Morning report

DEPARTEMEN T OF
NEUROLOGY
MARCH, 15 th 2014

IDENTIFY PATIENT
o Name : Mrs. Musriani
o Age
: 58 Years Old
o Gender
: Female

ANAMNESE
Chief Complain : Unconsciousnes
Present illness history
Her family complaints that the patient low
consciousnes since 2 months ago. All part of body
was lemah since 1 weeks before admit to hospital.
Fever (+), cough (+) , couldnt clear talk, couldnt
wake 2 foot.
Past illness history
TB (+) 1 years ago (2-3 month consumed TB drugs
but Its not continue), HT (-), DM (-), Trauma (-)
Family illness history
None of family have the same illness

Social illness history : (-)

Primary Survey
A:
B:
C:
D:

Physical Examination
Vital sign :
BP : 110/83mmHg
RR : 37x/mnt
T : 37,2 C
General examination :
Head-neck
: a/i/c/d -/-/-/Thorax :
simetris (+), regular -/-, vesikuler/vesikuler,
S1 S2 solitary, murmur (-), gallop (-)
Abdomen :
flat, soefl, metalic sounds (-) , Liver and spleen are not
palpable.
Extremitas : Warm, dry, and red, edema (-)

Affect and emotion

: within normal limit

Thinking process

: within normal limit

Intelligence

: within normal limit

Willingness

: within normal limit

Psychomotor

: within normal limit

Neurological Examination

N. I (Olfactorius)

: its not be evaluated

N. II (Opticus)
Visus
Visual field
Funduscopy

:
: cannot be evaluated
: cannot be evaluated
: cannot be evaluated

N. III (Okulomotorius)
Ptosis
exoftalmus
eye movement
Pupil
Light reflect
N. IV (Trochlearis)
eye position
eye movement
N. VI (Abducen)
eye movement

:
:-/:-/: cannot be evaluated
: 3mm/3mm, rounded, isokor
: +/+
:
: ortoforia
: cannot be evaluated
:
: cannot be evaluated

N. V (Trigeminus)
Sensibility
: N V1
N V2
N V3
Motorik

:
: cannot be evaluated
: cannot be evaluated
: cannot be evaluated

Inspection
Palpation
chewing
bite

: within normal limit

: within normal limit
: cannot be evaluated
: cannot be evaluated

N. VII (Facialis) :
Sensorik
: not evaluated
Motorik
:
M. Frontalis
M. Oblique oculi
M. oblique oris

: cannot be evaluated
: cannot be evaluated
: cannot be evaluated

N.VIII (acusticus) :
within normal limit

N. IX, X (GLOSSOFARINGEUS, VAGUS):

sensory 1/3 posterior : not evaluated
arcus pharynk position : mot evaluated
reflek muntah
: not evaluated
N.XI (accecorius) : not evaluated
N. XII (Hipoglossus) : not evaluated

Affect and emotion

Language ability
Memories
Visuospatial
Intellegence

: not evaluated
: not evaluated
: not evaluated
: not evaluated
: not evaluated

Clue and Cue

Female, 58 yr
unconsciousnes
Past history illness : TB (+) 1 years
ago (2-3 month consumed TB
drugs but Its not continue)

Assessment
Clinical Diagnose
unconsciousnes
Topic Diagnose
Meningen dan Ensefalon
Etiologic Diagnose
meningoensefalitis TB

Planning Diagnose
DL
CT-Scan
Foto Thorax AP

Laboratorium Result

Diffcount
0/3/64/17/16
Hct 39,7
Hb 11,9 g/dl
LED 36/61
Lekosit
6700
Trombosit 299.000
SGOT
23
SGPT
15
Cl serum
105
K serum
3,7
Na serum 143
Serum creatinine 1,1
Urea 99
Natrium
149,8
GDA 100

Planning Therapy

5B!!
IVFD asering 1500 cc / 24 hr
Inj Novalgin 3x1 amp
Inj. Acran 2x1 amp
Inj. Ceftriaxon 2 x 1 g
Inj Levofloxacin 1x500 mg
Inj kalmeco 1x1 amp
Inj Piracetam 5x3 g
Inj Streptomicin 1x750 mg
Inj Kalmetason 3x1 amp
Reimstar 1-20
C/ Sp.PD & Sp.S

Vital sign
Neurologic disorders

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 at bonam