Morning Report

Departement of Neurology
 OB
Tn . Nurokim (33.08.01)Suspect meningitis
 Identity
Name : Tn. N
Age : 45 Y.O 10 month 0 day
Address :Lamongan
Religion : Moslem
Admission : 2nd november, 2016 (20.27)
 Anamnesis
Chief Complain : headache
Present illness History :
nyeri kepala sejak jam 12 siang SMRS, nyeri yang dirasakan cekot cekot terus
dan sampai ke tengkuk. Tidak berkurang meskipun istirahat maupun
aktivitas. Sebelumnya pasien juga sudah dibawa ke RS suyudu dan tidak ada
perbaikan. Pasien juga pernah merasakan nyeri kepala pada saat 9 tahun yang
lalu. Headache(+), nausea (-), vomit (-), fainting (-)
 Previous illness history:
HT and DM (-)
Family illness history: (-)
Social History : -
 Physical Examination
GCS 456
Vital Sign
BP 116/64 mmHg
HR 76x/min
RR 21 x/min
Temp 36.9C
Primary survey
A :clear, gargling (-), snoring (-), speak frequently (-), potential
obstruction (-)
B :spontaneous, RR 20x/mnt, ves/ves, rh -/-, wh -/-, O2
saturation 100% with NRM
C :acral dry red warm, CRT < 2, N 73 x/mnt, BP 116/64
mmHg
D : GCS 456, lateralisation (-), PBI 3mm/3 mm, RC +/+
E : Temp 36,90C
 Secondary Survey
GCS 456
K/L a - / i - / c - / d - , enlargement (-)
Tho symetris, retraction (-)
P : ves/ves, Rh -/-, Wh -/-
C: S1S2 single, murmur (-), Gallop (-)
Abd flat, met(-) ,H/L unpalpable
Ext DRW
 Neurological Examination
Head : Position : Normal, middle
Mass :-
Shape | size : normal | normal
Auskultation : normal

Nervus Cranialis :
N.I (Olfaktorius)
Smell sensasion : not evaluated
N.II (Optikus)
Visual acuity : not evaluated
Field of vision : not evaluated
Funduscopy : not evaluated
 N. III (Okulomotorius)
slit eye : Ptosis : -| -
Exoftalmus : -| -
Movement of eye ball :normal
Pupil : Pupil round isokor 3/ 3 mm
Light perception : direct :+|+ non-direct
:+|+
nistagmus : -|-

N.IV (Troklearis)
Position of eye ball : normal
movement of eye ball : normal
 N.VI (Abdusen)
movement of eye ball : normal
N.V (Trigeminus)
Sensibility : N. V I : normal
N. V II : normal
N. V III : normal
Motorik :
Inspeksi : not evaluated
Palpasi : not evaluated
chewing : not evaluated
Bitting : not evaluated
Reflek masseter : not evaluated
Reflek cornea : not evaluated
 N.VII (Fasialis)
Motorik:
m. frontalis : normal
m. oblik okuli : normal
m. oblik oris : normal
taster of 2/3 front tongue : not evaluated

N.VIII (Vestibulokoklearis)
wrist watch : not evaluated
whispered voice : normal
Tes weber : not evaluated
Tes Rinne : not evaluated
 N.IX (Glossofaringeus)
taster 1/3 (back side) : not evaluated
sensibilitas faring : not evaluated
N.X (Vagus)
the arc of arcus faring : not evaluated
Reflek swallow/vomit : not evaluated
N.XI (Acsessorius)
Shruging : not evaluated
Looked away : not evaluated
N.XII (Hipoglossus)
normal
 Meningeal Sign
KK (+), Brudzinski 1,2 (-) kernig +

Physiologic Reflex
BPR : +2 | +2
TPR : +2 | +2
KPR : +2 | +2
APR : +2 | +2

Patologic Reflex
Hoffman : -|-
trommer : -|-
Babinski : -|-
Chaddock : -|-
 Motorik
5 /5
5/5

Sensorik N
Autonom retensio uri alvi (-)
 Laboratorium
Leukosit 6500 MCV 93.00
Neutropil 74.3 MCH 30.40
Limfosit 15.9 MCHC 32.70
Monosit 4.6 RDW 10
Eosinophil 4.1 Trombosit 203.000
Basofil 1.1 MPV 3
Eritrosit 4.57 LED 1 : 44
Hb 13.9 LED 2 : 64
Hct 42.5
 Clue and cue
Male 45 YO
Sub febrile
Cephalgia
Meningeal sign+, kernig+
 Diagnosis

Male 45 meningen Menigitis

Clinical Diagnosis

Diagnosis Topis

Etiological Diagnosis
YO
Sub
febrile
Cephalgia
Meningeal
sign+,
kernig+
 Planning Diagnosis
DL
CT SCAN Kontras
 Planning Therapy
02 nasal 3 lpm-saO2%
INF aseing 1500/24jam
Inj Ceftriaxon 2x2g iv
Inj santagesic 3x1 gr IV
Inj acran 2x50mg iv
Inj ceteron 8mg kp muntah
Inj kortidex 4x5mg
 Planning Monitoring
Vital sign
GCS
Subjective complaints of patients
cephalgia
 Planning Education
Explain to the family about diagnose (meningitis)
Explain to the family about planning diagnose CT Scan
Risk Factor
Therapy
Complication
Prognose