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Morning reportFriday 8th January 2016

ER: dr. BetsiConsultant: dr. DiahStroke unit: dr. Daniel-dr.TheoWard: dr. Runi-dr. NanikPATIENTS IDENTITYName: Mrs. WAge: 56 years oldGender: FemaleOccupation: HousewivesMR Number: C529514Hospital admission: 8th January 2016

HISTORY (autoanamnesis)Chief complaint : UnconsciousOnset : 1 hour before hospital admissionQuality: only can awake with pain stimulationQuantity: ADL independently

HISTORYChronology : 1 hour before hospital admission, family said that patient suddenly unconscious. Family said she was sleep at that moment. Family said patient Cant communicate. Weakness (+) all extremity,slurred speech (-), vomit(-), headache (-), seizures (-), fever(-). Family than brought her to BPJS Clinic, and suggested transferred to dr Kariadi HospitalHISTORYAggravated Factors : -Extenuated Factors : -Concomitant Symptoms : - Weakness in all extremityHISTORYPast Medical History- Stroke, 1 year ago. Hospitalized in Tugu Hospital for four days, she permitted to go home and Family said that she had weakness in right part of body, slurred speech (+),Family Disease History : no family history had the same illnessSocial Economic-Status And Personal History : housewives

CLINICAL FINDINGSPresent StatesGCS : E3M5Vsusp afasiaVital signs :BP 150/80 mmHgHR 49x/min RR 20x/minTemp 36.5 (axilla)Eye: pupil round, isocor 3/3 mm,light reflex +/+Thorax: normal breathing, Rh-/-, Wh -/- normal heart sound, murmur (-),gallop (-)Abdomen : unpalpable liver and spleen, ascites (-)

CLINICAL FINDINGSCranial Nerves: difficult to assest

MotoricSup InfMovement/ / Strength cant be assest, hemiparese bilateral spastikTonushipertonus/hipertonus hipertonus/hipertonusTrophyE/EE/EFR ++/++ ++/++PR-/--/+(B,C) Clonus-/-

CLINICAL FINDINGSSensibility : cant be assestVegetative : normalLaboratorium

Osm : 2(138+4.0)+ (163:18)+(30:6)=298.5FD : 298.5-295 xO,6x6O= 0.3 L295ECG

Thorax

No Tuberculosis imaging, Cor is normalMRI LUMBAL

ImpressionSpondilolistesis L4-5HNP L3-4,L4-5, L5-S1Spondilosis LumbalBuldging L2-3DIAGNOSISClinical Diagnosisunconsciousness Hemiparese Bilateral SpasticTopical Diagnosis Corona radiataEtiologic Diagnosis : Reccurent Stroke Infarction

II. HT Stg IIIII. Sinus Bradicardia

INITIAL PLANS & THERAPYConsult to Cardiologist, Ophtalmologist,Physical Medicine and RehabilitationTherapy : O2 Nasal canul 3 lpm, head up 30 degreeIVFD : RL 20 drop per minutesInj Ranitidine 50 mg/12 ho IVAspilet 80 mg/24 h.o p.oVitamin B1B6B12 1 tab/8 hours p.oMONITORING : GCS, vital signs, neurologic deficits, fluid balance

EDUCATION : diagnosis, management, complications, prognosisTHANK YOU