MORNING

REPORT
Wednesday , 1st of March 2023
WEDNESDAY, 1st OF MARCH 2023fv
On Duty: Consultant on Duty:
• dr. Jesisca dr. Theresia Runtuwene, Sp.N(K)
• dr. Vinson
• dr. Regina
• dr. Aristo
• dr. Elbert
• dr. Poek
• dr. Aurelia
• dr. Harley
 STATISTICS

1. Mrs. CK/87 Y.O/ CVD SI at right MCA (ASPECT 2) 1st day onset,
emergency hypertension
2. Mr. FS/65 Y.O/ Triggered episodic vestibular syndrome ec susp.
BPPV, Grade 1 hypertension
3. Mrs. TKD/ 65 Y.O/ Sequele of stroke, Unconsciousness ec sepsis ec
urosepsis dd susp pulmonary TB, Uncontrolled DM type 2
hyperglycemic episode, CKD stage 4 ec DKD dd HNS, hematemesis
ec stress ulcer, controlled hypertension, geriatric syndrome
 STATISTICS

4. Mrs. HM/ 20 Y.O/ Secondary headache ec possible Meningitis TB

(MARAIS Score 8), Susp pulmonary Tuberculosis, Urinary tract
Infection, Leukocytosis (19.800)
A 20-year-old female with chief complaint of
severe headache 1 weeks before admission
COVID SCREENING

• Recent onset fever (+), cough (+), dyspnea (-)

• History of travelling abroad on this past 2 weeks was denied
• Recent history of domestic travelling was denied
• History of contact with COVID-19 patients was denied
• History of COVID-19 vaccination is unknown
• History of confirmed COVID-19 is unknown
 HISTORY OF PRESENT ILLNESS

• Chronic cough • Headache worsened

• Fever (+), cold sweat (+), weight loss
of 6 kg within 1 month
• Treated symptomatically ->
improvement and stopped taking
medication
• Stabbing headache
• Admitted to Kotamobagu Hospital
• Intermittent -> gradually become
• Given Ceftriaxon IV, Dexamethasone
more severe, continuous
IV,
Admitted
• Improved with drug, worsened with
Ketorolac IV, Diazepam drip, to Kandou
coughing/straining.
• Non-projectile vomiting > 5 times Omeprazole IV, Ondansetron IV Hospital

1 year before admission 3 weeks before admission 1 weeks before admission

Other symptoms such as ear discharge, blurred or double vision, one side weakness, fainting, seizures,
behavioral changes, and memory loss were all denied.
HISTORY OF PAST ILLNESS

 History of left pleural effusion and was pleural punctured 6 months ago,
the result was unknown
 History of pulmonary TB, tumor, hypertension, diabetes, kidney, heart and
liver disease were all denied.
 GENERAL EXAMINATION

• Condition : Moderate • Conjunctiva : pale (-/-), icteric (-)

• Consciousness : Compos Mentis • Cor : regular heart sound I
• BP : 123/89 mmHg (MAP : 100) II, murmur (-), gallop
• HR : 79 bpm, regular (-)
• RR : 24 x/min • Pulmo : vesicular +/+, rhonchi
• Temp : 36.5oC -/-, wheezing -/-
• SpO2 : 98% room air • Abdomen : flat, normal peristaltic
• NRS : 7-8 • Extremities : warm acral, pitting
edema (-/-), deformity
(-).
 NEUROLOGICAL EXAMINATION

• GCS E4M6V5
• Pupil examination: round pupil, isochor, 3 mm/3 mm, direct
light reflex +/+, indirect light reflex +/+
• Meningeal sign : nuchal rigidity (+), lasegue <70/<70, kernig
<135/<135
• Cranial nerves : N. II-XII intact
• Funduscopy (FODS): hyperemic papil, blurred margin,
cupping (-), A:V ratio 2:3, impression of 1st grade papilledema.
NEUROLOGICAL EXAMINATION
•Motoric examination:
Muscle Strength : Muscle Tone : Physiology Reflex Pathologic Reflex :
:
RIGHT LEFT
RIGHT LEFT RIGHT LEFT
RIGHT LEFT

- -
5555 5555 N N ++ ++ ++ ++
++ ++

++ ++
5555 5555 N N -
++ ++ -

• Sensory examination : normoesthesia

• Autonomic function : urine et alvi incontinence -/-
Marais Scoring

Total Marais score= 8

Working Diagnosis

• Secondary Headache e.c. Possible Meningitis TB

(MARAIS Score 8)

Differential Diagnosis
• Secondary Headache e.c. Bacterial Meningitis dd Viral
Meningitis
 PLANNING

• Communication, Information, & Education • IVFD NaCl 0.9% 500 ml /8 hrs

• Adequate oxygenation • Ranitidine 2x50 mg IV

• Head elevation 30 degrees • Ketorolac 30 mg IV extra if NRS >=

7
• Chest X-ray AP, ECG, laboratory check
• Paracetamol 3x500 mg PO
LABORATORY TEST (1/3/23)

• Hb : 13.8• RBG : 128

• Hct : 38.9• Na : 135
• WBC : 19.800 • K : 3.8
• Plt • Cl
: 572.000 : 99
• Ureum : 25 • PT : 17.9/13.7
• Creatinin : 0.4 (1.3x)
• SGOT : 12 • INR : 1.36
• SGPT :7 • APPT : 37.1/30.9 (1.2x)
• Anti HIV, HCV, HBsAg : Non
Reactive
URINALYSIS TEST (1/3/23)

• Color : Yellow, cloudy• Urobilinogen : Negative

• Leukocytes : 6-8 • Bilirubin : Negative
• Blood : 15-20 • Nitrites : Positive
• Epitel : 2-3 • Crystal : Negative
• Proteins : 2+ • Bacteria : Positive
• Glucose :- • Fungi : Negative
• Ketones : 2+
• Amoeba : Negative
 ECG (1/3/23)

Sinus Rhythm, 75 bpm, normoaxis

 Chest X-ray (1/3/23)

Opacity at upper field of the left

lung -> suspected pulmonary
tuberculosis
DIAGNOSIS

CLINICAL DIAGNOSIS:

Headache, TOPIC DIAGNOSIS

Nuchal rigidity, 1st grade
papilledema Meningeal

ETIOLOGY DIAGNOSIS PATHOLOGY DIAGNOSIS

Mycobacterium tuberculosis Inflammatory response

Additional Diagnosis

• Susp pulmonary Tuberculosis

• Urinary tract infection
• Leukocytosis (19.800)
Additional Planning

• Ceftriaxon 2x1 gram IV (day 6) • Rifampicin 1x600 mg PO

• Dexamethasone 3x5 mg IV, tapered • INH 1x300 mg PO
off each week • Ethambutol 2x500 mg PO
• Diazepam 3x2 mg PO • Pyrazinamide2x500 mg PO
• Vitamin B6 2x1 tab PO
Additional Planning

• Consult to neuroinfection division at • Check urinalysis

ward
• Pro lumbar puncture at ward
• Consult to internal department
• Monitoring of vital sign/8 hours • Pro GeneXpert check at ward
• Monitoring of urine output/24 hours • Pro Brain CT Scan with contrast
• adequate fluid balance
at ward
• Periodic blood glucose check
• Urine culture
THANK YOU