mr neuryfgyhgo 4 oktr15 - copy
DESCRIPTION
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MORNING REPORT4 oktober2015
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Anamnesa• Keluhan utama:
Lemas pada kaki kiri
• Riwayat penyakit sekarang:
Pasien mengatakan bahwa pasien lemas pada kaki kiri tadi sore sampai tidak bisa jalan. Pasien mengatakan bahwa kepikiran pada cucunya sehingga tiba-tiba lemas. Sebelumnya pasien pernah seperti ini 1 tahun yang lalu tapi tidak sampe parah dan tidak bisa jalan seperti ini.
Riwayat: DM(-), HT(+)
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Pemeriksaan Fisik
• GCS :456
• Tensi :170/90
• Nadi :89x/mnt
• Suhu :36,5 drajad
• RR :20x/mnt
• Reflek cahaya (+) pupil isokor
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• Kepala : a/i/c/d -/-/-/-
• Leher : PKGB(-) PJVP(-)
• Abdomen : BU(+), soefl
• Genitalia : DBN
• Ekstremitas : kaki kiri lemas
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Status Neurologis
- Meningeal sign
Kaku kuduk (-)- Reflek patologis
Babinzky : -/+
Chadox : -/-- Nervus VII: (-)- Nervus XII: (-)
• Reflek fisiologis- Bisep : +2/+2- Trisep: +2/+2- Patella : +2/+2- Achiles :
• Motorik- Tangan : 5/5- Kaki : 3/0
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HASIL LAB• HB :9,57
• WBC :10,3
• PLT :389
• BUN :13
• SK :1,1
• Na :152
• Kal :4,2
• Clorida :111
• GDA:189
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Diagnosa
• Klinis
- Parase
- Nausea
• Topis
- Cerebelum
- NV
• Etiologis
- Stroke Infark
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Penatalaksana
• Infus Asering 2 fl/24 jam
• Inj. Calmeco 1x1
• Inj. Ranitidin 2x1
• Inj. Antrain 3x1
• Inj. Citicolin 2x500
• Inj. Alinamin 3x1