Morning Report

Neurology Departement
Oct, 9 th 2015

Patient Identity
Name : Mr. M
Age : 53 years old
Sex : Male
Address : Lamongan

Anamnese
Chief complain: Stiffness of the body
Present illness history:
Patient reference from sartika clinic , patient complained
stiffness of the body since 2 days ago at night after work.
stiffness initially felt in the back , the abdomen , chest ,
legs , and mouth difficult to open and talk . stiffness of the
body does not disappear when he take a rest. Right cheek
was stiff , sore throat +, difficult to swallowing and eating ,
stiff neck muscles +. Patient said last week worked
continuously as construction laborers . There is no injury on
patient's body . patients admitted have a dental carries.

Past illness history:

never experienced similar before, HT -, DM -

Family illness history:

-

Physical Examination
Present Status
GCS: 456
Vital sign :
BP : 125/87 mmHg
HR : 67x/mnt
RR : 20 x/mnt
T : 37.3 C
General examination :
Head-neck : a/i/c/d -/-/-/Thorax :
simetris (+), retraction (-), sonor/sonor, vesikuler/vesikuler,
S1 S2 solitary, murmur (-), gallop (-)
Abdomen :
flat, soefl, intestinal sounds (+) normal, Liver and spleen are
not palpable.
Extremitas : Warm, dry, and red, edema (-)

NEUROLOGIC
EXAMINATION

Mental State Examination

Affect and emotion:normal
Language ability : normal
Memories
: normal
Visuospatial
: normal
Intellegence
: normal

Neurologic Examination

Nervus Cranialis
N. I (Olfactorius)

: not evaluated

N. II (Opticus)
:
Visus
: normal
Visual field : normal
Funduscopy: not evaluated

Nervus Cranialis
N. III (Okulomotorius) :
Ptosis
:-/exoftalmus : - / eye movement : normal
Pupil
: 3mm/3mm, rounded, isokor
Light reflect : +/+
N. IV (Trochlearis) :
eye position : ortoforia
eye movement : normal
N. VI (Abducen) :
eye movement : normal

Nervus Cranialis
N. V (Trigeminus) :
Sensibility : N V1 : normal
N V2 : normal
N V3 : normal
Motorik

Inspection : normal
Palpation : normal
chewing : normal
bite
: normal

Nervus Cranialis
N. VII (Facialis) :
Sensorik : normal
Motorik
:
M. Frontalis
: normal
M. Oblique oculi : normal
M. oblique oris : normal
N.VIII (acusticus) :
normal

Nervus Cranialis
N. IX, X (GLOSSOFARINGEUS, VAGUS):
sensory 1/3 posterior : not evaluated
arcus pharynk position : normal
vomit reflex
: not evaluated
N.XI (accecorius) : normal
N. XII (Hipoglossus) : normal

Neurological
Examination
Meningeal sign :
neck stiffness : (-)
kernig
: (-)
brudzinsky I-IV : (-)
Motorist

: 5/5
5/5

Physiologic reflex :
BPR : +2 / +2
KPR : +2 / +2
TPR : +2 / +2
APR : +2/ +2

Pathological reflex :
Babinsky : - / Chaddock : -/Hoffman : -/Trommer : -/ Sensorik : normal
Autonom : normal

Clue and Cue

Male, 53 years old
Stiffness of the body
Opistotonus +
Trismus +
Dental carries

Assessment
Clinical Diagnose
Trismus, opistotonus, dental carries
Topic Diagnose
NMJ
Etiologic Diagnose
Tetanus
DD: Meningitis

Planning Diagnose
DL
GDA
LVT
RFT

Laboratorium
Examination Result

Diffcount
Ba 3.4
Hct
43.0
Hb
14.4 g/dl
MCV
89,6
MCH
30
MCHC
33,5
RDW
11
Trombosit
291.000
MPV
4
LED 1
6
LED 2
11

Planning Therapy
O2 nasal 3 lpm
IVFD asering 1500cc/24j
Inj. Metronidazole 3x500mg
Inj. Ceftriaxone 2x1 g
Inj Acran 2x50mg
Inj Tetagram 6 amp im
Consultation:
Dr. Irawan, Sp.S

ANNING MONITORING
Vital sign
Neurologic disorders

LANNING EDUCATION
Explain to the family about the disease,
about its therapy and intervention will be
done, and also about its complication and
prognosis