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TRANSCRIPT
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Tertaparese flaccid+hipesthesia 4
finger under neck to toe+retensiourine
By: Santoso wibowoAdviser: Dr. H. A. Rachman Toyo, SpS (K)
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Identification
Mr. A/ 27 yrs/ P.bungur/ Islam/administered at august 10, 2009
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Anamnesis Patient administered into hospital because of
inability to walk concerning weakness of bothlegs within gradual onset.
4 days before hospitalized, patient feltnumbness on his both legs without weakness on
both legs.and felt that he could not urinated anddefecation.
20 hours before hospitalized, patient felt hisboth legs became weak and felt the numbness
on his both legs ascending up to hisstomach.When Patient administered intohospital, patient felt hard to breath and armweakness with his both legs could not move andnumbness from his stomach to his toe.
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Patient had History of fever and cough 7 daysago, history of trauma on the lower back wasdenied, and history of growing something on thelower back was denied.
Patient suffered from this illness for the firsttime.
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Physical examination
General condition
Conciousness : GCS E4M6V5= 15 Blood Pressure : 110/70 mmHg
Pulse : 68 x/mins
Respiratory Rate : 30x/mins
Temperature : 37,4oC
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Neurological statusCranial nerves:
N. VII : Forehead wrinkle isasymmetrical(right left behind), showing
teeth the right left behind
(parese N VII perifer)
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Motoric Function RA LA RL LL - Movement Lack lack no no
- Strength 4 4 0 0
- Tone de de de de
- Clone - -
- Physiological Refl. de de de de
- Patological Refl. - - - -
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Sensoric Function : Hipesthesia from 4finger under the neck to toe both legs
Vegetative : retensio urine
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Laboratory findingsBlood (august 10th, 2009) Leukosit abnormal 13200/mm3
LCS(august 15th, 2009)
no distosiation cito albumin
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DIAGNOSIS
Clinical diagnosis : tetraparese flaccid+parese n VII dextra perifer + retensio urine+hipestesi 4 finger from neck to toe both legs
Topical diagnosis : total tranversal lesionmedulla spinalis C2-C3
Etilogical diagnosis : gullian Barre
syndrom
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Differential diagnosis
poisonings with organophosphate, poisonhemlock, thallium, or arsenic
botulismwith early loss of pupillary reactivity
diphtheriawith early oropharyngeal dysfunction
Lyme diseasepolyradiculitis and other tick-borne paralyses
porphyriawith abdominal pain, seizures,psychosis
poliomyelitiswith fever and meningeal signs
myasthenia gravis
tranverse myelitis
http://en.wikipedia.org/wiki/Organophosphatehttp://en.wikipedia.org/wiki/Poison_hemlockhttp://en.wikipedia.org/wiki/Poison_hemlockhttp://en.wikipedia.org/wiki/Thalliumhttp://en.wikipedia.org/wiki/Arsenichttp://en.wikipedia.org/wiki/Botulismhttp://en.wikipedia.org/wiki/Diphtheriahttp://en.wikipedia.org/wiki/Lyme_diseasehttp://en.wikipedia.org/wiki/Porphyriahttp://en.wikipedia.org/wiki/Poliomyelitishttp://en.wikipedia.org/wiki/Myasthenia_gravishttp://en.wikipedia.org/wiki/Myasthenia_gravishttp://en.wikipedia.org/wiki/Poliomyelitishttp://en.wikipedia.org/wiki/Porphyriahttp://en.wikipedia.org/wiki/Lyme_diseasehttp://en.wikipedia.org/wiki/Diphtheriahttp://en.wikipedia.org/wiki/Botulismhttp://en.wikipedia.org/wiki/Arsenichttp://en.wikipedia.org/wiki/Thalliumhttp://en.wikipedia.org/wiki/Poison_hemlockhttp://en.wikipedia.org/wiki/Poison_hemlockhttp://en.wikipedia.org/wiki/Organophosphate -
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treatment
Dopamine amp in 100 cc Nacl 0,9%
Dobutamin amp in 100 cc Nacl 0,9%
02 3-4 L/ minute(nasal) Inj dexametason 4x2 amp
Inj ceftriaxon 2x I gr
Inj ranitidine 2x 1 amp
Inj bisolvon 2x1 amp
Parasetamol tab 3x 500mg
IVFD RL gtt XX/menit
Vitamin B1, B6, B12 3x1 tab
Diet BB
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Prognosis
Quo ad Vitam: dubia ad bonam Quo ad Functionam: dubia ad bonam
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topic diagnosis
lesion on ms C2-C3 Sign on the patient
Tetraparese /tertaplegia(motoric) tetraparese flaccid
Sensoric deficit according to
dermatom
Hipesthesia from 4 finger under
the neck to toe both legs
Otonomic disorder(retensio urine) Retensio urine
Total lesion (disorder of motoric,
sensoric, otonomic)
Yes
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differential diagnosis of etiologi
swollen clostridium
botulism
no
Contaminated injury no
Paralysis nervus craniales Nervus vII dextra perifer
paralysis descending paralysis ascending
paralysis respiratory muscle Paralysis respiratory muscle
Botulism can be rule out
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differential diagnosis of etiologi
diftheria can be rule out
Sore throat no
High fever yes
Pseudomembran on
tonsil
No finding
paralysis respiratory
muscle
Paralysis respiratory
muscle
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differential diagnosis of etiologi
Poisoning can be rule out
swollen
organofosfat,nitrofurantoin,dap
sone
no
Disorder of lacrimation,
salivation, incontinensia urine,miosis
no
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differential diagnosis of etiologi
porfiria can be rule out
Pain attack no
Mental
disorder(halusinasi,depresi,paran
oid)
no
Vomit with pain in stomach
no
Aritmia of heart no
Sensitive to light no
Muscle weakness Tetraparese weakness
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differential diagnosis of etiologi
Tranversal mielitis(segmen c3,4,5) Sign on patient
paralysis respiratory muscle Paralysis respiratory muscle
Progesive weakness yes
Arm with UMN dan LMNlegs with UMN
Arm ang legs flaccid (spinal shock)
fever yes
Spinal shock (all extrimities are flaccid in
the first weak and then return to spastic)
no
LCS with increase of protein and cell
account
no
Deficit sensoric and otonom Yes
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differential diagnosis of etiologi
SGB can not rule out
Sindrom Guillain-Barre (SGB) Sign on patient
Tetraparese flaccid/Paraparese
flaccid (ascending type)
Tetraparese flaccid ascending type
History of infection on respiratoy
and gastrointestinal
Yes(respiratory)
Deficit sensoric,disorder of otonom Yes(retensio urine)
N craniales involment especially
nervus fascialis
n VII perifer dextra
No sign of fever on onset There is fever on onset
LCs distosiation of cyto albumin No
paralysis respiratory muscle Paralysis respiratory muscle
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Thank you