CASE 1

NEUROLOGY REPORT CASE

SKOLASTIKA INDAH
KEVIN RAYADI
BEPRI AGNESIA KAWI

MEDICAL CLERKSHIP NEUROLOGY ROTATION

ROYAL TARUMA HOSPITAL
TARUMANAGARA UNIVERSITY
IDENTITY

• Name : Mr. ES
• Age : 41 years old
• Address : Duri Kepa Kebon Jeruk, West Jakarta
CURRENT MEDICAL HISTORY
(FRIDAY, 24 MAY 2019 AT ZIRCON WARD ROYAL TARUMA HOSPITAL)

Chief complaint : Dizziness since three days ago before admitting to the hospital.

Patient came to Royal Taruma Hospital's ER with dizziness since three days ago before admitting
to the hospital. He felt like he wanted to fall. He also felt weakness in the whole body and
double vision. He said that he feels both of his toes and fingers of his right hand was numb. He
had been take some drugs but there’s no improvement.
No complaints of nausea, vomitus, loss of consciousness, and slurred speech.
 PAST MEDICAL HISTORY
• No history of hypertension
• Medicine consumption: (-)
• No history of diabetes mellitus
• No history of heart disease

HABIT HISTORY
• Smoking : Yes

• Alchohol : No

• Physical exersice: No
PHYSICAL EXAMINATION
General condition Compos Mentis
GCS E4V5M6
VITAL SIGN
Blood pressure 130/80 mmHg
Heart Rate 84 x/minute, regular, adequate
RR 20 x/minute
Temperature 36.5℃
SpO2 99%
Weight 77 kg
Height 167 cm
BMI 27,7
 PHYSICAL EXAMINATION

Head Normochepali, black dan short hair, even distribution

Pupil: round, equal, Ø 2mm/2mm, palpebral edema (-/-), anemic
Eyes
conjunctiva (-/-), icteric sclera (-/-)
Ears Normal shape, otorrhea (-/-)
Nose Septum deviation (-), secrete (-/-)
Mouth Mucose: wet, hyperemic (-)
Neck Tracheal deviation (-), no lymph node enlargement
 PHYSICAL EXAMINATION

Inspection Simetrical, both sides are even in static and dynamic state
Palpation No palpable mass, no crepitation
Thorax –
Percussion Sonor on both lungs
Pulmo
Auscultation Vesicullar (+/+), rales (-/-), wheezing (-/-)

Inspection Ictus cordis pulsation not seen

Palpation Ictus cordis pulsation palpable on ICS V MCLS
• Right heart margin : ICS III - V linea parasternalis dextra
• Left heart margin : ICS V, 1 cm at medial line
Cor Percussion MCLS
• Upper heart margin : ICS III linea parasternalis
sinistra
S1 and S2 heart sound in normal range, murmur (-), gallop
Auscultation
(-)
 PHYSICAL EXAMINATION

Inspection Flat on inspection, wound (-), mass (-)

Auscultation bowel sounds (+)
Abdomen Muscular defence (-), no pain response, no liver or spleen
Palpation
enlargement palpated
Percussion Tympanic on all abdomen region
Extremitie
All extremities warm, CRT < 2sec, edema (-/-)
s
Skin Skin turgor in normal range, cyanosis (-)
NEUROLOGICAL EXAMINATION

MENINGEAL SIGN
Cervical stiffness
(-)
Brudzinsky I

Brudzinsky II (-)

Brudzinsky III (-)

Brudzinsky IV (-)

Laseq (-) (-)

Kernig (-) (-)

NEUROLOGICAL EXAMINATION

CRANIAL NERVE
N. I No examinations were performed
N. II No examinations were performed
Ocular movements In normal range In normal range
Ptosis - -
N. III
Pupil size 2 mm 2 mm
N. IV
Pupil shape Round, equal Round, equal
N. VI
Direct Light Reflex + +
Indirect Light Reflex + +
NEUROLOGICAL EXAMINATION

N. V Open mouth
Moving the jaw
+
Biting

Palpebral fissure
Frontal contraction +
N. VII
Grinning
Lagopthalmus -/-
NEUROLOGICAL EXAMINATION

N. VIII No examinations was performed

Swallowing
N. IX
Pharynx Arc
N. X +
Uvula
M. Sternocleidomastoideus
N. XI No examinations were performed
M. Trapezius

N. XII Tongue Tremor +

NEUROLOGICAL EXAMINATION
PHYSIOLOGIC REFLEX
Right Left
Biceps + +
Triceps + +
Patella + +
PATHOLOGICAL REFLEX
Hoffman - tromner - -
Babinski - -
Chaddock - -
Schaefer - -
Gordon - -
Oppenheim - -
Klonus paha - -
Klonus kaki - -
NEUROLOGICAL EXAMINATION

MOTORIC NERVE
Right Left
Strength 5555 5555
5555 5555
Tonus Normotony
Trophy Normotrophy
 LABORATORIUM 24 MAY 2019 UNIT NORMAL RANGE
Hemoglobin 17,1 g/dl 14.0-18.0
LED 7 mm/jam 2-30
Leukocyte 7.4 103/uL 5.0-10.0
Basophils 0 % 0-1
Eosinophils 0 % 1-3
Segmen 47 % 50-70
Lymphocytes 45 % 21-40
Monocytes 8 % 2-8
MCV 86 u3 82 – 92
MCH 29 pg 26 – 32
MCHC 36 g/dl 31 – 36
Hematocrit 48.0 Vol % 42.0-52.0
Erythrocytes 5,72 106/uL 4.50-5.50
Platelets 229.0 103/uL 150.0-450.0
Ureum 24 mg/dl 15-37
Creatinin 1,01 mg/dl 0.80-1.30
GDS 75 mg/dl 70-180
 LABORATORIUM 24 MAY 2019 UNIT NORMAL RANGE
SGOT 34 u/l 15 – 37
SGPT 64 u/l 12 – 78
Kalium 3.10 mmol/l 3.50 – 5.10
Natrium 140 mmol/l 137 – 145

LABORATORIUM 24 MAY 2019 UNIT NORMAL RANGE

Uric acid 4.9 mg/dl 3.5-7.2
Total cholesterol 128 mg/dl Desirable: <200
Borderline: 200-239
High: >240
LDL 76 mg/dl Patient w/o CHD risk <130
Patient w/ CHD risk <100
HDL 39 mg/dl Low <40
High >= 60
Triglycerides 173 mg/dl Desirable: <150
Borderline: 150-199
High: 200-499

• Rontgen Thorax : Cor and Pulmo normal

WORKING DIAGNOSIS

• CVD Ischemic
TREATMENT

• Aspilet 1 x 4 tab
• Betahistine 2 x 24 mg
• Clopidogrel 2 x 75 mg
• Atrovastatin 1 x 40 mg
• Kalium L-aspartat 3 x 1 tab
• Manitol 4 x125 ml
• Ceftriaxone 1 x 2 gr
• Pantoprazole 1 x 40 mg
• Infus Asering 500 + Pentoxifylline 150 mg/12 jam
CASE 2
CASE 3
IDENTITY

• Name : Mr. SB
• Age : 69 years old
• Address : Jln. Tanjung Duren Utara 7 Gg. 8 No. 596
Jakarta Barat
CURRENT MEDICAL HISTORY (SATURDAY, 25 MAY 2019)

Alloanamnesis :

Chief complaint : headache

Patient was admitted into the Royal Taruma Hospital Emergency Room on Friday, 17 May 2019 due
to headache. Headache was felt since 2 days before admitted into ER. After that, the patient
consumed Saridon and later felt weak. So his family decided to bring him to the ER. When the
patient arrived in ER, the patient can barely talk. When he talked, the sound of his voice became
smaller than usual.

No complaints of nausea, vomitus, vision loss, loss of consciousness, and facial droopy are present.
PAST MEDICAL HISTORY

• History of dyslipidemia
• No history of hypertension
• No history of hypertension

HABIT HISTORY
• Smoking : No
• Alcohol : No
PHYSICAL EXAMINATION

General condition Moderately ill

GCS E4V5M6
VITAL SIGN
Blood pressure 100/70 mmHg
Heart Rate 78 x/minute
RR 20 x/minute
Temperature 36,7 ℃
PHYSICAL EXAMINATION

Head Normochepali,, hair: black, and white, even distribution

Pupil: round, equal, Ø 2mm/2mm, anemic conjunctiva (-/-), icteric
Eyes
sclera (-/-), lagophthalmus (-/-), ptosis (-/-),
Ears Normal shape, battle’s sign (-/-), otorrhea (-/-), blood (-/-)
Nose Septum deviation (-), secrete (-/-), blood (-/-), NGT (+)
Mouth Dry lips, hyperemic (-)
Neck Tracheal deviation (-)
PHYSICAL EXAMINATION

Inspection Simetrical, both sides are even in static and dynamic state
Palpation No palpable mass, no crepitation
Thorax –
Percussion Sonor on both lungs
Pulmo
Auscultation Vesicullar (+/+), rales (-/-), wheezing (-/-)

Inspection Ictus cordis pulsation not seen

Palpation Ictus cordis pulsation palpable on ICS V MCLS
• Right heart margin : ICS III - V linea parasternalis dextra
Cor Percussion • Left heart margin : ICS V, 1 cm at medial line MCLS
• Upper heart margin : ICS III linea parasternalis sinistra
S1 and S2 heart sound in normal range, murmur (-), gallop
Auscultation
(-)
PHYSICAL EXAMINATION

Inspection Flat on inspection, wound (-), mass (-)

Auscultation Rigid (-), bowel sounds (+)
Abdomen Muscular defence (-), no pain response, no liver or spleen
Palpation
enlargement palpated
Percussion Tympanic on all abdomen regions
Extremitie
All extremities are warm, CRT < 2sec, edema (-/-)
s
Skin Skin turgor in normal range, cyanosis (-)
NEUROLOGICAL EXAMINATION

RANGSANG MENINGEAL
Cervical stiffness
(-)
Brudzinsky I
Brudzinsky II (-)
Brudzinsky III (-)
Brudzinsky IV (-)
Laseq (-) (-)
Kernig (-) (-)
NEUROLOGICAL EXAMINATION

CRANIAL NERVE
N. I No examinations were performed
N. II No examinations were performed
Ocular movements In normal range In normal range
Ptosis - -
N. III
Pupil size 2mm 2mm
N. IV
Pupil shape Round, equal Round, equal
N. VI
Direct Light Reflex + +
Indirect Light Reflex + +
NEUROLOGICAL EXAMINATION

N. V Open mouth +
Moving the jaw
+
Palpebral fissure
Symmetric
N. VII Frontal contraction +
Grinning
+ (limited)
NEUROLOGICAL EXAMINATION

N. VIII No examinations was performed

Swallowing +
N. IX
Pharynx Arc Cannot be
N. X
Uvula evaluated
Cannot be
evaluated
M. Sternocleidomastoideus
N. XI No examinations were performed
M. Trapezius
Tongue Protrution +
N. XII Tongue Tremor -

Tongue Fasciculation -
NEUROLOGICAL EXAMINATION

PHYSIOLOGIC REFLEX
Right Left
Biceps + +
Triceps + +
Patella + +
PATHOLOGICAL REFLEX
Hoffman - tromner - -
Babinski - -
Chaddock - -
Schaefer - -
Gordon - -
Oppenheim - -
Klonus paha - -
Klonus kaki - -
NEUROLOGICAL EXAMINATION

MOTORIC NERVE
Right Left
Strength 5555 5555
3333 3333
Tonus Normotony
Trophy Normotrophy
 LABORATORIUM 17 MAY 2019 UNIT NORMAL RANGE
Hemoglobin 13,5 g/dl 14.0-18.0
LED 5 mm/jam 2-30
Leukocyte 9,8 103/uL 5.0-10.0
Basophils 0 % 0-1
Eosinophils 0 % 1-3
Segmen 84 % 50-70
Lymphocytes 12 % 21-40
Monocytes 4 % 2-8
MCV 95 u3 82 – 92
MCH 33 pg 26 – 32
MCHC 34 g/dl 31 – 36
Hematocrit 39,5 Vol % 42.0-52.0
Erythrocytes 4,16 106/uL 4.50-5.50
Platelets 323,0 103/uL 150.0-450.0
Ureum 24 mg/dl 15-37
Creatinin 1,00 mg/dl 0.80-1.30
GDS 79 mg/dl 70-180
 LABORATORIUM 17 MAY 2019 UNIT NORMAL RANGE
SGOT 24 u/l 15 – 37
SGPT 26 u/l 12 – 78
Kalium 4.10 mmol/l 3.50 – 5.10
Natrium 137 mmol/l 137 – 145

LABORATORIUM 18 MAY 2019 UNIT NORMAL RANGE

Uric acid 3,4 mg/dl 3.5-7.2
Total cholesterol 194 mg/dl Desirable: <200
Borderline: 200-239
High: >240
LDL 119 mg/dl Patient w/o CHD risk <130
Patient w/ CHD risk <100
HDL 71 mg/dl Low <40
High >= 60
Triglycerides 100 mg/dl Desirable: <150
Borderline: 150-199
High: 200-499
 BRAIN FLUID ANALYSIS 20 MAY 2019 UNIT

Colour Colorless

Clarity Clear

Number of cell 5 /ul

Total protein 100,0 * mg/dl

Glucose 67 mg/dl

Nonne Negative

Pandy Positive 1*

Chloride 113 mmol/l

Natrium 139 mmol/L

THYROID HORMONE

TSHs 1,13 uIU/ml (0.38-4.31)

17 May 2019

21 May 2019
CT BRAIN

17 MAY 2019 21 MAY 2019

MRI BRAIN 18 MAY 2019
WORKING DIAGNOSIS

• CVD
TREATMENT

• Aspilet 1 x 80 mg
• Truvaz (Atorvastatin) 1 x 20 mg
• Arcalion (Thiamine) 200mg 1-1-0
• Ceftriaxone 1 x 2 gr
• Pranza (Pantoprazole) 1 x 40 mg
• Invomit (Ondansentron) 3 x 4 mg prn