MORNING REPORTNEUROLOGY A-21 April 17th 2015

Patient IdentityName: Mr. KhuNamAge: 45 years oldSex: FemaleAddress: Paciran, LAOccupation: SailormanReligion: Moslem

Last Education: Junior High SchoolMR Number: 29.00.91 Room: Zam-zam 14Admission: April 16th 2015

ANAMNESISChief complaint: headachePresent illness history: Patient complained with severe headache since 1 month, and get worse for 1 week. Headache felt like theng-theng in all parts of the head, especially on the back of head and the patient's head was throbbing pain in head. Pain occur continuously over time, day by day. Felt more severe pain when a change of position, especially when getting out of bed. Since then the patient can not walk because of dizziness and sight began to blur. double vision -, seizures-, . She had vomiting for 3 times, like nyembur, or incontinence and complained of no memory problems. Fever (-), nosebleed (-), hearing loss (-), tinnitus (-)

Previous Illness Historydenied a history of hypertension and diabetes, asthma (-), cardiac disease (-), drugs allergy (-) patients had been treated at the hospital about 1 week with diagnosis of cerebellar abscessFamily History of Diseasehad no family history of tumors and similar complaints

General Physical ExaminationAwareness : 456BP: 114/86 mmHgpulse: 89x/minutesTemp: 36 CRR: 20x, regulerAnemic: -Icterus: -Cyanotic: -

Status Present

ThoraxInspection: symmetrical chest wall movement Palpation: fremitus + / + Lung: Percussion: sonor / sonor Auscultation: vesicular / vesicular heart: Percussion: V ICS parasternal right limit dex, the left boundary of V mid clavicula sin ICS, ICS II upper left parasternal Auscultation: S2 S1 single murmur (-) Gallop (-)

AbdomenInspection: flat Palpation: soepel, tenderness (-) Percussion: Tympani Auscultation: BU (+) N Liver: no palpable Lien: no palpable

Psychological Status

Affective and emotional: within normal limits The process of thought: within normal limits Intelligence: within normal limits Absorption: within normal limits Willpower: within normal limits Psychomotor: within normal limits

Neurological Statushead: Position: normocephali Protrusion: (-) Shape / size: normal impression

Cranial NerveN.I (olfactory) Smelling: within normal limitsN.II (optic) Visual acuity: OD> 2/60, OS 1/60 Field of view: within normal limits / within normal limits Funduscopic: not evaluated

N.III (okulomotorius) Ptosis: - / - Eksoftalmus: - / - Eye movements: well in all directions / well in all directions Size: 3mm/3mm, isokor Light reflex: + / +N.IV (trokhlearis) The position of the eye: ortoforia / ortoforia Eye movements: well in all directions / well in all directionsN.VI (abduscen) eye ball movement : well in all directions cannot / glance in lateral views, diplopia (+)

N.V (trigeminal) sensibility: V1: wnl / wnl V2: wnl / wnl V3: wnl / wnl motor: Inspection: wnl / wnl Palpation: wnl / wnl Chewing: wnl / wnl Biting: wnl / wnl Reflex chin / masseter: wnl Corneal reflexes: + / +

N.VII (fascialis) wnlN.VIII Seconds watches: wnl / wnl Voice whispered test: wnl / wnl Test weber: not evaluated Rinne test: not evaluated N.IX (glossifaringeus) Taste: wnl N.X (vagus) Pharyngeal arch Position: wnl Vomiting reflex: +

N.XI (accessory) Shrug: + / + Turning heads: + / +N.XII (hipoglosus) Devisasi tongue: - / - Fasciculations: - / - Tremor: - / - Atrophy: - / -

NeckInflammatory markers meninges Stiff neck: - Kernig's sign: - Carotid Artery: + / + Palpation: Strong palpable / palpable strong Auscultation: bruit (-) / bruit (-) Thyroid: - / -

AbdomenAbdominal wall skin reflexes

vertebral column Inspection: wnlPalpation: wnl Movement: wnl Percussion: wnl++++++

extremitymotor Movement: wnl/wnlStrength : 5 5 5 5Muscle tone: Spastic: - / - Rigidity: - / - Klonus knee: - / - Klonus Achilles: - / -

Physiological reflex: BPR: N / N TPR: N / N KPR: N / N APR: N / NRadius: N / N Ulna: N / N pathological reflexes Hoffman tromer: - / - Gordon: - / - Babinzki: - / - Schaefer: - / - Chaddock :-/ - Oppenheim: - / - Mendel B: - / - Rossolimo: - / -

sensibility Eksteroseptif: Pain: wnl / wnl Temperature: wnl / wnl Touch: wnl / wnl proprioceptive Shakes: wnl / wnl Position: wnl / wnl Flavor combinations (combine sensation) Stereognosis: wnl / wnl Barognosis: wnl / wnl

Impaired coordination Finger-nose test: wnl / wnl Test pronation / supination: wnl / wnl Examination of the function of the sublime: Affective / emotional: good impression Language skills: good impression Memory: good impression Visualspasial: good impression Intelligence: good impression

Laboratory FindingsDiffcount: 0/0/80/15/5Hematokrit: 43,9 %Hemaglobin: 15,6 g/dLLED: 45/76Leukosit: 10.100Trombosit 247.000/mmBilirubin direct: 0,31Bilirubin total: 0,47SGOT: 21SGPT: 47

Clorida serum: 97 mol/cKalium serum: 3,3Natrium serum: 132Serum Creatinin: 0,7Urea: 16 Uric acid: 4,9GDA: 128

X-Ray Thorax

CT Scan without contrast

CT Scan without contrast

DiagnosisClinical: cephalgia chronic progressive, Vission blurred, diplopia, parese N. VI sinistraThe topics: cerebrumAetiological: Brain tumors susp. cerebral abscess Hydrocephalus

Planning therapyInf RL 1500 cc /24 jamInj. Metamizole 3x1gInj. Ranitidine 2x50mgInj. Dexamethasone 4x5mgInj. Neurobion 1x1gInj. Fenitoin 3x1 g

Planning monitoring GCS, Vital sign, complaints Planning education Explained to the family that suffered the disease tentangt px px, what action will be performed, checking what to do, what treatment will be given, complications will occur, and the prognosis that may occur.

PrognosisDubia et bonam

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