Scribd Logo
Upload

Welcome to Scribd!

  • 64 views

    Case Saraf Bepri 5

    Uploaded by

    Wen wen
    This neurology report summarizes a case of a 58-year-old female patient presenting with nausea, vomiting, and pain in her back, hands, and knees. On physical examination, her cranial nerves, motor function, and sensory function were normal. Laboratory tests showed mild anemia and elevated eosinophil levels. Working diagnoses included dyspepsia, low back pain, and dactylitis. She was prescribed medications including corticosteroids, sucralfate, celecoxib, and ondansetron.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Case Saraf Bepri 5

    Uploaded by

    Wen wen
    64 views14 pages
    This neurology report summarizes a case of a 58-year-old female patient presenting with nausea, vomiting, and pain in her back, hands, and knees. On physical examination, her cranial nerves, motor function, and sensory function were normal. Laboratory tests showed mild anemia and elevated eosinophil levels. Working diagnoses included dyspepsia, low back pain, and dactylitis. She was prescribed medications including corticosteroids, sucralfate, celecoxib, and ondansetron.

    Original Title

    Case Saraf Bepri 5.pptx

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This neurology report summarizes a case of a 58-year-old female patient presenting with nausea, vomiting, and pain in her back, hands, and knees. On physical examination, her cranial nerves, motor function, and sensory function were normal. Laboratory tests showed mild anemia and elevated eosinophil levels. Working diagnoses included dyspepsia, low back pain, and dactylitis. She was prescribed medications including corticosteroids, sucralfate, celecoxib, and ondansetron.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    64 views14 pages

    Case Saraf Bepri 5

    Uploaded by

    Wen wen
    This neurology report summarizes a case of a 58-year-old female patient presenting with nausea, vomiting, and pain in her back, hands, and knees. On physical examination, her cranial nerves, motor function, and sensory function were normal. Laboratory tests showed mild anemia and elevated eosinophil levels. Working diagnoses included dyspepsia, low back pain, and dactylitis. She was prescribed medications including corticosteroids, sucralfate, celecoxib, and ondansetron.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    You are on page 1of 14

    NEUROLOGY REPORT CASE

    K E V I N R AYA D I
    B E P R I AG N E S I A K AW I
    S KO L A S T I K A I N DA H

    Medical Clerkship Neurology Rotation


    Royal Taruma Hospital
    Tarumanagara University
    CASE 1
    IDENTITY

    • Name : Mrs. RHT


    • Age : 58 years old
    • Address : Green Lake City, Cluster America EC 3 No. 19
    CURRENT MEDICAL HISTORY

    • Chief complaint : nausea and vomitus


    • Patient came to Royal Taruma Hospital’s ER with nausea and vomitus since a
    few hours before admitting to the hospital. She vomited 3 times after
    consuming Zaldiar (Tramadol HCl/Paracetamol). Before this, she consumed
    Zaldiar once and had the same complaint but it got better after she consumed
    antacid. She consumed Zaldiar due to the pain in her back, hands, and knees
    which she already felt 3 weeks before admitting to the hospital. She felt pain in
    her knees after long walking. She also felt the pain in her back and hands every
    time she woke up in the morning. Besides that, she also felt stiffness which
    lasted for about 30 minutes in her hands every morning after waking up. The
    second day she was in the hospital, her left fingers was swollen and red, but no
    complaints of pain felt.
    • No complaints of fever and headache.
    PAST MEDICAL HISTORY

    • History of dyspepsia (+)


    • No history of psoriasis
    • No history of allergy
    PHYSICAL EXAMINATION

    • Consciousness : compos mentis


    • GCS : E4V5M6

    MENINGEAL SIGN

    Cervical stiffness
    (-)
    Brudzinsky I

    Brudzinsky II (-)

    Brudzinsky III (-)

    Brudzinsky IV (-)

    Laseq (-) (-)


    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 + +


    N.V Open mouth

    Moving the jaw +

    Biting

    Palpebral fissure

    Frontal contraction +
    N.VII
    Grinning
    Lagopthalmus -/-
    N.VIII No examinations was performed

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

    N. XII Tongue Tremor


    MOTORIC NERVE
    Right Left
    Strength 5555 5555
    5555 5555
    Tonus Normotony
    Trophy Normotrophy

    SENSORIC NERVE
    Pain sensation
    Touch sensation Normal
    Hot and cold sensation
    OTONOM FUNCTION
    • Blood pressure : 100/70 mmHg
    • Heart rate : 84 x/m
    • RR : 20 x/m
    • Temperature : 36,7℃
    • Weight : 56 kg
    • Height : 155 cm
    • BMI : 23,33 kg/cm2
    LABORATORIUM 15 June 2019 UNIT NORMAL RANGE
    Hemoglobin 10,4 g/dl 12.0-16.0
    LED 15 mm/jam 2-30
    Leukocyte 7.5 103/uL 5.0-10.0
    Basophils 0 % 0-1
    Eosinophils 6 % 1-3
    Segmen 45 % 50-70
    Lymphocytes 42 % 21-40
    Monocytes 7 % 2-8
    MCV 85 u3 82 – 92
    MCH 27 pg 26 – 32
    MCHC 32 g/dl 31 – 36
    Hematocrit 32,4 Vol % 37.0-47.0
    Erythrocytes 3,81 106/uL 4.00-5,00
    Platelets 285,0 103/uL 150.0-450.0
    Ureum 24 mg/dl 15-39
    Creatinin 0,78 mg/dl 0.60-1.00
    GDS 110 mg/dl 70-180
    LABORATORIUM 15 June 2019 UNIT NORMAL RANGE
    SGOT 27 u/l 15 – 37
    SGPT 22 u/l 12 – 78
    Kalium 3.90 mmol/l 3.50 – 5.10
    Natrium 139 mmol/l 137 – 145

    LABORATORIUM 17 June 2019 UNIT NORMAL RANGE


    FT3 3,45 pmol/l 4,00-8,30
    FT4 11,33 pmol/l 10,60 – 19,40
    TSH 1,22 ulU/ml 0,38 – 4,31

    LABORATORIUM 18 June 2019 UNIT NORMAL RANGE


    hs-CRP 0,37 mg/L 0,00 – 3,30
    Rheumatoid factor <8 IU/ml <8
    WORKING DIAGNOSIS

    • Dyspepsia
    • Low back pain
    • Dactylitis
    TREATMENT

    • Medixon 16 (methylprednisolone) 1 x 1 tab


    • Inpepsa (Sucralfat) syrup 3 x 1C ac
    • Starmuno 1 x 1 tab
    • Cavit D3 2 x 1 tab
    • Glutrop (L-glutamine) 1x1 tab
    • Maganol (Paracetamol) 3 x 1 tab
    • Torasic (Ketorolac tromethamine 10mg) 3 x 1 amp
    • Invomit (Ondansentron) 2 x 4 mg
    • Celebrex (Celecoxib) 2 x 100 mg

    You might also like