Morning Report

August 3 , 2017
th

DEPT OF NEUROLOGY
M28
 DAFTAR OB NEURO

 Ny. S  Meningioma
 Ny. Amanah  Tetanus
 Identity

 Name : Ny. S
 Age : 40 years old
 Address : Cungkup,Lamongan
 Admission : August 2nd, 2017 at
21.30 pm
 SUMMARY OF DATABASE

 Chief of complaint:
 Seizure
 Chief Complaint Seizure

 Present history
Patient complained seizure attack since 3 hours before admitted to
hospital during activity. Seizure were experienced twice with
duration ±5 minutes without loss of consciousness, criteria of
seizure were eyes glanced upward, stiff of extremity without
tongue bitten. Patient spoke with wrong articulation, Vomit
admitted once before arrived to the hospital and once within the
hospital. Headace appeared since 7 days before, felt throbbing and
worsen a day. Defecation within normal limit and micturition felt
normal limit. Patient had seizure again during hospital twice at
22.38 and 23.00. blurriness(-), hearing loss(-). Patient admitted
that never got this complaint before
 Past history of Illness

•HT (-) , DM (-),

 Family history

No familial related

 Social history : (-)

 Vital Signs

 BP
 123/71 mmHg

 Pulse
 82 x/min, strong, reguler

 Temp
 36,8 C

 RR
 24x/min
 A: clear, gargling (-), snoring (-), speak fluently (-),
potential obstruction (-)
 B: spontan, RR 24x/min, ves / ves, rh +/+, wh -/-,
SaO2 97% without O2 support.
 C: CRT <2’, N 82 x/min, BP 123/71 mmHg
 D: GCS 456, lateralisasi -, PBI 3mm/ 3mm, LP +/+
 E: temp 36,8 C
 General condition : weak
 Awareness : composmentis
 GCS : 456
 H/N : a -/i-/c-/d -
lymph node enlargement at neck (-)
 Thorax
 Inspection
 Symmetrical, retraction -

 Palpation
 Thrill (-), fremitus WNL

 Percussion
 Lungs: sonor / sonor

 Cor: N

 Auscultation
 Lungs: ves /ves, rh +/+, wh -/-

 Cor: S1S2 single, M -, gallop -

 Abdomen
 Inspection
 flat

 Auscultation
 Met -, bowel sound WNL

 Palpation
 Pain (-)

 Liver/Spleen within normal limit

 Percussion
 Tymphany
 Extremities

 Inspection
 Clubbing fingers (-), icteric (-), cyanosis (-), edema (-), atrofi
lower extremity (-)
 Palpation
 Cold and wet, CRT <2’
 Status Neurologic

 GCS: 456  Fisiologic reflex:

 Meningeal sign:  BPR +2/+2

 Kaku kuduk -  TPR +2/+2

 Kernig -/-  KPR +2/+2

 Brudzinski 1,2 -/-  APR +2/+2

 Nervus Cranialis:  Patologic reflex:

 NII: PRI 6mm/3mm, light  Babinski -/-
reflex +/+,  Chaddock -/-
 N III, IV, VI: normal  Hoffman trommer -/-
 NVII: normal  Motoric: 5-/5
 N IX: normal  5-/5
 N XII: normal  Sensoric: normal
 Planning Diagnosis

 Complete blood count

 CT-Scan
 Thorax photo
 Random blood glucose
 Laboratory Findings

 MCH 28,70
 Eritrosit 4.78
 Hb 13.7  MCV 84,50
 LED 1 22  MCHC 33,90
 LED2 53  MPV 6
 Limposit 38,6.  RDW 11
 Basofil 1,0  Trombosit 232
 Eosinopil 1,4  Clorida serum 105
 Neutropil 53,7  Kalium serum 3,8
 Hematokrit 40,4  Natrium serum 137
 Monosit 5,3  GDA 162
 Leukosit 18,0.
 Ct scan results

 Edema cerebri sinistra

 Meningioma frontalis
sinistra
 Diagnosis

 Diagnosis:
 Clinical : hemiparese dextra, convulsion, headache.

 Topical : Meningen frontalis sinistra

 Etiology: Meningioma, edema cerebri

 Planning Therapy

IVFD asering 1500cc/24 hours

Inj Dexamethason 4x1 amp
Inj. citicolin 3x500 mg iv
Inj. antrain 3 x 1 amp iv
Inj. ranitidin 2x50mg iv
Inj. Phenitoin 3x100mg iv
 PLANNING MONITORING

 Vital Signs
 Patient’s complaint
 Adverse effect
 DL
 PLANNING EDUCATION

 Explain to the patient and his family about the

disease, cause, complication, intervention of the
therapy and prognosis.