MORNING REPORT

NEUROLOGY A-21
April 17th 2015

Patient Identity

Name: Mr.
KhuNam
Age: 45 years old
Sex: Female
Address: Paciran,
LA
Occupation:
Sailorman
Religion: Moslem

Last Education:
Junior High School
MR Number:
29.00.91
Room: Zam-zam
14
Admission: April
16th 2015

ANAMNESIS

Chief complaint: headache

Present illness history: Patient complained with
severe headache since 1 month, and get worse
for 1 week. Headache felt like theng-theng
in all parts of the head, especially on the back
of head and the patient's head was throbbing
pain in head. Pain occur continuously over
time, day by day. Felt more severe pain when
a change of position, especially when getting
out of bed. Since then the patient can not walk
because of dizziness and sight began to blur.
double vision -, seizures-, . She had vomiting
for 3 times, like nyembur, or incontinence
and complained of no memory problems. Fever
(-), nosebleed (-), hearing loss (-), tinnitus (-)

Previous Illness History

denied a history of hypertension and diabetes, asthma (-),

cardiac disease (-), drugs allergy (-) patients had been treated at
the hospital about 1 week with diagnosis of cerebellar abscess

Family History of Disease

had no family history of tumors and similar
complaints

General Physical
Examination
Status Present

Awareness : 456
BP: 114/86 mmHg
pulse: 89x/minutes
Temp: 36 C
RR: 20x, reguler
Anemic: Icterus: Cyanotic: -

Thorax

Inspection: symmetrical chest wall

movement
Palpation: fremitus + / +
Lung:
Percussion: sonor / sonor
Auscultation: vesicular / vesicular
heart:
Percussion: V ICS parasternal right limit dex,
the left boundary of V mid clavicula sin ICS,
ICS II upper left parasternal
Auscultation: S2 S1 single murmur (-) Gallop
(-)

Abdomen

Inspection: flat
Palpation: soepel, tenderness (-)
Percussion: Tympani
Auscultation: BU (+) N
Liver: no palpable
Lien: no palpable

Psychological Status

Affective and emotional: within normal

limits
The process of thought: within normal
limits
Intelligence: within normal limits
Absorption: within normal limits
Willpower: within normal limits
Psychomotor: within normal limits

Neurological Status

head:
Position: normocephali
Protrusion: (-)
Shape / size: normal impression

Cranial Nerve

N.I (olfactory)
Smelling: within normal limits
N.II (optic)
Visual acuity: OD> 2/60, OS 1/60
Field of view: within normal limits / within
normal limits
Funduscopic: not evaluated

N.III (okulomotorius)
Ptosis: - / Eksoftalmus: - / Eye movements: well in all directions / well
in all directions
Size: 3mm/3mm, isokor
Light reflex: + / +
N.IV (trokhlearis)
The position of the eye: ortoforia / ortoforia
Eye movements: well in all directions / well
in all directions
N.VI (abduscen)
eye ball movement : well in all directions
cannot / glance in lateral views, diplopia (+)

N.V (trigeminal)
sensibility:
V1: wnl / wnl
V2: wnl / wnl
V3: wnl / wnl
motor:
Inspection: wnl / wnl
Palpation: wnl / wnl
Chewing: wnl / wnl
Biting: wnl / wnl
Reflex chin / masseter: wnl
Corneal reflexes: + / +

N.VII (fascialis)
wnl
N.VIII
Seconds watches: wnl / wnl
Voice whispered test: wnl / wnl
Test weber: not evaluated
Rinne test: not evaluated
N.IX (glossifaringeus)
Taste: wnl
N.X (vagus)
Pharyngeal arch Position: wnl
Vomiting reflex: +

N.XI (accessory)
Shrug: + / +
Turning heads: + / +
N.XII (hipoglosus)
Devisasi tongue: - / Fasciculations: - / Tremor: - / Atrophy: - / -

Neck

Inflammatory markers meninges

Stiff neck: Kernig's sign: Carotid Artery: + / +
Palpation: Strong palpable / palpable
strong
Auscultation: bruit (-) / bruit (-)
Thyroid: - / -

Abdomen

Abdominal wall skin reflexes

+
+

+
+

vertebral column
Inspection: wnl
Palpation: wnl
Movement: wnl
Percussion: wnl

extremity

motor
Movement: wnl/wnl

Strength : 5 5
5 5
Muscle tone:
Spastic: - / Rigidity: - / Klonus knee: - / Klonus Achilles: - / -

Physiological reflex:
BPR: N / N
TPR: N / N
KPR: N / N
APR: N / N
Radius: N / N
Ulna: N / N
pathological reflexes
Hoffman tromer: - / - Gordon: - / Babinzki: - / - Schaefer: - / Chaddock :-/ - Oppenheim: - / Mendel B: - / - Rossolimo: - /

sensibility
Eksteroseptif:
Pain: wnl / wnl
Temperature: wnl / wnl
Touch: wnl / wnl
proprioceptive
Shakes: wnl / wnl
Position: wnl / wnl
Flavor combinations (combine sensation)
Stereognosis: wnl / wnl
Barognosis: wnl / wnl

Impaired coordination
Finger-nose test: wnl / wnl
Test pronation / supination: wnl / wnl
Examination of the function of the
sublime:
Affective / emotional: good impression
Language skills: good impression
Memory: good impression
Visualspasial: good impression
Intelligence: good impression

Laboratory Findings

Diffcount: 0/0/80/15/5
Hematokrit: 43,9 %
Hemaglobin: 15,6 g/dL
LED: 45/76
Leukosit: 10.100
Trombosit
247.000/mm
Bilirubin direct: 0,31
Bilirubin total: 0,47
SGOT: 21
SGPT: 47

Clorida serum: 97
mol/c
Kalium serum: 3,3
Natrium serum:
132
Serum Creatinin:
0,7
Urea: 16
Uric acid: 4,9
GDA: 128

X-Ray Thorax

CT Scan without contrast

CT Scan without contrast

Diagnosis

Clinical: cephalgia chronic progressive,

Vission blurred, diplopia, parese N. VI
sinistra
The topics: cerebrum
Aetiological: Brain tumors susp. cerebral
abscess
Hydrocephalus

Planning therapy

Inf RL 1500 cc /24 jam

Inj. Metamizole 3x1g
Inj. Ranitidine 2x50mg
Inj. Dexamethasone 4x5mg
Inj. Neurobion 1x1g
Inj. Fenitoin 3x1 g

Planning monitoring
GCS, Vital sign, complaints

Planning education
Explained to the family that suffered the
disease tentangt px px, what action will
be performed, checking what to do, what
treatment will be given, complications
will occur, and the prognosis that may
occur.

Prognosis

Dubia et bonam