MORNING REPORT

MONDAY, JULY 23TH, 2018

Resident in Charge: SEP/JAR/BIT/KAN/RIR

SUPERVISOR : dr. Dessika, Sp.S
MODERATOR : dr. Eko Arisetijono, Sp.S(K)
 Resume Of Duty
• Previous Duty Patients :
1. Mr. S/ 79 y.o/ W. 26 fl 1/ Susp. ME Viral with Vasculitis + Herpes Zooster Ophtalmicus D + HT st II +
Leukocytosis + Azotemia prerenal.
2. Mrs. Su/ 57 y.o/ SU/ CVA Emboli OD-3 + AF NVR + HF st B + HT st I.
3. Mrs. Sul/ 42 y.o/ W. 26 fl 1/ Status GTK Seizure dt Withdrawal OAE + Susp. Epilepsy Idiopathic dd
Symptomatic + Leukocytosis.
4. Mr. B/ 48 y.o/ ER Plan to W 12/ CVA ICH Thalamus D Vol. 3.8 cc 2nd Attack OD-2 + IVH + Mild
Hydrocephalus Pro Urgent VP Shunt + HT st II + Hipernatremia + Azotemia Renal ( Shift Leader NS).

• New Patients :
1. Mr. Dju/ 59 y.o/ ER plan to W. 29/ Susp. Meningitis TB with Vasculitis + Susp. TB Paru +
Pneumonia CAP + Ht st I.
2. Mr. Sur/ 52 y.o/ ER plan to W 26 fl 1/ Post Status GTK Seizure dt Susp. Post Stroke Epilepsy + CVA
Sequele + Ht st II + DM Type 2 + Hypokalemia.
3. Mr. Har/ 69 y.o/ ER plan to W Non Intensive/ CVA Thrombotic OD-4 + Ht st II + Hypokalemia +
Acute Diarrhea.
•  
Previous consultation :
1. Mrs. KT/ 56 y.o/ ER-Pulmonology --> SU/ CVA Thrombotic dt Hyperkoagulable State OH-
2 + HT st II + Adeno Ca Bronchogenic D T4N2M1b st IV ( Shift Leader Neuro).

New Consultation :
2. Mrs. Yun/ 37 y.o/ ER-OBG --> W. 22/ HNP Lumbalis ( NRS 7-8) + Tumor Solid Ovarium
( Shift Leader Neuro).
3. Mr. AW/ 35 y.o/ W. 29-Pulmonology Dept./ Susp. ME TB dd ME Fungi dd Toxoplasmosis
Cerebri + TB Milier + HIV + Hepatitis B ( Join care).
4. Mrs. FK/ 65 y.o/ W. 12-Ortho/ CVA Thrombotic 2nd Attack OD-2 + HT st I + Close
Fracture Regio Collum Femur D Post Arthoplasty + Peri Prostetic Fractur Regio Femur D
Post Pelvic Stabilization + Leukocytosis + Hypoalbuminemia ( Raber).
5. Mr. Suy/ 44 y.o/ CVCU-Cardio/ Hipoxic Encephalopathy + MassivePericard effusion
without Collapse Chamber + Pulmonary Hypertension Type III + CPC Decompensated +
Acidosis Respiratorik + SOPT + Pneumonia Atypical + Immunocompromised State +
Azotemia Prerenal + Slight Hyponatremia + Hypochloremia ( Did not join care).
Death : -
IDENTITY
Name : Mr. Dju
Age : 59 yo
Address : Singosari
Occupation : private employee
Hospitalized : July 20th, 2018
Reg. No : 1139xxxx
History Taking
Chief complaint: Half body weakness
The patient suffered from right half body weakness gradually since 4 days ago,
with assymetrical face. Patient also experienced hoadeache especially at back of
head since 5 days ago, and accompanied with low grade fever. The patient also had
cough since 1 month ago.
There were no half body tingling/numbness, slurred speech, seizure, vertigo,
ataxia, difficulty to swallow, double vision, blurred vision, forgetfullness, or
shortness of breath, disturbaance of defecaion and miction (-), decreased of body
weakness (-).
History of past illness:
• History of lung TB before (-)
• History Ears infection (-)
• History of tootache (-)
• History of exposed to TB patient (-)
• History of tumor (-)

History of medication:
• 3 days before admission, pasien hospitalized to Private Hospital and diagnosed with susp ME

Family history:
• There were no family members that have the same complain as the patient.

Lifestyle:
• The patient didn’t use to smoke, consume an alcohol, or do some exercises, free sex-, alcoholic-.
Timeline

The patient
admitted to
private hospital
The patient suffered from cough since 1 and suspected to
month ago, ME

The patient suffered form gradual

half body weakness and
assymetrical face 4 days ago
 Physical Examination:
Internal Status
Vital Sign: BP 140/90, Resp 22 tpm, HR 90 bpm, temp axilla: 360C

Head and neck Anemic -, icteric –

Enlargement of lymph node (-)
Thorax Cor: S1S2 single, murmur (-)
Pulmo: Vesicular +/+ , rhonki -/- wheezing -/-

Abdomen Flat soefl, normal intestine sound

Liver/spleen unpalpated

Extremity Edema -/- warm acral

Anemic -/-
 Neurological Status
GCS: 456, HCF: Aphasia , Alexia , Agraphia , Agnosia , Apraxia  wnl

Meningeal Sign Nuchal rigidity (+), Burdzinski I-IV (-) , Kernig (-)

N. I (Olfactorius) Hyposmia, Anosmia, Hyperosmia, Parosmia  wnl

N. II (Opticus) Visual Acuity dte, Funduscopy (Papil Edema -/-) ,

Visual field wnl

N. III , IV, VI Ptosis (-), pupil in the middle, round isocor 3 mm/3
(Okulomotor, mm , Light reflect +/+ , Eye movement wnl
Troklearis,
Abducens)
N. V Masseter Reflex, Sensory  wnl

N.VII Motoric: parese D UMN type

Bell Sign and Lagophtalmus (-) , Sensory of the taste,
Hiperacusis (Stapedius raflex) wnl

N. VIII Whispered test, Schwabach , Rinne , Weber  wnl,

Nistagmus (-/-)

N. IX, X Palatum arcus, Gag Reflex, Vernet’s Rideau Phenomen

, Disfagia , Disfonia  wnl

N. XI wnl

N. XII wnl
Motoric Inspeksi: atrophy (-)
Tonus: N| N
N| N

Power: 3| 5
3| 5
Sensoric - Protopathic (Touch, Pain, Temperature)  wnl
- Propioceptive (Position, Trill, Deep pain)  wnl

Autonom wnl

Physiological Reflex BPR +2/+2 TPR +2/+2 KPR +2/+2 APR +2/+2

Pathological Reflex H/T --/--, B +/+, C-/-, O -/-, G-/-, S -/-

Primitive reflex Palmomental -/-, snout -/-, sucking -/-, grasping -/-
Clinical Dx:
Male, 59 yo
Acute gradual Hemiparese D
Acute parese N VII D UMN
Headache
SubFebris
Nuchal Rigidity (+)
Cough 1 month
Thwaits score 2

Topical dx: Meningen

Ethiological dx:
Susp Meningitis TB with vasculitis dd Bacterial

Secondary dx:
Susp. Lung TB
HT St 1
PDx:
• Lumbal puncture
• Head CT scan + contrast
• ECG
• Chest X-Ray AP
• CBC, RBG, LFT, RFT, SE, Albumin, FH (INR)
• Co/ Pulmonology
 LABORATORY RESULT NORMAL VALUE UNIT
12,00
Hb 13,4-17,7 g/dL
12.170
Leucocyte 4.700-11.300 /µL
35,80
Hematocrit 40-47 %
364.000
Thrombocyte 142.000-420.000 /µL
31
SGOT 0-40 U/L
36
SGPT 0-41 U/L
118
GDS <200 mg/dl
38,80
Ureum 16,6-48,5 mg/dL
1,01
Creatinine <1,2 mg/dL
134
Na 136-145 mmol/L
4,39
K 3,5-5,0 mmol/L
100
Cl 98-106 mmol/L
 LABORATORY RESULT NORMAL VALUE UNIT
10,70
PPT 9,4 – 11,3 Second (s)

1,03
INR
26,20
APTT 24,6 – 30,6 Second (s)
Non Reactive
Anti HIV
70
ESR < 20 mm/hour
1,08
Bil Tot <1,0 mg/dL
0,78
Bil Direct < 0,25 mg/dL
0,30
Bil Indirect < 0,75 mg/dL
LCS Result I Result II Normal range
macroscopic
Color No color No color
Clot - -
Clearness clear clear
Microscopic
Ery 500 0
Leuco 10 10
PMN 0 0
MN 100% 100%
Chemistry
Protein 168,2 173,3
Glocose 66
LDH Hasil menyusul 98
Nonne + +
Pandy + +
Head CT scan + contrast (20/07/18)
Conclusion:
There is no pathological lesion brain intraparenchim

Head CT scan + contrast (19/05/18)

Chest X-Ray AP
(19/07/2018)
private hospital

• Cardiomegali
• KP sinistra minimal
lesion
ECG

• Sinus Takikardi 108 x bpm

PTx :
• Head of bed elevation 300
• IVFD NaCl 0,9% 20 dpm
• Inj. Antrain 3x1 gr iv (prn)
• Inj. Omeprazole 1x40 mg iv
• Inj. Streptomicin 1x1 gr i.m
• P/NGT:
• RHZ (600/400/1000 mg) 1x1
• Vit B6 1x 25 mg
• Diet HCHP 1500 kkal/day

PMo : VS, GCS, Subjective, sign of increase intracranial

pressure
Co/ Pulmonology department
Assessment:
• Susp ME TB
• Susp Lung TB
• Pneumonia CAP

PDx: Sputum TCM, Sputum kultur Media LG

PTx:
• Ceftriaxon injection 2x1 gr
• OAT if diagnosis Positive
• Po: Azithromicine1x500 mg (3 days)
NAC 2x600 mg

The patient will be joined care.

Thank You