MORNING REPORT

Monday , 22 February 2021

Doctor Specialist: Dyah Yuniati, dr., Sp. S

Co-ass : Yuniar Revayanti I (6120020041)
 Neurology’s patient in Emergency Room

Neurology patients :
Mr. A, 32 years old

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 Patient Identity
 Name : Mr. A
 Age : 32 years old
 Gender : Male
 Marriege :
 Occupation :
 Address : Berbek IB/7A, Sidoarjo, RT.004, RW. 001, Desa/Kel. Berbek, Kec. Waru, Kab.
Sidoarjo
 Examination date : 13/02/2021

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 Anamnesis

Main complain : Fever

Present illness history :
• Demam sudah 2 minggu ini, terutama malam hari
• Mual
• Perut terasa penuh
• Muntah sering
• Batuk sudah sembuh
• cold sweat at night? (-)
• muscle ache ? (+) 2 minggu
• sore throat ? (+)
• Malaise? Kelemahan seluruh tubuh bersamaan dengan keluhan utama

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Past medical illness :
• Have experienced the same thing : ? (-)
• TB (), DM (-), HT (-), penurunan BB, merokok, batuk
• Covid history : (-)
• Transplant? (-)
• Transfusion? (-)
Family medical history :
• Have had the same thing : ? (-)
• DM (-), HT (-), TB(-)

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Medication used history :
Mengkonsumsi obat untuk nyeri
Habit / Social / Economic History :
• Exercise routine
• Alcohol consumption (), smoking (+)
• Pets (cats, dogs, goats, pigs etc.) ? (-) banyak kucing liar
• Frequently consumed foods?
• Habit (kerja diluar kota)

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 Objective
Physical Examination
General condition : relax
Awareness : GCS 3/1/4 ()
TTV
• TD : 110/60 mmHg
• HR : 100x/minute
• RR : 24x/minute
• Temperature : 37,8°C
• VAS :5
• SpO2 : 98
• BB : - kg

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Head-Neck Cardio (dbn)
Inspeksi :
 A/I/C/D : -
Palpasi :
 Trachea is central () Perkusi :
 Enlarged KGB and tyroid glands () Auskultasi :
 Palpable mass ()
 Increase JVP () Abdomen (dbn)
Inspeksi :
Auskultasi :
Pulmo (dbn) Palpasi :
 Inspeksi : Perkusi :
 Palpasi :
Extremity
 Perkusi : General weakness
 Auskultasi : Motorik 4

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 Fungsi Luhur dan Meningeal Sign

• GCS : Meningeal sign :

• Fungsi luhur :
• Disartria : Kaku kuduk : (+)
• Aphasia : Brudzinski I : -
Brudzinski II : -
BrudzinskiIII : -
Brudzinski IV : -
Kernig sign : -

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 Nervus Cranialis Examination
Nervus I
Kanan Kiri

Hiposmia/Anosmia - -

Parosmia - -

Halusinasi olfactorius - -

Nervus II
Right Left
Visus Hari ke 3 kesan normal >2/60 Hari ke 3 kesan normal >2/60
Tdk ada katarak dan Tdk ada katarak dan
konjungtivitis konjungtivitis

Visual field dbn dbn

Colour Mengenali warna baju pemeriksa Mengenali warna baju pemeriksa

Funduskopi

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Nervus III , Nervus IV , Nervus VI

Right Left
Tengah, gerak bola
Tengah, gerak bola
mata dbn, tidk ada
Eyeball position mata dbn, tidk ada
nistagmus
nistagmus

• To nasal
• To temporal
• To the top
Eyeball movement dbn Dbn
• To the Down
• To the lower temporal
• To the nasal top
Exophthalmos - -
Ptosis - -
• Shape
• Width
• Width difference
Pupil 3mm
• Direct light reaction
• Consensual light reaction
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Nervus V

Right Left
• Close the teeth (M.Masseter
and M.Temporalis)
Motoric Branch • Open Mouth (M. Pterygoideus
Lateralis)

• Raba
Sensory Branch • Nyeri
• Suhu

Reflex jaw jerk

Reflex kornea

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Nervus VII

Right Left
Quiet Time • Forehead wrinkles
• High brow
• The angle of the eye
• Nasolabial folds
Motorik • Raise the eyebrows (frontalis)
• Blindfold (orbicularis occuli)
• Nasal lobe (nasal)
• Whistling (orbicularis oris)
• Smiling (zygomatucus)
• Grimace (bisorius)
• Pulling the chin up (mentalist)
Tasting 2/3
front of the
tongue
Otonom Kelenjar lakrimal

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 Nervus VIII
Right Left
Vestibuler
Tuli konduksi
Tuli sensoris
Tes bisik dan detik arloji dbn dbn

Nervus IX, Nervus X

  Right Left
Gerakan Palatum
Gag Reflex

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Nervus XI
Right Left
Shrug (M. Trapezius) Normal
Turn face (M. normal
Sternocloidomastodius)

Nervus XII

Right Left
Tongue in Dbn
Tongue out Dbn
Atrofi Dbn
Fasikulasi Dbn 15
 Motorik
Trofi Otot : Kekuatan Otot : 4

 Inspeksi : ada atrofi?, fasikulasi ?  Upper extremity : 4

 Lower extremity :4
 Palpasi : hipertrofi?, dan peningkatan tonus?

Tonus Otot : Gerakan Spontan/Abnormal/Tak Terkendali :

 Hipotonus / Hipertonus (spastic/rigid)  Tremor/Chorea/Distonia/Athetosis (?)

Gait

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 Sensoris

Le. KA Le. KI Tung. KA Tung. KI Tub. KA Tub. KI

Rasa Eksteroseptik
• Rasa nyeri superficial
• Rasa suhu (panas/dingin)
• Rasa raba ringan
Rasa Propioseptik:
• Rasa gerak dan posisi
• Sensasi getar
• Nyeri tekan dalam

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Physiological Reflex : ?
Right Left
BPR
TPR
KPR
APR

+2
Cutaneus superficial reflex : -/-
Abdomen ?
Reflex plantar ?

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Pathological Reflex : -

Right Left
Babinski - -
Chadock - -
Gordon Reflex - -
Schaeffer Reflex - -
Openheim - -
Mendel – bechterew - -
Rossolimo - -
Gonda Reflex - -
Stransky Reflex - -
Hoffman - -
Tromner - -

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 Cerebellar sign :

Koordinasi Gerakan :
 Finger to nose :
 RAM :
 Fenomena rebound :

Keseimbangan :

Tonus :

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 Supporting Examination

 Darah Lengkap Hitung Jenis Leukosit  Hematologi Darah Lengkap (13/02/21)

(13/02/21) Pemeriksaan Hasil Nilai Rujukan

Pemeriksaan Hasil Nilai Rujukan Eritrosit 4.88 juta/uL 4,4-5,9 juta/uL

Basofil 1,34% 0-1% Hemoglobin 11.93 g/dL 13,2-17,3 g/dL

Neutrofil 61,12% 39,3-73,7% Hematokrit 38,6 % 40-50%

Limfosit 25,08% 25-40% RDW-CV 11,3% 11,5-14,5 %

Eosinofil 0,46% 2-4% Trombosit 298 ribu/uL 150-440 ribu/uL

Monosit 12,00% 2-8% MPV 7.248 fl 6,5- 11 fl

Leukosit 5,46 ribu/uL 3,8-10,6 ribu/uL

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 Supporting Examination

 Darah Lengkap Index Eritrosit (13/02/21)  Fungsi Ginjal (14/02/21)

Pemeriksaan Hasil Nilai Rujukan

BUN 10,4 mg/dl

Pemeriksaan Hasil Nilai Rujukan 10 – 20 mg/dl
Creatinin 0,95 mg/dl
MCV 79,1 fl 84,0-96,0 fL 0.5 – 1,1 mg/dl

MCH 24,4 pg 28,0-34,0 pg

 Elektrolit Natrium/ Kalium/ Chlo (Darah) (14/02/21)
MCHC 30,9 % 32-36%

Pemeriksaan Hasil Nilai Rujukan

Natrium 119,70mEq/L 135 – 147 mEq/L

Kalium 3,48 mEq/L 3,5 - 5,0 mEq/L

Klorida 89,40 Eq/L 95 – 105 mEq/L

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 Immuno Serologi (13/02/21)  Glukosa Darah (15/02/21)

 Immuno Serologi (15/02/21)  Biologi Molekuler (16/02/21)

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Foto Thorax

 Cor : Besar dan bentuk normal

 Pulmo : Tampak infiltrat di perihiller,

paracardial kanan

 Kedua sinus phrenicocostalis tajam

 Tulang-tulang dan soft tissue normal

 Kesimpulan :

suspek pneumonia interstitial

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CT Scan
 Tampak lesi hypodens batas tidak tegas yang cukup luas dilobus frontal
kiri

 Tak tampak deviasi mid line struktur

 System ventrikel menyempit

 Sulci dan Gyri merapat

 Tak tampak kalsifikasi di basal ganglia ka/ki

 Mastoid, sinus frontalis, ethmoidalis, sphenoidalis kanan kiri normal

 Tulang-tulang calvaria tampak normal, tak tampak fraktur

 Pons dan cerebellum kesan normal

 Kesimpulan : suspek cerebritis, DD : massa cerebri

 Advis: CT Scan kepala dengan kontras, oedem cerebri

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Subjective Objective Assesment Planning
 Main complain : Fever General Condition: Clinical Dx : Dx :
 Demam sudah 2 minggu ini,  GCS : 456 (compos mentis Fever • DL
terutama malam hari  TD : 127/84 mmHg Vomiting • Fungsi ginjal
 Nausea  HR : 90x/minute headache • Serum elektrolit
 RR : 100x/minute ? Nausea • EKG
 Vomiting Cough • GDA
 dispepsia  Temperature : 36°C
Malaise • SGOT SGPT
 Cough  spO2: 100% Myalgia • IgG igM toxoplasmosis
 cold sweat at night? muscle Kaku kuduk + • Foto thorax
ache ? sore throat ? Malaise?  Pemeriksaan fisik Decrease of consciousness • CT Scan kepala dengan kontras
 Past medical illness : • Immuno serologi (rapid HIV 1
 Fungsi Luhur dan Meningeal Sign Topis Dx : metode)
Have experienced the same
Meningen • Immuno serologi (sars cov-2
thing : ? Cerebri hemisphere ka/ki antibody)
TB (), DM (), HT ()  Nervus Cranialis :
• Tes ELISA
Covid history : Etiology Dx : • MRI
Transplant?  Motorik Meningitis • Polymerase Chain Reaction
Transfusion? Ensefalitis (PCR)
 Sensoris Tumor cerebri • CD4
 Family medical history : SAH
Have had the same thing : ?  Physiological Reflex Theraphy :
DM (), HT (), TB() Secondary Dx : • Amankan jalan nafas, spO2,
 Pathological Reflex dispepsia berikan oksigen
 Medication used history : • Perpertahankan sirkulasi
darah
 Cerebellar sign • Cegah peningkatan TIK
 Habit : Differential Diagnosis :
Meningitis • Infus dengan PZ (NaCL 0,9%)
 Foto thorax : Tampak infiltrat di Ensefalitis 1000cc/24 jam
perihiller, paracardial kanan Tumor cerebri • Cabang infus NaCL 3% 500cc/
 CT Scan : Tampak lesi hypodens batas SAH 24 jam
tidak tegas yang cukup luas dilobus • Pirimetamin (dosis awal
frontal kiri, System ventrikel 200mg, lanjutan 50-75mg/hari)
menyempit, Sulci dan Gyri merapat • Sulfadiazin (4-6 g/hari dosis
dibagi menjadi 4)
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• Leucovorin (calcium folinate
10-15mg/hari)
“ THANK YOU

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