 x/mnt. From neurological examination, hemiparese dextra, Parese N. VII left central type, increasing of left side bodys physiology reflect, positively of left side bodys pathology reflect. From summary above : SIRIRAJ SCORE (2,5x0) + (2x0) + (2x0) + (0,1x103) (3x1) 12 = -4.7 < -1 CVA infark

Clinical diagnosis
hemiparese dextra, Parese N. VII left central type, increasing of left side bodys physiology reflect, positively of left side bodys pathology reflect.

Topis diagnosis
a. Cerebri media

Etiologic diagnosis
CVA infark

Head CT scan without contrast X ray Thorax CBC Random blood glucose test ECG electrolytes


Diffcount : 6/0/67/21/6 Hct: 43.2% Hb: 15.2 mg/dL LED: 8/17 Leucocytes : 8.300 Trombosite: 171.000 OT / PT: 17/28 U/L Albumin: 3.7 mg% Globulin: 1.9 gr% Total protein: 5.6 mg% Chloride serum: 105 mol/l Calium serum: 4.0 mmol/l Natrium serum: 136 mmol/l Serum creatinin 0.8 mg/dl Urea: 22 mg/dl Uric acid: 5.1 mg/dl


O2 nasal 2 lpm IVFD RL 1500 cc / 24 hr Inj. Metamizole 3x1 gr Inj. Ranitidine 2x 50 mg Inj. Piracetam 4 x 3 gr Inj. Citicoline 3x250 mg Inj. Arixtra 1x1 P.O Plavic 3ddI Foley cathether Consult Sp.S

Vital sign, subjective complaints of patients

Explain to the family about the disease of the family, about its therapy and intervention will be done, and also about its complication and prognosis (dubia ad bonam)