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Morning Report: Department of Neurology Dr. Sardjito Hospital Gadjah Mada University of Yogyakarta
Morning Report: Department of Neurology Dr. Sardjito Hospital Gadjah Mada University of Yogyakarta
Monday
July 30th, 2018
Department of Neurology
Dr. Sardjito Hospital
Gadjah Mada University of
Yogyakarta
Neurology In-Patients
Tisna Ari Nuria 01.85.26.47 Cognitive impairment cum PN VII et X11 sinistra UMN cum Trauma IS
hemiparese Sin ec sequele post TB
Ngatinem 01.83.72.98 Sopor cum left lateralization susp brain metastase dd Oncology WN
intracranial infiltration
Suginah 01.85.71.90 susp AML dd leukemi without neurological deficit CV IP
Denied : Shortness of breath, dropped eyelid, blurred vision, double vision, fever, seizure, decrease of
consciousness, nausea, vomiting, diarrhea, pallor, facial muscle twitching, swallowing difficulty, disphonia,
dysartria, hypersalivation
Recent Medical History
2 weeks before admission
• Patient trying start to decrease consumpting
methylprednisolone
• The weakness was worsened again
• He also start to feel the numbness again from below
the neck until his foot
Day of admission
• The complaint was getting heavier
• He cannot move his legs
• Patient had slight difficulty to control his urinary
urgency
Denied : Shortness of breath, dropped eyelid, blurred vision, double vision, fever, seizure, decrease of
consciousness, nausea, vomiting, diarrhea, pallor, facial muscle twitching, swallowing difficulty, disphonia,
dysartria, hypersalivation
Past History Family History
• Diagnosed with Denied:
cervical Schwannoma • HT
• Diagnosed with • DM
compression of
• Stroke
lumbal 1 vertebra
• Smoker for 9 years • Tumor
• Heart disease
• Denied :
• History of other tumor
• Hypertension
• DM
Systemic Anamnesis
Cerebrospinal system : numbness below the neck
Cardiovascular system : no complaint
Respiratory system : no complaint
Musculoskeletal system : weakness in all extremities
Genitourinary system : urinary incontinensia
Integumentum system : striae (+), thin skin appearance
Summary of Anamnesis
A man, 28 years old, came to emergency department with
worsening of weakness in all extremities in cervical Schwannoma
patient. Patient already go through surgery in 2012 and 2017.
Routinely control to neurologist and consumed
methylprednisolone, mecobalamine, lansoprazole
Temporary Diagnosis
BP : 128/85 mmHg
HR : regular, 120 bpm
RR : 16x/minute
Temp : 36,5°C
NPS :0
Neurology Examination
Consciousness : CM, E4V5M6
normal normal - -
tonus edema
normal normal - -
◻ NEUROLOGICAL STATUS
Physiologic +3 +3 Pathological + +
Reflex +4 +4 Reflex + +
Clonus + +
Monocyte 5,6%
Radiology Examination
Chest X-ray, July 27th, 2018
Expertise Result :
-Cor and pulmo within
normal limit
-There is no sign of skeletal
metastase in visualized bone
Radiology Examination
MRI Cervical, December 21st,
2017
Radiology Examination
MRI Cervical, December 21st,
2017
Radiology Examination
MRI Cervical, December 21st,
2017
Radiology Examination
MRI Cervical, December 21st,
2017
Radiology Examination
MRI Cervical, December 21st,
2017
Radiology Examination
MRI Cervical, December 21st,
2017
Problems
• Immobilized patient
• Relapsing illness
• Cushing syndrome
• Therapy management
Final Diagnosis
Spastic tetraparese cum hypoestesi
Clinical Diagnosis below thoracal 2 dermatom cum urinary
incontinensia
Plan
- MRI
Prognosis
Death : Bonam
Disease : Bonam
Dissability : Bonam
Discomfort : Malam
Dissatisfaction : Malam
Destitution : Malam