case andri
TRANSCRIPT
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Case Presentation
Hemiparese sinistra spastik +
parese N.VII sinistra perifer
Department of Neurology – RSMH Palembang
Faculty of Medicine University of Sriwijaya
By: M.Andri Junaidi, S.Ked.
Supervisor: Dr. H. A. R. Toyo, Sp.S (K)
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IDENTIFICATION
Mr.M/65 years/male/married/islam/
Palembang/ january 5th 2007
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ANAMNESIS
The patient was hospitalized in neurology wardRSMH because of walking disturbance which wascaused by weakness on his left arm and lower
limb, which happened suddenly.
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± 3 hours before admitted to the hospital, when the
patient was taking wudhu’, suddenly he felt weakness onhis his left arm and lower limb without unconsciousness.
At that time, he didn’t get headache, nausea and vomit,
without stiffness, and without disturbance of sensibility
on the left side. The weakness between arm and lowerlimb was felt same. The patient uses right hand to work.
He could express his mind by talking, writing and giving
sign. The patient understood other people’s mind which
was expressed by talking, writing and giving sign. Hedidn’t feel throbbed and sorebreath.
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ANAMNESIS
History of getting headache oftenly (-)
History of getting lesion in the eksternal genital
which was painless and self healing (-)Skin lesion which was painless, self healing (-)
His wife history of abortion in > 16 weeks (-)
This illness was the first time for him.
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Physical Examination
Generalis Status
General Condition : moderate sickness
Sens : compos mentis (GCS=E4M6V5)
Nutrition : enough
Temp. : 36,8ºC
Pulse : 80 x/minute
Respiratory rate : 18 x/minute
Blood Pressure : 130/80 mmHg
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Physical Examination
Generalis Status
Heart : HR: 80 x/menit,
murmur(-), gallop(-)Lung : vesikuler(+) normal,
ronchi (-), wheezing(-)
Liver : not palpableSpleen : not palpable
Ekstremity : refer to neurological status
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Physical Examination
Neurological Status
N. VII sinistra :
- forehead fold : flat
- lagoftalmus (+)
- angle of the mouth
- nasolabialis fold : flat
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Physical Examination
Motorik
Fungtion
Arm Leg
Right Left Right Left
Movement enough less enough less
Power 5 4 5 4
Tonus Normal Normal
Klonus - - -
Physiological R. Normal Normal
Patological R. - - - (+) B
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Physical Examination
Sensorik function : no abnormality
Vegetatif function : no abnormality
Noble function : no abnormality
MES : no
Abnormal Movement : no
Gait : can’t be examined
Balance and coordination : Romberg (+)Dysmetri finger to finger (+)
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Radiology
Ro Thorax PA:
LVHCT scan :
Infark in cerebellum sinistra
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Diagnosis banding topik
1. Lesion at the cortex of
hemispherium cerebri dextra,signs:
In the patient, signs :
- motoric deficyt - hemiplegi sinistra type spastic
- iritation sign (-)
- focal sign - weakness in the left arm and
lower limb was felt same
-sensoric deficyt (-)
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2. Lesion at the subcortex
hemispherium cerebridextra, signs:
In the patient, signs :
- motoric deficyt - hemiplegy sinistra typespastyc
-afasia motoric if the lesion
in dominan hemispherium.
(-)
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3. Lesion at Capsula
interna hemispherium
cerebri dextra, signs:
In the patient, signs :
- hemiparese/hemiplegy
typica
- hemiplegi sinistra tipe
spastik
weakness in the left arm and
lower limb was felt same- weakness in the left arm and
lower limb was felt same
Focal sign & iritatif sign (-) Focal sign & iritatif sign (-)
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Topical Diagnosis :
Capsula interna hemispherium dextra + cerebellum
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Etyological Diff Diagnose :
1. Hemorrhagic cerebri,
signs:
In the patient, signs :
- When activity -mild activity (wudhu’)
- Unconsiousness > 30 menit (-)
- headache, nausea, vomit before (+)
(-)
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2. Emboli cerebri, signs: In the patient, signs :
- arterial fibrilation (+) (-)
- Unconsiousness < 30 menit (-)
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3. Trombosis cerebri,
signs:
In the patient, signs :
- When taking a rest -mild activity (wudhu’)
- Unconsiousness (-) (-)
- Risk factor foraterosklerosis (+)
(+)
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Siriraj Stroke Score = -2
CVD non Hemorrhagic
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Etiological Diagnosis :
Trombosis Cerebri
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Diagnosis
Clinical Diagnosis :Hemiparese sinistra spastik + parese N.VIIsinistra perifer
Topical Diagnosis :
Capsula interna hemispherium dextra +cerebellum
Etiological Diagnosis :
Trombosis Cerebri
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Management
IVFD Ringer Laktat gtt xx/mnt
Diet rice low salt
Brain Act 2 x 250 mg intravenous
Aspilet 1 x 80 mg tab per oral
Grahabion 2 x 1 tab per oral
Physiotherapy : IRR and gait training
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PROGNOSIS
Quo ad Vitam : bonam
Quo ad Functionam : dubia ad bonam