STRUCTURE

MORNING REPORT
Saturday, January 27th 2024
Supervisor: dr. Yovita Andhitara, Sp.N(K), MSi.Med, FINS, FINA
ON CALL TEAM

Emergency room : dr. Bagus

US : dr. Anin
Consul : dr. Resita and dr. Irena
Tandem US : dr. Annisa
Yellow Ward : dr. Nova
Red Ward : dr. Lana, dr. Sisil, and dr. Anti
PATIENT’S IDENTITY

Name (Initial) : Mr. EY

RM Number : C974XXX
Age : 21 years old
Gender : Male
Adress : Semarang
Occupation : self-employed
Hospital admission : 27th January 2024
HISTORY (AllO ANAMNESIS)

• Chief complaint: Decreased consciousness

• Onset: 1 week SMRS
• Quality: Spontaneous eye opening but contact (-)
• Quantity: ADL fully assisted by family
HISTORY (ANAMNESIS)
Chronology

Since -/+ 2 weeks before admission, the patient complained of weakness throughout the body, swelling
throughout the body, the patient was hospitalized in Salatiga Hospital, after hospitalization the patient
improved. The patient was discharged for outpatient control. At that time the patient contact and
communication (+), seizure (-).
-/+ 1 week before admission, 3 days after the patient was admitted from Salatiga Hospital, the patient had
2x seizures in 1 day, during the day the seizure form was stiff throughout the body, lasted 5 minutes, the
eyes glanced up during the seizure the patient was unconscious, after the seizure the patient was limp. The
second seizure was in the evening, before the seizure the patient was babbling, the patient then had a
seizure, the form of the seizure was rigid throughout the body, 5 minutes, the seizure stopped on its own,
after the seizure the patient was limp. Since then contact and communication were minimal, stiffness of all
four limbs and fever (+). According to the patient's mother, the patient never complained of headache
before or after the seizure.
HISTORY (ANAMNESIS)
Chronology

When examined in the room, the patient opened his eyes spontaneously, blank stare, the patient could not
follow commands to move limbs, stiffness of all four limbs when moved, Fever has dropped, seizures (-).
History of traveling was denied, history of transfusion was denied.
HISTORY (ANAMNESIS)

Concomitant symptoms : heartburn, hair loss

Aggravating factors : head position, waking up
Relieving factors : rest and taking pain medication.
PAST MEDICAL HISTORY
• Patients with special needs (+)
• History of Nephrotic Syndrome (+) Internal medicine poly control

PAST MEDICAL FAMILY HISTORY

• No relatives with similar complaints
SOCIO-ECONOMIC HYSTORY
• The patient still lives with his parents. The patient is unemployed. Treatment
with BPJS, socioeconomic impression is adequate.
CLINICAL FINDINGS – Present States

• General Status : Apathy

• GCS : E4M5V3
• BP : 120/75 mmHg
• HR : 88 bpm
• RR : 20x/minute
• Temp : 37 C
• SpO2 : 100% Room Air
• Body Weight : 60 kg
Cor : on normal limit • Body Height : 162 cm
Pulmo : on normal limit • Body Mass Index : 22.9 kg/m2
Abdomen : on normal limit (normoweight)
CLINICAL FINDINGS –
Neurological Status
Eyes : round isochor pupils, diameter 3 mm/3 mm, direct indirect light reflex (+/+)
Neck : stiff neck (+)
Nn. Cranialis : difficult to evaluate

Motoric Sup Inf

Movement difficult to evaluate (stiffness of all four extremities)
Strength lateralization is not clear, the patient is difficult to evaluate
Tonus Hiper/Hiper Hiper/Hiper
Trophy E/E E/E
Physiological Reflex +++/+++ ++++/+++
Patological Reflex H+T+/H+T+ -/-
Clonus -/+
Sensibility : difficult to evaluate
Vegetative : With diaper, NGT attached (+)
Kernig sign (+)
 Laboratorium (27/01/24)
EXAMINATION RESULT HR EXAMINATION RESULT HR
GDS 49 80 – 160 L
Hb 15.1 13.2 – 17.3
Natrium 142 136 – 145
Ht 46.1 32 – 62 Kalium 3.6 3.5 – 5.0
Eritrosit 5.36 4.4 – 5.9 Chlorida 102 95 – 105
Ureum 19 15-39
MCH 27.7 27 – 32
Creatinin 0.7 0.6-1.3
MCV 84.4 76 – 96 Magnesium 1.3 0.74 – 0.99 H
MCHC 32.8 29 – 36 Calcium 2.3 2.12 – 2.52

Leukosit 12 3.6 – 11 H
Trombosit 330 150 – 400

RDW 13.1 11.6 – 14.8

MPV 10.2 4.00 – 11.00
Thorax Photo 26/1/24

Expertise :
- Cor not enlarged
- Pulmo does not appear
abnormal
MSCT of the head without contrast 12/1/24

Expertise :
- White matter infarction in
parietal lobe dextra with
subdural hygroma in
temporalis region dextra
- No intracerebral mass / SOL
- There was no intracerebral
hemorrhage.
- There was no subfalcin
herniation
- Sinusitis maxillaris dextra
picture
MSCT of the head without contrast 12/1/24

Expertise :
- White matter infarction in
parietal lobe dextra with
subdural hygroma in
temporalis region dextra
- No intracerebral mass / SOL
- There was no intracerebral
hemorrhage.
- There was no subfalcin
herniation
- Sinusitis maxillaris dextra
picture
MSCT of the head without contrast 12/1/24

Expertise :
- White matter infarction in
parietal lobe dextra with
subdural hygroma in
temporalis region dextra
- No intracerebral mass / SOL
- There was no intracerebral
hemorrhage.
- There was no subfalcin
herniation
- Sinusitis maxillaris dextra
picture
ASSESMENT
1.
DK:Meningeal sign stiff kuduk (+) Kernig sign (+)Acute symtomatic seizure
DT: Intracranial
DE: Susp meningoencephalitis

2. History of Nephrotic Syndrome

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PROGRAM

Neurology Program
• Observation of KU, TTV, neurological deficit, seizure Lumbar puncture
• Consul TS Medical Rehabilitation dr. Wahyudati, Sp.KFR
• CT Scan Head with contrast

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MANAGEMENT
Neurology Therapi
• Inf. RL 12 tpm
• Paracetamol injection 1 gram/8 hours i.v.
• Dexamethasone 10 mg/8 hours i.v.
• Ranitidine 50 mg/12 hours i.v.
• Diazepam 10 mg i.v slow bolus if seizure, can be repeated 1 time
with a minimum distance of 5 minutes
• inj. Phenytoin 200mg/24 hours bolus for 5 minutes

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THANK YOU DOCTOR