joincase alvin
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NEUROPSYCHIATRY JOIN
CASE
Consultants:Abdulloh Machin, dr. Sp.S
Didi Aryanto, dr. Sp.KJ (K)
Presented by: Alvin Rahmawati, dr.
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CASE REPORT2
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IDENTITY
Name : Mr. A
Age : 42 y.o
Sex : Male
Address : Semampir Gang Kelurahan107, Surabaya
Religion : Moslem
Occupation : - Marital status : Divorced
Hospitalized : March 17, 2013
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ANAMNESIS
Chief complaint: seizure
History of present illness:
Patient had seizure 1x, 4 hours before admission
when sleeping the night (at 02.30 am),
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ANAMNESIS
At ER, patient had seizure, 1x, type of seizure
was similar. After wake up, he was mumble.
Half body weakness (-), numbness/tingling (-),
slurred speech (-),visual disturbances (-), hearingdisturbance (-), micturition and defecation
difsturbances (-) forgetfulness (-), not
understoodable communication (-), wandering (-),
other behaviour changes (-).
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ANAMNESIS
Patient had been seizure when he was 16 yo. He
always had mumble after seizure.
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ANAMNESIS
History of past illness:
Neoplasma(-), Infection(-), Stroke(-),
Hypertension(-), DM (-), Febrile convulsion(-)
Psychiatric outpatient clinic haloperidol tab
2x0.5 mg
Neurology outpatient clinic carbamazepin2x200mg, vit B6 1x1, as folat 1x1
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GENERAL EXAMINATION
Vital Signs :
BP 120/ 80mmHg; PR 80x/m,regularly ; RR20x/mnt ; T 36,5C
Head & Neck : A-/I-/C-/D- ; JVP not increased ;Bruits carotid -, solid mass in the cervicallymphonodi (-)
Chest :
- Cardiac : S1, S2 single ES-/G-/M-
- Lung : Ves / Ves, Rh-/-, Whz-/-
Abd : H/L not palpable, peristaltic (+)N
Extremities : Warm, edema -/-
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NEUROLOGICAL
EXAMINATION
GCS : 456 Meningeal sign : Nuchal rigidity -, Br I-IV : -/- Cranial Nerves :
II,III : pupil round 3mm/3mm, lightreflex +/+visus ODS: >2/60, visual field: wnl
VII : wnl
XII : wnlother cranial nerves wnl Motor system : 55555/ 55555, tonus: rigidity
wnl55555/ 55555
Sensory system : wnl
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NEUROLOGICAL
EXAMINATION Physiological Reflexes :
BPR +2 /+2TPR +2 /+2KPR +2 /+2
APR +2 /+2
The Superficial (Cutanneous) ReflexesBHR +/+
+/+
Pathologic ReflexesBabinski sign -/- Chaddock sign -/-Hoffmann & Tromner sign -/-
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NEUROLOGICAL
EXAMINATION
Primitive reflex : Palmomental -/-, snout (-),
glabella (-), sucking (-), graps (-)
CV / ANS : wnl
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LABORATORIUM
Leu : 13.800
Hb : 13.2
Tromb : 376.000
RBG : 119 mg/dL
SGOT/SGPT : 31/20
BUN/SK : 5/0.9
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Ro THORAX-PA
Cor/pulmo wnl
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Results: Abnormal EEG III (anterior
temporal sharp wave in the right and left,
and general CSA)
Abnormal EEG indicates potentialepileptogenicity in bilateral anterior
temporal region with mild diffuse
encephalopathy
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HEAD MSCT WITH
CONTRAST
Within normal limit
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NEUROBEHAVIOUR
EXAMINATION
1. Atensi : 4 digit (abnormal)
2. Vigilance (konsentrasi) : ommision error : 0
comission error: 0
(normal) 3. Token test : 36 (normal) mild
4. MMSE : 27 (normal)
5. CDT : 4 (normal)
6. Constructional praxis : 12 (normal)
7. Mirror test : normal
8. Trail making test : >180 detik(abnormal)
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NEUROBEHAVIOUR
EXAMINATION
9. Visual memory : 12/12 (normal)
10. Verbal memory : 7.5/10 (abnormal)
11. Categorical naming : 10 (abnormal)
12. Delay recognition task : I.5 II.6 III.8 (total
19) normal
There are abnormal results in attention, trail
making B, verbal memory, and categoricalnaming which could be caused by underlying
disease. Long term use haloperidol could
affect cognitive function
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DIAGNOSIS
Clinical : - status generalized tonic clonic seizure
-behaviour changes
Topical :
Etiological: psychotic epilepsy
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MANAGEMENT
1. PHARMACOTHERAPY:
- Psychiatry: haloperidol 2x0.5 mg tab
- Neurology: carbamazepin 2x200mg, folic
acid 1x1, piridoxin 1x1
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MANAGEMENT
2. Supportive Psychotherapy
3. Family psychoeducation
4. Re-test neurobehaviour examination in next
3 months.
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THANK YOU22
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