NEUROLOGY MEDICAL RECORD

IDENTIFICATION
Name

: Mr. AM

Age

: 25 years old

Sex

: Male

Address

: Sekayu

Religion

: Islam

Admission date

: October 7th, 2014

ANAMNESIS (October 17th, 2014)

The patient was admitted to Neurology ward Moh.Hoesin General Hospital because
decreased of consciousness gradually.
+ 4 months before admitted to the hospital, the patient had persistent headache,
cough, mucous (+), blood (-). He had fever, loss of appetite, sweat in night, and loss of body
weight, nausea and vomiting. + 3 months before admitted to the hospital, the patient had
admitted to Sekayu hospital because he had feel weakness of his body, and the doctor said
that he got lung disease. Then he got the medicines and after around 1 week he feels better,
then he stopped to drink medicine and he did not control to hospital. At home, he drunk
drugs regularly, but he stopped. + 2 days before admitted to the hospital, the patient had
decreased of consciousness gradually, such as anxious and disorientation. He had headache,
nausea and vomiting, no seizures, no hemiparese.
He had no history of ear infections, no history of seizures, no history of diabetes, no
head trauma.
The patient suffered this illness for the first time.
PHYSICAL EXAMINATION (October 17th, 2014)
PRESENT STATE
Internal State
Sense

:E3M5V3

Palpation : stem fremitus of left chest

Nutrition

: Sufficient

decreased

Temperature
Pulse

: 38.9 oC
: 90 beats/min

Percussion : hipersonor in left chest

Auscultation: vesicular in left chest
1

Respiratory rate

: 20 times/min

decreased

Blood pressure

: 130/100 mmHg

Liver

: No abnormality

Spleen

: No abnormality

Extremities

:See neurological

Heart

: No abnormality

Lungs

Inspection : Static and Dinamis, left state

chest : left behind

Genital

: No abnormality

Psychiatric state
Attitude : Not yet assessed

Facial Expression : Not yet assessed

Attention : Not yet assessed

Psychology contact: Not yet assessed

Neurological state
Head
Shape

Brachiocephaly

Deformity

: No

Fracture

: No

Size

: Normal

Fracture pain

: No

Symetric

: Yes

Vessel

: No widening

Hematome

: No

Pulsation

: No disorder

Tumor

: No
Deformity

: No
: No

Neck
Position

: Straight

Tumor

Torticolis

: No

Vessels

: No widening

Nape of neck stiffness : Yes

CRANIAL NERVES
N.I: Olfaktorius nerve

Right

Left

Smelling

Not yet assessed

Not yet assessed

Anosmia

Not yet assessed

Not yet assessed

Hyposmia

Not yet assessed

Not yet assessed

Parosmia

Not yet assessed

Not yet assessed

Right

Left

N.II: Opticus nerve

Visual acuity

Campus visi

Not yet assessed

Not yet assessed

V.O.D

V.O.S

Anopsia

Not yet assessed

Not yet assessed

Hemianopsia

Not yet assessed

Not yet assessed

Oculi fundus

Edema papil

No

No

Atrophy papil

No

No

Retina bleeding

No

No

Right

Left

Not yet assessed

Not yet assessed

No

No

No

No

No

No

No

No

No

No

No

No

Not yet assessed

Not yet assessed

Round

Round

3mm

3mm

N.III: Occulomotorius,
N.IV: Trochlearis, and
N.VI: Abducens nerves
Diplopia
Eyes gap
Ptosis
Eyes position

Strabismus

Exophtalmus

Enophtalmus

Deviation conjugae

Eyes movement
Pupil

Shape

Size

Isochor/anisochor

Midriasis/miosis

Isochor
No

Isochor
No

Light reflex

Positive

Positive

direct

Positive

Positive

consensuil

Positive

Positive

accommodation

No

No

Right

Left

Not yet assessed

Not yet assessed

Not yet assessed

Not yet assessed

Not yet assessed

Not yet assessed

Not yet assessed

Not yet assessed

Not yet assessed

Not yet assessed

Not yet assessed

Not yet assessed

Argyl Robertson
N.V: Trigeminus nerve
Motoric

Biting

Trismus

Corneal reflex

Sensory

Forehead

Cheek

Chin
Right

N.VII: Facialis nerve

Left

Not yet assessed

Not yet assessed

Motoric

Normal

Normal

Frowning

Normal

Angle paralysis

Eyes closing

Normal

Flat

No disorder

No disorder

Not yet assessed

Not yet assessed

Not yet assessed

Not yet assessed

No disorder

No disorder

No disorder

No disorder

No disorder

No disorder

Giggling
Nasolabial fold
Facial shape

rest

Speaking/whistling

Sensory

2/3 anterior tounge

Autonomy

Salivation

Lacrimation

Chvosteks sign
Right

Left

N.VIII: Statoacusticus nerve

Not yet assessed

Not yet assessed

Cochlearis nerve

Not yet assessed

Not yet assessed

Whispering

Not yet assessed

Not yet assessed

Hour ticking

Not yet assessed

Not yet assessed

Rinne test

Not yet assessed

Not yet assessed

Vestibularis nerve

Not yet assessed

Not yet assessed

Right

Left

N.IX: Glossopharyngeus, and

Not yet assessed

Not yet assessed

N.X: Vagus nerves

Not yet assessed

Not yet assessed

Pharyngeal arch

Not yet assessed

Not yet assessed

Uvula

Not yet assessed

Not yet assessed

Normal

Normal

Heart beat

No disorder

No disorder

Reflex

No disorder

No disorder

Weber test

Nystagmus
Vertigo

Swallowing disorder
Hoarsing/nasalising

Vomiting

No disorder

No disorder

Coughing

No disorder

No disorder

Occulocardiac

Caroticus sinus

Not yet assessed

Not yet assessed

Sensory
1/3 posterior tounge
N.XI: Accessorius Nerve

Right

Left

Shoulder Raising

Not yet assessed

Not yet assessed

Head Twisting

Not yet assessed

Not yet assessed

N.XII: Hypoglossus Nerve

Right

Left

Tounge Showing

Not yet assessed

Not yet assessed

Fasciculation

Not yet assessed

Not yet assessed

No

No

Not yet assessed

Not yet assessed

Right

Left

Papil Athrophy
Dysarthria
MOTORIC
Arms
Motion

Lateralization to Left side

Power

Lateralization to Left side

Tones

Normal

Increase

Physiological Reflex

Biceps

Normal

Increase

Triceps

Normal

Increase

Radius

Normal

Increase

Ulna

Normal

Increase

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Right

Left

Pathological Reflex

Hoffman Tromner

Leri

Meyer

Trofik

LEG

Lateralization to Left side

Motion

Lateralization to Left side

Power

Normal

Increase

Negative

Positive

Negative

Positive

Physiological reflex

Normal

Increase

KPR

Normal

Increase

APR

Tones
Clonus

Tigh

Foot

Pathological reflex

Negative

Positive

Babinsky

Negative

Positive

Chaddock

Negative

Negative

Oppenheim

Negative

Negative

Gordon

Negative

Negative

Schaeffer

Negative

Negative

Rossolimo

Negative

Negative

Mendel Bechterew

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Abdominal skin reflex

Upper

Middle

Lower

Tropik
SENSORY
Not yet assessed
PICTURE

VERTEBRAL COLUMN
7

Kyphosis

: No

Tumor

: No

Lordosis

: No

Meningocele

: No

Gibbus

: No

Hematome

: No

Deformity

: No

Tenderness

: No

SYMPTOMS OF MENINGEAL IRRITATION

Right

Left

Nape of neck stiffness

Yes

Yes

Kerniq

No

Yes

Lasseque

No

Yes

Brudzinsky

Neck

No

No

Cheek

No

No

Symphisis

No

No

Leg I

No

No

Leg II

No

No

GAIT AND EQUILIBIRIUM

Gait

Equilibirium and Coordination

Ataxia

: Not yet assessed

Romberg

: Not yet assessed

Hemiplegic

: Not yet assessed

Dysmetri

: Not yet assessed

Scissor

: Not yet assessed

finger finger

: Not yet assessed

Propulsion

: Not yet assessed

finger nose

: Not yet assessed

Histeric

: Not yet assessed

heel - heel

: Not yet assessed

Limping

: Not yet assessed

Reboundphenomenon : Not yet assessed

Steppage

: Not yet assessed

Dysdiadochokinesis : Not yet assessed

Astasia-Abasia: Not yet assessed

Trunk Ataxia

: Not yet assessed

Limb Ataxia

: Not yet assessed

MOTION ABNORMAL
Tremor

: No

Chorea

: No

Athetosis

: No

Ballismus

: No

Dystoni

: No

Myoclonus

: No

VEGETATIVE FUNCTION
Micturition

: Urine Catheter

Defecation

: No abnormality

Erection

: Not yet assessed

LIMBIC FUNCTION
Motoric aphasia

: Not yet assessed

Sensoric aphasia

: Not yet assessed

Apraksia

: Not yet assessed

Agraphia

: Not yet assessed

Alexia

: Not yet assessed

Nominal aphasia

: Not yet assessed

LABORATORY FINDINGS
BLOOD (7th October 2014)
Hb

: 11.7 gr/dl

(12-16)

Erythrocyte

: 4.41 ml/mm3

(4.0-5.0)

Hematocrit

: 33 vol%

(37-43 vol%)

Leucocyte

: 13300/mm3

(5000-10000)

LED

: 120mm/hour

(<15)

Thrombocyte

: 547000/mm3

(200.000-500.000)

MCV

: 74,8 fL

(85-95)

MCH

: 27 pg

(28-32)

MCHC

: 36 g/dL

(33-35)

Diff Count

: 0/0/0/91/5/4

(0-1/1-6/2-6/50-70/20-40/2-8)

Blood Glucose

: 113 mgdL

(<200)

Albumin

: 3,5 g/dL

(3,5-5)

Cholesterol Total

: 172 mg/dl

(<200)

Cholesterol HDL

: 18 mg/dL

(>65)

Cholesterol LDL

: 114 mg/dL

(<150)

Ureum

: 26 mg/dl

(15-39)

Uric acid

: 1,5 mg/dL

(<8,4)

Creatinin

: 0,85 mg/dl

(0,6-1,0)

Na

: 132 mmol/l

(135-155)

: 3,4 mmol/l

(3,5-5,5)

Ca

: 9,3 mg/dL

(8,4-9,7)

Phospor

: 3,5 mg/Dl

(2,5-5,0)

Mg

: 2,70 mEq/L

(1,4-21,1)

Cl

: 93 mmol/L

(96-106)

CRP Kualitative

: positive

(negative)

CRP Quantitative

: 44 mg/L

(<5)

URINE
Epithel

: Not performed

Protein

: Not performed

Leucocyte

: Not performed

Glucose

: Not performed

Eritocyte

: Not performed

FECES
Consistency

: Not performed

Erytrocyte

: Not performed

Slime

: Not performed

Leucocyte

: Not performed

Blood

: Not performed

Worm egg

: Not performed

Amoeba coli : Not performed

Hystolitica

: Not performed

CEREBRO SPINAL FLUID (9th October 2014)

Macroscopic
Volume

: 3 cc

Colour

: Colorless (transudate: yellowist; exudate yellow to red)

Clarity

: slightly cloudy (transudate: clear; excudate: cloudy)

10

Smelly

: no smelly (transudate: no smelly; exudate: odor)

Specific weight

: 1.020 (transudate: > 1,016; exudate: > 1,016)

Clot

: negative

pH

: 9.0 (transudate: 7,4-7,6; exudate: < 7,3)

Microscopic
Leukosit

: 11,0 sel/l (transudate: < 500; exudate: > 500)

Diff.count
PMN cell

: 18% (transudate: less; exudate: more)

MN cell

: 82% ((transudate: more; exudate: less)

Nonne

: negative

Pandy

: positive

Protein

: 0,3 g/dL (transudate: < 2,5; exudate: > 3)

Glucose

: 41,7 gr/dL (transudate: same in serum; excudate: < in serum)

LDH

: 99 U/L (transudate: < 200; exudate: > 200)

Cloride

: 118 mEq/L (98-107)

CULTURE CSF (9th October 2014)

Bacteria

: Staphylococcus epidermidis

Microscopic

: gram (+), coccus (+), leukosit 0-4/lp, epitel 0-1/lp

Antibiotic

: Amikacin sensitive

CULTUR BTA (13th October 2014)

BTA 1,2,3 sputum

: positive (3+)

BTA from CSF

: negative
SPECIFIC EXAMINATION
Cranium X- Ray

: Not performed

Chest X- Ray

: Pulmonary Tuberculosis and

pneumothorax

Vertebral column X- Ray

: Not performed

11

Electroencephalography

: Not performed

Electroneuromyography

: Not performed

Electrocardiography

: Not performed

Arteriography

: Not performed

Pneumography

: Not performed

Head CT-Scan

: Not performed

RESUME
IDENTIFICATION
Mr. AM, male, 25 years old, admission date 7th October 2014
ANAMNESIS
The patient was admitted to Neurology ward RSMH because decreased of
consciousness gradually.
+ 4 months before admitted to the hospital, the patient had persistent headache,
cough, mucous (+), blood (-). He had fever, loss of appetite, sweat in night, and loss of body
weight, nausea and vomiting. + 3 months before admitted to the hospital, the patient had
admitted to Sekayu hospital because he had feel weakness of his body, and the doctor said
that he got lung disease. Then he got the medicines and after around 1 week he feels better,
then he stopped to drink medicine and he did not control to hospital. At home, he drunk
drugs regularly, but he stopped. + 2 days before admitted to the hospital, the patient had
decreased of consciousness gradually, such as anxious and disorientation. He had headache,
nausea and vomiting, no seizures, no hemiparese.
He had no history of ear infections, no history of seizures, no history of diabetes, no
head trauma.
The patient suffered from this illness for the first time.
EXAMINATION
Present State
Sense

: E3M5V3

Nutrition

: Sufficient

Temperature

: 38.9 oC

12

Pulse

: 90 beats/min

Respiratory rate

: 20 times/min

Blood pressure

: 130/100 mmHg

Neurological state
Nn. Craniales
N. VII: Left angle paralysis of mouth, and flat nasolabial fold.
Motoric function
Motoric function
Motion
Power
Tones
Clonus
Physiological reflex
Pathological reflex

Arm

Leg

Right
Left
Lateralization to Left side
Lateralization to Left side
N

N
-

Sensory function

: Not yet assessed

Limbic function

: Not yet assessed

Vegetative function

: Not yet assessed

Right

Left

N
N
-

+B,C

Meningeal Irritation : Positive (Nape of neck stiffness, Kerniq, Lasseque)

Abnormal Movement : Negative
Gait & Stability

: Not yet assessed

LABORATORY FINDINGS
BLOOD (7th October 2014)
Hb

: 11.7 gr/dl

(12-16)

Hematocrit

: 33 vol%

(37-43 vol%)

Leucocyte

: 13300/mm3

(5000-10000)

LED

: 120mm/hour

(<15)

Thrombocyte

: 547000/mm3

(200.000-500.000)

MCV

: 74,8 fL

(85-95)

MCH

: 27 pg

(28-32)

MCHC

: 36 g/dL

(33-35)
13

Diff Count

: 0/0/0/91/5/4

(0-1/1-6/2-6/50-70/20-40/2-8)

CRP Kualitative

: positive

(negative)

CRP Quantitative

: 44 mg/L

(<5)

CEREBRO SPINAL FLUID (9th October 2014)

Macroscopic
Volume

: 3 cc

Colour

: Colorless (transudate: yellowist; exudate: yellow to red)

Clarity

: slightly cloudy (transudate: clear; exudate: cloudy)

Smelly

: no smelly (transudate: no smelly; exudate: odor)

Specific weight

: 1.020 (transudate: > 1,016; exudate: > 1,016)

Clot

: negative

pH

: 9.0 (transudate: 7,4-7,6; exudate: < 7,3)

Microscopic
Leukosit

: 11,0 sel/l (transudate: < 500; exudate: > 500)

Diff.count
PMN cell

: 18% (transudate: less; exudate: more)

MN cell

: 82% ((transudate: more; exudate: less)

Nonne

: negative

Pandy

: positive

Protein

: 0,3 g/dL (transudate: < 2,5; exudate: > 3)

Glucose

: 41,7 gr/dL (transudate: same in serum; exudate: < in serum)

LDH

: 99 U/L (transudate: < 200; exudate: > 200)

Cloride

: 118 mEq/L (98-107)

CULTURE CSF (9th October 2014)

Bacteria

: Staphylococcus epidermidis

Microscopic

: gram (+), coccus (+), leukosit 0-4/lp, epitel 0-1/lp

Antibiotic

: Amikacin sensitive

CULTUR BTA (13th October 2014)

BTA 1,2,3 sputum

: positive (3+)

14

BTA from CSF

: negative

SPECIFIC EXAMINATION
Chest X- Ray

: Pulmonary Tuberculosis and pneumothorax

DIAGNOSIS
Clinical Diagnosis

: Hemiparese sinistra spastic + parese N VII sinistra central type +

Meningeal Irritation

Topic Diagnosis

: Meningen, encephalon

Etiologic Diagnosis

: Tuberculous Meningoencephalitis

Additional Diagnosis : Pulmonary Tuberculosis + pneumothorax post WSD

MANAGEMENT
IVFD NaCl 0,9% gtt XXX/m
Dexamethasone 3 x 1 mg IV
Ranitidin 2 x 50 mg IV
ATD

: Rifampicin 1x450 mg PO
Isoniazid 1x300 mg PO
Pirazinamid 1x1000 mg PO
Etambutol 1x75 mg PO

Paracetamol 3x1000 mg IV
O2 6-8 liters/m NRM
Catheter urine
Liquid diet 1800 kkal
PROGNOSIS
Quo ad vitam

: Dubia

Quo ad functionam

: Dubia

CASE ANALYSIS
Differential diagnosis
Tuberculous Meningoencephalitis

Symptoms of the patient were:

15

History : cough with mucous and blood, fever, + 4 months: persistent headache, cough,
loss of appetite, sweat in the night, loss of mucous (+), blood (-), fever, loss of
body weight
appetite and body weight, sweat in night.
Decreased of consciousness which happened The patient was admitted to Neurology
gradually

ward

RSMH

because

decreased

of

Cranial nerves are involved

consciousness which happened slowly.

N. VII: Left angle paralysis of mouth, and

flat nasolabial fold.

GRM
Present
Chest X-ray, Sputum
Pulmonary Tuberculosis, BTA 1,2,3 (+)
CSF
Tuberculous Meningoenchepalitis
So the possible diagnose of Tuberculous Meningoencephalitis can be fulfilled
Bacterial Meningoencephalitis
Symptoms of the patient were:
Manifestation: fever, headache, photofobia, Fever, headache were present, but
seizure.
History of extra cranial infection, such as

photofobia and seizure were not found.

No found

otitis, sinusitis
Decreased of consciousness which happened The patient was admitted to Neurology
gradually

ward RSMH

because decreased of

Cranial nerves are involved

consciousness which happened gradually.

N. VII: Left angle paralysis of mouth,

and flat nasolabial fold.

GRM
Present
CSF Culture
Staphylococcus epidermidis
There is possible possibility of Bacterial Meningoencephalitis
SAH
Persistent Headache
Seizure
Head trauma history or hypertension history
Eye disorder

Symptoms of the patient were:

+ 4 months: persistent headache
No history of seizure
No history of head trauma or

hypertension
No present
There is no possibility of SAH

16