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MENINGITIS TUBERCULOSIS
SENIOR CLINICAL CLERKSHIP
By :
Frida E A Wulandari
04124708008
04101401056
Advisor
DEPARTMENT OF NEUROLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
MOHAMMAD HOESIN GENERAL HOSPITAL
PALEMBANG
2014
ENDORSEMENT PAGE
Case Report
MENINGITIS TUBERCULOSIS
Presented by:
Frida E A Wulandari
04124708008
Nahtadia L Pohan
04101401056
Has been accepted as one of requirements in undergoing senior clinical clerkship period of
August 4th September 8th in Department of Neurology Faculty of Medicine Sriwijaya
University Mohammad Hoesin General Hospital Palembang.
IDENTIFICATION
Name
Age
Sex
Occupation
Admitted
ANAMNESIS
Patient was admitted to decreasing level of consciousness
2 days before admission patient was having a difficulty to communicate with his
family, he was just lying on bed, and sometimes freaked out and blabbering. The history of
headache (+), high fever (+).
Patient was once diagnosed with meningitis TB approximately 2 months ago, with
chief complaint headache (+), convulsion (+), and decreasing level of consciousness. Patient
was treated with MDT-TB category 1, and it only lasted for 2 days.
This is the second time, patient presents these symptoms.
PHYSICAL EXAMINATION
PRESENT STATE
Internal State
Conciousness
Nutrition
Temperature
Pulse
Respiratory rate
Blood pressure
: E3M5V3
: Sufficient
: 36.7 oC
: 80 beats/min
: 20 times/min
: 100/70 mmHg
Heart
Lungs
Liver
Spleen
Extremities
Genital
Psychiatric state
Attitude
Attention
: Cooperative
: Normal
Facial Expression
: Natural
Psychological contact : Natural
: Brachicephaly
: Normal
: Yes
: No
: No
Deformity
Fracture
Fracture pain
Vessel
Pulsation
: No
: No
: No
: No widening
: No disorder
: Straight
Deformity
: No
Neurological state
Head
Shape
Size
Symetric
Hematome
Tumor
Neck
Position
: No abnormality
: No abnormality
: No abnormality
: No abnormality
: See neurological state
: No abnormality
Torticolis
: No
Nape of neck stiffness : No
CRANIAL NERVES
N.I: Olfaktorius nerve
Smelling
Anosmia
Hyposmia
Parosmia
N.II: Opticus nerve
Visual acuity
Campus visi
Anopsia
Hemianopsia
Oculi fundus
Edema papil
Atrophy papil
Retina bleeding
N.III: Occulomotorius,
N.IV: Trochlearis, and
N.VI: Abducens nerves
Diplopia
Eyes gap
Ptosis
Eyes position
Strabismus
Exophtalmus
Enophtalmus
Deviation conjugae
Eyes movement
Pupil
Shape
Size
Isochor/anisochor
Midriasis/miosis
Light reflex
direct
consensuil
accommodation
Argyl Robertson
Tumor
Vessels
: No
: No widening
Right
No disorder
No
No
No
Left
No disorder
No
No
No
Right
6/6 PH (-)
V.O.D
Left
6/6 PH (-)
V.O.S
No
No
No
No
No
No
No
No
No
No
Right
No
No
No
Left
No
No
No
No
No
No
No
No abnormality
No
No
No
No
No abnormality
Round
3mm
Isochor
No
Round
3mm
Isochor
No
Positive
Positive
Positive
No
Positive
Positive
Positive
No
Right
No disorder
No
Yes
Left
No disorder
No
Yes
Normal
Normal
Normal
Normal
Normal
Normal
Right
Simetric
Normal
Normal
Normal
Left
Simetric
Normal
Normal
Normal
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
Right
No disorder
No disorder
Normal
Normal
Left
No disorder
No disorder
Normal
Normal
No
No
No
No
Right
No disorder
No disorder
No
No
Normal
Left
No disorder
No disorder
No
No
Normal
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
Caroticus sinus
Sensory
1/3 posterior tounge
No disorder
No disorder
Right
No disorder
No disorder
Left
No disorder
No disorder
Right
No deviation
No
No
No
Left
No deviation
No
No
No
Right
Lateralisation (-)
Lateralisation (-)
decrease
Left
Lateralisation (-)
Lateralisation (-)
decrease
Right
Lateralisation (-)
Lateralisation (-)
decrease
Left
Lateralisation (-)
Lateralisation (-)
decrease
negative
negative
negative
negative
Decrease
Decrease
Decrease
Decrease
Positive
Positive
Negative
Negative
Negative
Negative
Negative
Positive
Positive
Negative
Negative
Negative
Negative
Negative
MOTORIC
Arms
Motion
Power
Tones
Physiological Reflex
Biceps
Triceps
Radius
Ulna
Pathological Reflex
Hoffman Tromner
Leri
Meyer
Trofik
LEG
Motion
Power
Tones
Clonus
Thigh
Foot
Physiological reflex
KPR
APR
Pathological reflex
Babinsky
Chaddock
Oppenheim
Gordon
Schaeffer
Rossolimo
Mendel Bechterew
Abdominal skin reflex
Upper
Middle
Lower
Tropik
SENSORY
Can not be assessed
PICTURE
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
VERTEBRAL COLUMN
Kyphosis
Lordosis
Gibbus
Deformity
: Yes
: No
: No
: No
Tumor
Meningocele
Hematome
Tenderness
: No
: No
: No
: No
Left
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
ABNORMAL MOVEMENTS
Tremor
: No
Chorea
: No
Athetosis
: No
Ballismus
: No
Dystoni
: No
Myoclonus
: No
VEGETATIVE FUNCTION
Micturition
: Catheterized
Defecation
: No abnormality
LIMBIC FUNCTION
Motoric aphasia
: No
Sensoric aphasia
: No
Apraksia
: No
Agraphia
: No
Right
Yes
Yes
No
Alexia
Nominal aphasia
: No
: No
LABORATORY FINDINGS
BLOOD (20 August 2014)
Hb
: 13.0 gr/dl
Erythrocyte
: 4.31 mil/mm3
Hematocrit
: 35 vol%
Leucocyte
: 8900/mm3
LED
: 35 mm/hour
Thrombocyte
: 288000/mm3
Diff Count
: 0/0/0/84/10/6
Total cholesterol
: 225 mg/dl
Ureum
: 17 mg/dl
Creatinin
: 0.93 mg/dl
Na
: 136 mmol/l
K
: 5.6 mmol/l
(12-16)
(4.0-5.0)
(37-43 vol%)
(5000-10000)
(<38)
(200.000-500.000)
(0-1/1-3/2-6/50-70/20-40/2-8)
(<200)
(15-39)
(0,6-1,0)
(135-155)
(3,5-5,5)
URINE
: Not Performed
CEREBRO SPINAL FLUID : Patients family refused to perform the lumbal punctie
SPECIFIC EXAMINATION
Cranium X- Ray
Chest X- Ray (June 14th 2014)
Lung tuberculosis suspected
Head CT-Scan (June 13rd 2014)
old infarction at left interne capsule
: Not performed
: minimal infiltration at upper-middle lung,
: mild ventriculomegaly with edema and an
RESUME
IDENTIFICATION
Name
Age
Sex
Occupation
Admitted
ANAMNESIS
Patient was admitted to decreasing level of consciousness
2 days before admission patient was having a difficulty to communicate with his
family, he was just lying on bed, and sometimes freaked out and blabbering. The history of
headache (+), high fever (+).
Patient was once diagnosed with meningitis TB approximately 2 months ago, with
chief complaint headache (+), convulsion (+), and decreasing level of consciousness. Patient
was treated with MDT-TB category 1, and it only lasted for 2 days.
This is the second time, patient presents these symptoms.
PHYSICAL EXAMINATION
Conciousness (GCS score) : GCS 11 (E3M5V3)
Temperature
: 36.7 oC
Pulse
: 80 beats/min
Respiratory rate
: 20 times/min
Blood pressure
: 100/70 mmHg
Neurological examination:
N III
Right trunk
Movement
Lateralisation (-)
Power
Lateralisation (-)
Left trunk
Right arm
Left arm
+BC
+BC
Tonus
Klonus
Physiological ref
Pathological ref
Sensory function
Limbic function
: no disorders
Vegetative function
: catheterized
Meningeal signs
LABORATORY FINDINGS
BLOOD (20 August 2014)
Hb
: 13.0 gr/dl
Erythrocyte
: 4.31 mil/mm3
(12-16)
(4.0-5.0)
Hematocrit
Leucocyte
LED
Thrombocyte
Diff Count
Total cholesterol
Ureum
Creatinin
Na
K
:
:
:
:
:
:
:
:
:
:
35 vol%
8900/mm3
35 mm/hour
288000/mm3
0/0/0/84/10/6
225 mg/dl
17 mg/dl
0.93 mg/dl
136 mmol/l
5.6 mmol/l
(37-43 vol%)
(5000-10000)
(<38)
(200.000-500.000)
(0-1/1-3/2-6/50-70/20-40/2-8)
(<200)
(15-39)
(0,6-1,0)
(135-155)
(3,5-5,5)
URINE
: Not Performed
CEREBRO SPINAL FLUID : Patients family refused to perform the lumbal punctie
SPECIFIC EXAMINATION
Cranium X- Ray
Chest X- Ray (June 14th 2014)
Lung tuberculosis suspected
Head CT-Scan (June 13rd 2014)
old infarction at left interne capsule
DIAGNOSIS
Clinical diagnosis
: Not performed
: minimal infiltration at upper-middle lung,
: mild ventriculomegaly with edema and an
Topical diagnosis
: meningen, encephalon
Ethiology diagnosis
: meningoencephalitis TB
MANAGEMENT
Non-pharmacology
Pharmacology
:
IVFL NaCL gtt XX/menit
Rifampisin tab 600 mg 1 x 1
Isoniazid tab 400 mg 1 x 1
Pirazinamid tab 500 mg 2 x 1
Dexamethasone ampoule 4x1
OMZ vial 40 mg 1x1
Haloperidol 3 mg 2x1.5 mg
Risperidone 4 mg 2x2 mg
Planning
:
Lumbal punctie
Head CT Scan with contrast
PROGNOSIS
Quo ad vitam
Quo ad functionam
: Dubia ad bonam
: Dubia ad malam
CASE ANALYZE
Differential diagnosis of etiology
Meningitis
1) Decreasing level of consciousness
2) Nape stiffness
3) Headache
Encephalitis
1) Decreasing level of consciousness
2) Convulsion
3) Headache
1)
2)
3)
4)
Meningoencephalitis
Decreasing level of consciousness
Headache
Convulsion
Nape stiffness