Tuesday , November 25nd, 2014

Chief complaint : weakness half of bodyPresent illness history :A 56-years-old female, weakness half body expecially right, suddenly and felt like tingling when he had activity. Headache (+), Nausea (-), vomit (+) five times watery, miction (+)N, defecation (+)N. Previous Illness HistoryHypertension (+) uncontrolledDM (-) Stroke (+)history of heart disease (-)

Family History of DiseaseHT (+), DM (-)

Sociality HistoryCigarrete (-)

STATUS PRESENTAwareness : 456BP: 174/93 mmHgpulse: 89x/minutesTemp: 36,7 CRR: 26x/minutesHead and Neck A-/i-/c-/d-

Inspection: symmetrical chest wall movement ICS retraction (-) Palpation: Lung: Percussion: sonor / sonor Auscultation: vesicular / vesicular, rh -/-, wh -/- Heart: Percussion: within normal limitAuscultation: S2 S1 single murmur (-) Gallop (-)

Inspection: flat Palpation: soepel, tenderness (-) Percussion: Tympany Auscultation: bowel sounds normal Liver: not palpable Lien: not palpable

Extremity :Warm, dry , red CRT

N.I (olfactory) Smelling: not to evaluated

N.II (optic) Visual acuity: not to evaluated Field of view: not to evaluated Funduscopic: not evaluated

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

N.V (trigeminal) sensibility: V1: not to evaluated V2: not to evaluated V3: not to evaluated motor: Inspection: normal Palpation: not evaluated Chewing: not evaluated Biting: not evaluated masseter reflex : not evaluated Corneal reflexes: +/+

N. VIIObrikularis oris :normalOrbikularis oculi :normalFrontalis :normalN. VIII Seconds watches: not to evaluated Voice whispered test: not to evaluated Test weber: not to evaluated Rinne test: not to evaluated N.IX (glossofaringeus) not evaluatedN.X (vagus) Pharyngeal arch Position: normal / normal Vomiting reflex: normal

N.XI (accessory) Shrug: not to evaluated Turning heads: not to evaluated

N.XII (hipoglosus) Devisasi tongue: normal Fasciculations: negative / negative Tremor: negative / negative Atrophy: negative / negative

Meningeal sign Stiff neck: - Kernig's sign: - Carotid Artery: + / + Palpation: strong palpable / strong palpable Auscultation: not evaluated Thyroid: - / -

Motor Movement: Strength : 3 / 5 3 / 5Physiological reflex: BPR: +2/+2 TPR: +2/+2 KPR: +2/+2 APR: +2/+2Pathological reflexes Hoffman tromer: -/- Gordon: -/- Babinsky : +/- Oppenheim : -/- Chaddock : -/-Sensibility :normal

Diffcount : 0/2/80/14/4Hct : 37,9Hb : 12,5LED : 53/72Leukocyte : 12.000Thrombocyte : 251.000Urea : 29Creatinin : 0,7GDA: 109

SGOT : 20SGPT : 16Potassium : 3,6Sodium : 140Chloride : 113Cholesterol : 231TG: 116

female, 56yo.right body weakness Headache (+), nausea (-), vomit (+)Siriraj score +1,3

Lipid profile

General:O2 Nasal 4 lpmIVFD Asering 1500 cc/24 jamInj. Methamizole 3x1 gram i.v.Inj. Ranitidin 2x50 mgInj. Ondansentron 3x1 amp

Specific: Inj. Citikolin 3x1 ampLoading Clopidogrel 4 tab 1x1 tabInj. Fondaparinux (Arixtra) 1x1 ampCA 1x1 tab

Consulted to neurologist

PROGNOSISDubia ad bonam

*************