Saturday, 27th Agust 2014

Morning Report
Neurologic Department
Patient identity
Name : Mr H
Age : 36 years old
Sex : Male
Work :
Address : Lamongan
Examination date : Agust 26th, 2014
Anamnesis
Chief Complaint
weak of legs
Present illness History
Patient weak of legs since 6 days before admision to
the hospital. Then, 3 days ago, his arms also became
weak. He couldnt speak well since 2 days ago. Vomit (-
), headache before (-). Before that, the patient had a
thypoid fever 2 weeks ago and hospitalized at PKU
karangasem. Cough +, influenza + before weak of his
legs. Dypsneu +.
Previously illnes history
Never like this before
HT and DM denial. Hiperkolesterol +
Family illnes History
HT didnt know
Medicine taking history
-
Social history
-
Vital Sign
GCS : 456
Blood pressure : 131/89 mmHg
Heart Rate : 87x /minutes
RR : 28x /minutes
Axilla temperature : 36.2
o
C
Head / neck : an (-), ict (-), cy (-), dys (-)
Thorax : Normal chest form, retraction (-),
Pulmonary
Pulmo : ves/Ves, Rh+/+, Wh -/-
Cor : S1-S2 single, murmur (-), gallop (-)
Abdomen
I : flat
P : soefl, Liver / Splen not palpable.
P : thimpany
A : Bowel sound (+) Normal
Extremity : aie -, warm, dry, CRT < 2
N. I (Olfactorius): SDE
N. II (Opticus) : round isokor 3mm/3mm, RC +/+
N. III (Okulomotorius) : SDE
N. IV (Trochlearis) : SDE
N. VI (Abducen) : SDE
N. V (Trigeminus) : SDE
N. VII (Facialis) : perifer sinistra
N.VIII (acusticus) : SDE
N. IX (Glossofaringeus) : SDE
N. X (Vagus) : SDE
N. XI (Assesorius) : SDE
N. XII (Hipoglossus) : SDE
Meningeal sign:
Kaku kuduk : -/- brudzinsky 1 :-/-
Kernig : -/-
Kekuatan : sde
Tonus muscle : flaccid
Reflek Fisiologis :
BPR : +1/+1 KPR : +1/+1
TPR : +1/+1 APR : +1/+1
Reflek Patologis :
Babinsky: -/- Hoffman Trommer : - /-
Chaddock: -/- Gordon : -/-
Schaefer: -/- Oppenheim : - / -
sde
Clue and cue
Male, 36 yo
Weak of legs
Weak of arms
Ascending paralisis
Tetraparese LMN
N7 perifer sinistra


PLANNING DIAGNOSIS
DL
Thorax Photo
LP
EMG
Laboratory finding
Diffcount : 0/0/89/4/4
Hematocrit : 47,5
Hb : 16,3
Leukosit : 19.700
Trombosit : 353.000
SGOT : 17
SGPT : 44
Urea : 35 (10-50 mg/dl)
Creatinin serum : 0,7 (0,7-12 mg/dl)
Clorida serum : 102
Kalium serum : 4,1
Natrium serum : 135
GDA : 119
Thorax xray

Clinical diagnosis
Ascending paralisis
Tetraparese LMN
N7 perifer sinistra
Topis diagnosis
poliradiks
Etiologic diagnosis
GBS
Monitoring
GCS
Vital sign
Planning theraphy
IVFD Ringer assering 1500/24 hours
Inj alinamin F 2x1 amp iv
Inj mecocobalamin 1x1 iv
Inj Metilprednisolon 1x125 mg iv
Inj Ceftriaxon 2x1 g iv
Inj ranitidin 2x50mg iv
DK, NGT
Suction periodic + chest physioteraphy
Consult: Sp.S
Pro ICU
Planning Education
Explain to the patients family about the
diagnosis, etiology, intervention of therapy,
complication, and prognosis.