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Morning report
DEPARTEMEN T OF
NEUROLOGYMARCH, 15 th 2014
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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% $e%, e%ema )&+
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ffe't an% emotionffe't an% emotion : 5ithin no$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%
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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$ia
eye movementeye movement : 'annot e evalate%: 'annot e evalate%
N. VI (Abducen)N. VI (Abducen) ::
eye movementeye movement : 'annot e evalate%: 'annot e evalate%
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N. V (Trigeminus)N. V (Trigeminus) ::
-ensiility-ensiility : N V1: N V1 : 'annot e evalate%: 'annot e evalate% N VN V : 'annot e evalate%: 'annot e evalate%
N V3N V3 : 'annot e evalate%: 'annot e evalate%
oto$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$mal limit
'he5ing : 'annot e evalate%'he5ing : 'annot e evalate%
iteite : 'annot e evalate% : 'annot e evalate%
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N. VII (Facialis)N. VII (Facialis) ::
-enso$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
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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
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!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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