5

5

Daftar pertanyaan dan alasan bertanya*

1. How many siblings does the patient have? 2 (To assess whether there is a family history of similar conditions or any potential genetic predisposition) 2. How are the results of the spatula test? test? gag refleks? positive (To evaluate the patient’s gag reflex and check for reflex spasms of the masseter muscle, which may indicate tetanus) 3. How is the bowel sound of the abdominal examination? decrease (To assess gastrointestinal function, as abnormalities may indicate autonomic dysfunction or complications such as ileus) 4. Is there any sign of cyanosis? not yet only dyspneu (To check for oxygenation status and assess if there is respiratory compromise due to muscle rigidity) 5. Does the patient experience excessive sweeting? yes (To evaluate autonomic nervous system involvement, which is common in conditions like tetanus) 6. Does the patient experience shortness of breath? YES (To assess respiratory muscle involvement, which can be life-threatening in conditions like tetanus) 7. Does the patient experience resting tremor? NO (To differentiate between conditions that cause muscle rigidity, such as tetanus or extrapyramidal disorders) 8.How does the patient urinates and defecates? YES (To assess bladder and bowel function, as autonomic dysfunction can lead to retention or incontinence) 9. Does the patient have a history of trauma? NO (To identify any wound or injury that may be a potential entry point for Clostridium tetani) 10.Does the patient have a history of allergy? NO (To determine the risk of allergic reactions to medications or vaccines that may be needed for treatment.) 11. Does the patient have a history DPT vaccine?NOT YET (To assess immunity against tetanus and determine if the condition could be vaccine-preventable.) 12. How is the patient’s diet? DIFFICULT AND VOMITING (To evaluate nutritional status, as malnutrition can worsen the prognosis of certain infections and neurological conditions.) 13. How is the patient's sleep pattern? BAD (To assess if there are disturbances in sleep due to muscle spasms, pain, or autonomic dysfunction, which may indicate conditions like tetanus or neurological disorders.) 14. How is the patient’s exercise pattern? BEFORE SICK IS WITHIN NORMAL LIMIT (To evaluate muscle function, physical activity level, and potential risk factors for muscle-related conditions.) 15. Does the patient smoke?NO (To determine exposure to toxins that may affect the nervous or respiratory system, which could worsen the patient's condition.) 16. Does the patient consume alcohol?NI (To assess the risk of alcohol-related neurological disorders or worsening of symptoms due to alcohol's effects on the nervous system.) 17. What is the patient's birth history? WNL WITHIN NORMAL LIMIT (To check for any perinatal complications, hypoxia, or infections that could contribute to neurological or muscular conditions.) 18. How is the patient's general condition? FROM TUTOR (To evaluate overall health status, including vital signs, hydration, and signs of systemic illness.) 19. How is the result of the brudzinski examination? FROM TUTOR (To assess for signs of meningeal irritation, which may indicate meningitis or other central nervous system infections. A positive Brudzinski sign suggests meningeal inflammation.) 20. How is the result of the kernig sign examination? TUTOR (To evaluate for meningeal irritation or central nervous system involvement. A positive Kernig sign suggests meningeal inflammation, commonly seen in meningitis.)

1. Bagaimana hasil pemeriksaan darah lengkap (eritrosit, diff count, dan LED) pasien? DI TUTUOR alasan: untuk mendeteksi adanya infeksi atau perdagangan 2. Bagaimana hasil pemeriksaan elektrolit kalsium dan magnesium pasien?TIDAK alasan: untuk mendeteksi ketidakseimbangan elektrolit yang menyebabkan kaku otot 3. Bagaimana hasil pemeriksaan SGOT/SGPT pasien?TIDAK ADA alasan: untuk menilai kerusakan hati atau gangguan metabolik yang menyebabkan kaku otot 4. alasan: Bagaimana hasil pemeriksaan BUN dan kreatinin pasien? TIDAK ADA untuk mengevaluasi fungsi ginjal 5. Bagaimana hasil pemeriksaan CK dan LDH pasien?TIDAK ADA alasan: untuk mendeteksi kerusakan otot 6. Bagaimana hasil pemeriksaan kadar gula darah pasien? TIDAK ADA alasan: memeriksa gangguan metabolisme gula yang menyebabkan kaku otot 7. bagaimana hasil pemeriksaan lumbal pungsi pasien? TIDAK DILAKUKAN alasan: untuk mendiagnosa adanya infeksi atau peradangan pada sistem saraf pusat