Morep 15 Maret Marwah

7/23/2019 Morep 15 Maret Marwah

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Morning report

DEPARTEMEN T OF

NEUROLOGYMARCH, 15 th 2014


2/23

IDENTIFY PATIENT

o Name : Mrs. Musriani

o Age : 58 Years Old

o

Gender : Female


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ANAMNEE

!"ie# !omplain : $n%ons%iousnes Present illness "istor&

'er #amil& %omplaints t"at t"e patient lo(%ons%iousnes sin%e ) mont"s ago. All part o# *od&

(as lema" sin%e + (ee,s *e#ore admit to "ospital.Fe-er /01 %oug" /0 1 %ouldn2t %lear tal,1 %ouldn2t(a,e ) #oot.

Past illness "istor&T3 /0 + &ears ago )4 mont" %onsumed T3 drugs

*ut It2s not %ontinue01 'T 401 DM 401 Trauma 40 Famil& illness "istor&

None of family have the same illness

o%ial illness "istor& : 40


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Primar& ur-e&

A :

3 :

! :D :


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P"&si%al E6amination

Vital sign :Vital sign :

BP : 110BP : 110//83mmHg83mmHg

RR : 37x/mntRR : 37x/mnt T :T : 3377,, !" !"

#ene$al examination :#ene$al examination :

Hea%&ne'(Hea%&ne'( : a/i/'/%: a/i/'/% &&/&/&/&/&/&/&

Tho$ax :Tho$ax :

simet$is )*+, $egla$ &/&, vesi(le$/vesi(le$,simet$is )*+, $egla$ &/&, vesi(le$/vesi(le$,

-1 - solita$y, m$m$ )&+, gallo. )&+-1 - solita$y, m$m$ )&+, gallo. )&+%omen :%omen :

flat, soefl, metali' son%s )&+ , ive$ an% s.leen a$e notflat, soefl, metali' son%s )&+ , ive$ an% s.leen a$e not

.al.ale2.al.ale2

xt$emitas : 4a$m, %$y, an% $e%, e%ema )&+xt$emitas : 4a$m, %$y, an% $e%, e%ema )&+


6/23

ffe't an% emotionffe't an% emotion : 5ithin no$mal limit: 5ithin no$mal limit

Thin(ing .$o'essThin(ing .$o'ess : 5ithin no$mal limit: 5ithin no$mal limit6ntelligen'e6ntelligen'e : 5ithin no$mal limit: 5ithin no$mal limit

4illingness4illingness : 5ithin no$mal limit: 5ithin no$mal limit

Psy'homoto$Psy'homoto$ : 5ithin no$mal limit: 5ithin no$mal limit


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Neurologi%al E6amination


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N. I (Olfactorius)N. I (Olfactorius) : its not e evalate%: its not e evalate%

N. II (Opticus)N. II (Opticus) ::

VissViss : 'annot e evalate%: 'annot e evalate%

Visal fiel%Visal fiel% : 'annot e evalate%: 'annot e evalate%

n%s'o.yn%s'o.y : 'annot e evalate%: 'annot e evalate%


10/23

N. III (Okulomotorius)N. III (Okulomotorius) ::

PtosisPtosis : & / &: & / &

exoftalmsexoftalms : & / &: & / &eye movementeye movement : 'annot e evalate%: 'annot e evalate%

P.ilP.il : 3mm/3mm, $on%e%, iso(o$: 3mm/3mm, $on%e%, iso(o$

ight $efle'tight $efle't : */*: */*

N. IV (Trochlearis)N. IV (Trochlearis) ::eye .ositioneye .osition : o$tofo$ia: o$tofo$ia

eye movementeye movement : 'annot e evalate%: 'annot e evalate%

N. VI (Abducen)N. VI (Abducen) ::

eye movementeye movement : 'annot e evalate%: 'annot e evalate%


11/23

N. V (Trigeminus)N. V (Trigeminus) ::

-ensiility-ensiility : N V1: N V1 : 'annot e evalate%: 'annot e evalate% N VN V : 'annot e evalate%: 'annot e evalate%

N V3N V3 : 'annot e evalate%: 'annot e evalate%

oto$i(oto$i( 6ns.e'tion : 5ithin no$mal limit6ns.e'tion : 5ithin no$mal limit

Pal.ation : 5ithin no$mal limitPal.ation : 5ithin no$mal limit

'he5ing : 'annot e evalate%'he5ing : 'annot e evalate%

iteite : 'annot e evalate% : 'annot e evalate%


12/23

N. VII (Facialis)N. VII (Facialis) ::

-enso$i(-enso$i( : not evalate%: not evalate%

oto$i(oto$i( ::2 $ontalis2 $ontalis : :'annot e evalate%'annot e evalate%

2 9lie o'li :2 9lie o'li :'annot e evalate%'annot e evalate%

2 olie o$is2 olie o$is : 'annot e evalate%: 'annot e evalate%

N.VIII (acusticus) :N.VIII (acusticus) :

5ithin no$mal limit5ithin no$mal limit


13/23

N. I! ("#O$$OFA%IN"&'$! VA"'$)N. I! ("#O$$OFA%IN"&'$! VA"'$) ::

senso$y 1/3 .oste$io$senso$y 1/3 .oste$io$ : not evalate%: not evalate%

a$'s .ha$yn( .ositiona$'s .ha$yn( .osition : mot evalate%: mot evalate%$efle( mntah$efle( mntah : not evalate%: not evalate%

N.I (accecorius) :N.I (accecorius) : not evalate%not evalate%

N. II (ipoglossus)N. II (ipoglossus) : not evalate%: not evalate%


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Affect and emotionAffect and emotion : not ealuated: not ealuated

#anguage abilit*#anguage abilit* : not ealuated: not ealuated

+emories+emories : not ealuated: not ealuatedVisuospatialVisuospatial : not ealuated: not ealuated

IntellegenceIntellegence : not ealuated: not ealuated


15/23

!lue and !ue

emale, ;8 y$

n'ons'iosnes

Past histo$y illness :T3 /0 + &ears

ago )4 mont" %onsumed T3drugs *ut It2s not %ontinue0


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Assessment

!lini%al Diagnose

n'ons'iosnes

Topi% DiagnoseMeningen dan Ense#alon

Etiologi% Diagnose

meningoense#alitis T3


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Planning Diagnose

D7

!T4%an

Foto T"ora6 AP


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7a*oratorium esult Di9%ount ;;;+5 mg

InC @almetason 6+ amp

eimstar +4)

!; p.PD p.


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Bital signNeurologi% disorders

E6plain to t"e #amil& a*out t"e disease o# t"e#amil&1 a*out its t"erap& and inter-ention (ill*e done1 and also a*out its %ompli%ation andprognosis du*ia at *onam


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Morep 15 Maret Marwah

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