MORNING REPORT

Monday
July 30th, 2018

Department of Neurology
Dr. Sardjito Hospital
Gadjah Mada University of
Yogyakarta
 Neurology In-Patients

Name MR Diagnosis Sub Doctor

division
Azis Alwi AlHusen 01.75.03.94 Tetraparese spastic cum hipestesia segemental thoracal II Oncology YD
ec schwanoma cervical
Martini 01.85.72.70 History of status epilepticus cum hemiparese dextra cum CV IP
afasia ec SNH dd SH dd Stroke like presentation
 Neurology Consulted
Name MR Diagnosis Sub Doctor
division
Tri Siwati 01.85.70.06 Visual loss of scotoma cum acute visual eye field Muscular YD
disturbances OS ec Neuritis retrobulbar; Multiple sclerosis
Nursidi 01.85.67.52 LBP Chronic non progressive inflamatoric type ec Pain YD
spondilogenic
Umiyatun 01.85.46.18 LBP ec cancer pain Pain IS

Tisna Ari Nuria 01.85.26.47 Cognitive impairment cum PN VII et X11 sinistra UMN cum Trauma IS
hemiparese Sin ec sequele post TB
Ngatinem 01.83.72.98 Sopor cum left lateralization susp brain metastase dd Oncology WN
intracranial infiltration
Suginah 01.85.71.90 susp AML dd leukemi without neurological deficit CV IP

Surifty 01.25.56.30 GTCS susp metabolic dd vasculitis cerebri SLE epilepsy TY

Vavilianning
 Neurology Consulted
Name MR Diagnosis Sub Doctor
division
Bambang 01.45.49.29 Inflamatory pain regio thoracal dd referral pain Pain YD
Supriyadi

Sudiharto 00.98.05.82 LBP Inflamatory pain ec BURST Fracture VL III Pain YD

Paulus Tri 01.83.20.46 Dizzines related cardiac problem (VES bigemini) CV IP

Jamidun 01.69.45.54 Left lateralization cum central vertigo ec susp Stroke rekuren CV TR

Banatun 01.85.72.19 Dizziness on TAVB CV IP

 Patient Identities
Name : Mr. AA
Age : 28 years old
Gender : Male
Religion : Islam
Address : Klaten
Job : Entrepreneur
Education : Senior High School
Admitted: July 27th , 2018
MR : 01.75.xx.xx
 Chief Complaint

Worsening of weakness in all extremities

 Recent Medical History
6 years before admission

• Patient felt the weakness in all extremities for the

first time. It was getting heavier until he cannot walk
only in one month
• Numbness from below the neck until tip of toe
• Patient was hospitalized in RSUP Sardjito, diagnosed
with cervical Schwannoma, went through removal
tumor surgery by the neurosurgeon
• The complaint was recovered, patient activities
become normal again
Denied : Shortness of breath, dropped eyelid, blurred vision, double vision, fever, seizure, decrease of
consciousness, nausea, vomiting, diarrhea, pallor, facial muscle twitching, swallowing difficulty, disphonia,
dysartria, hypersalivation
 Recent Medical History
9 months before

• Patient felt the weakness was worsened again in all

extremities
• Patient was hospitalized again and diagnosed with
cervical Schwannoma.
• Patient go through the surgery for the second time
• The weakness was recovered but not back to normal.
Patient still had difficulty in activities
• Patient had to consumed routine drugs and routinely
controlled to neurologist
• MP 3x8mg, Mecobalamine 2x1 tab, Lansoprazole 2x1 tab
Denied : Shortness of breath, dropped eyelid, blurred vision, double vision, fever, seizure, decrease of
consciousness, nausea, vomiting, diarrhea, pallor, facial muscle twitching, swallowing difficulty, disphonia,
dysartria, hypersalivation
 Recent Medical History
3 months before admission

• Patient get injured while he do some exercise

• He feels pain in his back and the weakness was
worsened
• Hospitalized in RSUP Sardjito, diagnosed with slight
compression in lumbal 1 vertebra
• The weakness was recovered but not back to normal

Denied : Shortness of breath, dropped eyelid, blurred vision, double vision, fever, seizure, decrease of
consciousness, nausea, vomiting, diarrhea, pallor, facial muscle twitching, swallowing difficulty, disphonia,
dysartria, hypersalivation
 Recent Medical History
2 weeks before admission
• Patient trying start to decrease consumpting
methylprednisolone
• The weakness was worsened again
• He also start to feel the numbness again from below
the neck until his foot
Day of admission
• The complaint was getting heavier
• He cannot move his legs
• Patient had slight difficulty to control his urinary
urgency

Denied : Shortness of breath, dropped eyelid, blurred vision, double vision, fever, seizure, decrease of
consciousness, nausea, vomiting, diarrhea, pallor, facial muscle twitching, swallowing difficulty, disphonia,
dysartria, hypersalivation
Past History Family History
• Diagnosed with Denied:
cervical Schwannoma • HT
• Diagnosed with • DM
compression of
• Stroke
lumbal 1 vertebra
• Smoker for 9 years • Tumor
• Heart disease
• Denied :
• History of other tumor
• Hypertension
• DM
 Systemic Anamnesis
Cerebrospinal system : numbness below the neck
Cardiovascular system : no complaint
Respiratory system : no complaint
Musculoskeletal system : weakness in all extremities
Genitourinary system : urinary incontinensia
Integumentum system : striae (+), thin skin appearance

Summary of Anamnesis
A man, 28 years old, came to emergency department with
worsening of weakness in all extremities in cervical Schwannoma
patient. Patient already go through surgery in 2012 and 2017.
Routinely control to neurologist and consumed
methylprednisolone, mecobalamine, lansoprazole
 Temporary Diagnosis

Tetraparese flaccid dd spastic cum hypoestesia

Clinical Diagnosis major part of body cum urinary incontinensia

Topical Diagnosis Cervical spinal cord

Ethiological Diagnosis Tumor (History of cervical Schwannoma)

Other Diagnosis Cushing Syndrome

 Physical Examination
General Status (July 28th, 2018)
General condition : Weak
W=75 kg, H=168 cm, BMI: 26.57 (obese)

BP : 128/85 mmHg
HR : regular, 120 bpm
RR : 16x/minute
Temp : 36,5°C

NPS :0
 Neurology Examination
Consciousness : CM, E4V5M6

Head : Isochor Pupils, ∅3 mm/3mm,

Light Reflex +/+, Corneal Reflex +/+,
Nystagmus (-)
Cranial Nerves : within normal limit
Neck : Meningeal Sign (-), Neck Rigidity (+)
Chest : Ronkhi (-), Heart murmur (-)
Extremities :
weakness weakness 3/3/2 4/4/3
motion strength
weakness weakness 1/1/1 2/2/2

normal normal - -
tonus edema
normal normal - -
◻ NEUROLOGICAL STATUS

Physiologic +3 +3 Pathological + +
Reflex +4 +4 Reflex + +

Clonus + +

⬜Sensibility : hipoestesia from below thoracal 2 dermatome

Sharp and Blunt sensation Decrea

se
Temperature Decrea
se
Vibration Decrea
se
Joint Position test Impaire
d
⬜Vegetative : Urinary Incontinensia
Laboratory Examination
Leucocyte 8,39 x 103/µL SGOT 41 U/L

Erythrocyte 5.36 x 106/µL SGPT 60 U/L

Hemoglobin 15.9 g/dL BUN 9 mg/dL

Haematocrit 44,9% Creatinin 0.67mg/dL

Thrombocyte 208 x 103/µL Chloride 103mg/dL

Neutrophil 87,3 % Natrium 140 mmol/L

Eosinophil 0% Kalium 4,06 mmol/L

Basophil 0.1 % GDS 121 mg/dL

Lymphocyte 6,8 % Albumin 3,4 mg/dL

Monocyte 5,6%
 Radiology Examination
Chest X-ray, July 27th, 2018

Expertise Result :
-Cor and pulmo within
normal limit
-There is no sign of skeletal
metastase in visualized bone
 Radiology Examination
MRI Cervical, December 21st,
2017
 Radiology Examination
MRI Cervical, December 21st,
2017
 Radiology Examination
MRI Cervical, December 21st,
2017
 Radiology Examination
MRI Cervical, December 21st,
2017
Radiology Examination
MRI Cervical, December 21st,
2017
Radiology Examination
MRI Cervical, December 21st,
2017
 Problems

• Immobilized patient
• Relapsing illness
• Cushing syndrome
• Therapy management
 Final Diagnosis
Spastic tetraparese cum hypoestesi
Clinical Diagnosis below thoracal 2 dermatom cum urinary
incontinensia

Topical Diagnosis Cervical spinal cord

Ethiological Diagnosis Tumor (Schwannoma)

Other Diagnosis Cushing Syndrome

 Therapy
- IVFD NaCl 0.9% 16 dpm
- Methylprednisolone inj 125mg/8hours
- Ranitidin inj 50mg/12hours
- Sucralfat syr 10ml/8 hours

Plan
- MRI
 Prognosis

Death : Bonam
Disease : Bonam
Dissability : Bonam
Discomfort : Malam
Dissatisfaction : Malam
Destitution : Malam