MORNING REPORT

MORNING REPORTNEUROLOGYOctober 17th, 201410/18/201411Patient IdentityName : Mr. SAge : 42 years oldSex: MaleAddress : Lamongan

10/18/201422Summary of DatabaseChief complain: Weakness of arms and limbsPresent illness history : Patient complained that suddenly he felt difficult to move both of arms and limbs, also he felt difficult to walk since 4 oclock in the morning (when he woke up). After that, he took a bath up with steam water then the complain just in the arms was wearing off. But it was still hard to walk. He also felt headache this week about two times and then he took Paramex, and then it felt better. Dizziness (-), Lose of conscious (-), nausea (-), vomit (-), febris (-), seizure (-), He also told that he caught a flu and cough about a month ago.10/18/201433Previous illness history : DM (-), HT (-), High uric acid (+) since 10 years ago, Asthma (+) since he was little,Gastritis (+) The same illness (+), about 10 years ago, but it was not as hard as this timeSocial illness history: Cigarette (+) maximal 1 packCoffee (+)

10/18/20144Physical ExaminationGenerally StatusGCS 456, Vital sign: BP 120/80 mmHg, HR 94x/m, temp 36,6c, RR 20x/mH/N : A- I- C- D-Thorax : Sim (+), ret -/-Pulmo: ves/ves, rh-/-, wh -/-Cor S1 S2 single, gallop -, murmur Abdomen : soefl, met -, Sound of stomach + N, H/L not palpableExtremity : dry, warm, red10/18/201455Neurological ExaminationGCS : 456

Meningeal sign : (-)

Motoric : 5- / 5- 4 / 4

Physiologic reflex :BPR: +2 / +2 KPR : +2 / +2TPR: +2 / +2 APR : +1 / +1Pathological reflex :Babinsky: - / - Hoffman : - / -Chaddock: - / - Trommer : - / -Sensorik : normal

N. I (Olfactorius): not evaluated

N. II (Opticus):Visus: not evaluated Visual field: not evaluatedFunduscopy: not evaluated

Nervus CranialisN. III (Okulomotorius):Ptosis: - / - exoftalmus: - / -eye movement: within normal linePupil: 3mm/3mm, rounded, isokorLight reflect : +/+N. IV (Trochlearis):eye position: within normal lineeye movement: within normal lineN. VI (Abducen):eye movement: within normal lineNervus CranialisN. V (Trigeminus):Sensibility: N V1: within normal line N V2: within normal line N V3: within normal line

MotorikInspection : within normal linePalpation : within normal linechewing : within normal linebite : within normal lineNervus CranialisN. VII (Facialis):Sensorik: not evaluatedMotorik:M. Frontalis : within normal lineM. Oblique oculi : within normal lineM. oblique oris : within normal line

N.VIII (acusticus) :within normal lineNervus CranialisN. IX, X (GLOSSOFARINGEUS, VAGUS):sensory 1/3 posterior : not evaluatedarcus pharynk position: centralreflek muntah: not evaluated

N.XI (accecorius) : not evaluated

N. XII (Hipoglossus) : within normal lineNervus CranialisComplete blood countDiffcount 2/0/89/8/2(1-2/0-1/49-67/25-33/3-7)Hct 44,3 %Hb 14,1 mg/dlLED 17/29Leukocyt 6.500Thrombocyt 194.000Kalium serum 3,4Natrium serum 147Chlorida serum 109Creatinin seum 0,3Urea 21Uric acid 8,8Random blood glucose 155

10/18/201413EKG10/18/201414Clue and CueSudden / Acute tetrapareseHistory of asthma and gastririsHigh uric acid Post upper respiratory tract infection

10/18/20141515Initial DiagnosisClinical Diagnosis: Acute tetraparese, High uric acid, History of headache

Topical Diagnosis: Radiks

Etiological Diagnosis: Susp. Guillain Barre Syndrome

10/18/20141616Planning DiagnosisCBCBlood glucoseRFTLFTPuncture LumbalElectromyography

10/18/20141717Planning TherapyO2 3 lpm with nasal canulIVFD Asering 1500 cc/24 jamInj Metamizole 3x1 amp ivInj Ranitidin 2x1 amp ivInj Ondansetron 2 x 1 amp ivInj Mecobalamin 1 x 1 amp ivInj Methylprednisolon 3 x 125 mg iv

10/18/20141818Planning MonitoringGeneral statusVital signSubjective complainmentNeurology examination10/18/20141919EducationExplain to the patient and the family about examination, diagnosis, treatment, complication, and prognosis of the disease.

10/18/20142020