paraparese spastik ah
DESCRIPTION
laporan kasus strokeKKS neurolapsuscase reportTRANSCRIPT
CASE REPORTSENIOR CLINICAL CLERKSHIP
Period of September 7th October 12th , 2009
JULDEPARTMENT OF NEUROLOGYFACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ RSMH
PALEMBANG
2009ENDORSEMENT PAGECase ReportParaparese inferior spastik + Hipestesia below processus xiphoideus to the tips of the toes + Retention urine et alviPresented by:
Agung Nopriansah
04080505041Has been accepted as one of requirements in undergoing senior clinical clerkship period of September 7th 2009 October 12th 2009 in Department of Neurology Faculty of Medicine Sriwijaya University / RSMH Palembang.Palembang, September 2009AdvisorDr. H. A. Rachman Toyo, SpS(K)NEUROLOGY MEDICAL RECORDIdentificationName
: Mrs RAge
: 53 years
Sex
: Female
Address
: Jl. Gajah Mati Sungai Lilin Musi BanyuasinReligion
: Islam
Admission date: September 26th, 2009AnamnesisThe patient was admitted to Neurology ward RSMH because of the weakness of both legs which happened gradually.+ 3 months before admitted to the hospital, the patient felt pain at her left flank that radiating to her back bone. There was no weakness of her legs. The patient had no complain concerning her activity daily living. Patient then felt numbness at the tips of her toes. But she didnt seek medical advice for this complaint. She had no complain concerning defecation and urinating. + 2 weeks before admitted to the hospital, she started to feel weakness of both legs, she felt walking were heavier. Also, numbness at her toes became more frequent and radiating to the upper legs. + 1 week before admitted to the hospital, weakness of both legs worsen and she was unable to walk. She felt numbness at her pelvic down to tip of her toes. She complained that she couldnt defecate and urinate.There was no history of trauma on her back. History of hipertension is positive, routine medically control. She had chronic cough but history of fever was denied.The patient suffered from this illness for the first time.
PHYSICAL EXAMINATIONPRESENT STATEInternal State
Sense: compos mentisNutrition: sufficient
Pulse : 110 beats/min
Respiratory rate: 20 times/minBlood pressure : 120/80 mmHgPsychiatric state
Attention: cooperative
Attention : normalNeurological state
Head
Shape: brachiocephalySize : normalSymetric: yes
Hematome: no
Tumor: no
Neck
Position : straightTorticolis: noNape of neck stiffness: noLungs
: no abnormalityLiver
: no abnormalitySpleen
: no abnormalityExtremities
: see neurological stateGenital
: no abnormalityFacial Expression: natural
Psyche contact
: natural
Deformity
: no
Fracture
: no
Fracture pain
: no
Vessel
: no widening
Pulsation
: no disorder
Deformity
: no
Tumor
: no
Vessels
: no widening
CRANIAL NERVESOlfaktorius nerveSmelling
Anosmia
Hyposmia
Parosmia
Opticus nerveVisual acuity
Campus visi
Anopsia
Hemianopsia
Oculi fundus
Edema papil
Atrophy papil
Retina bleeding
Occulomotorius, Trochlearis and Abducens nerves
Diplopia
Eyes gap
Ptosis
Eyes position
Strabismus
Exophtalmus
Enophtalmus
Deviation conjugae
Eyes movement
Pupil
Shape
Size
Isochor/anisochor
Midriasis/miosis
Light reflex
direct
consensuil
accommodation
Argyl Robertson
Trigeminus nerveMotoric
Biting
Trismus
Corneal reflex
Sensory
Forehead
Cheek
Chin
Facialis nerve
Motoric
Frowning
Eyes closing
Giggling
Nasolabial fold
Facial shape
rest
Speaking/whistling
Sensory
2/3 anterior tounge
Autonomy
Salivation
Lacrimation
Chvosteks sign
Statoacusticus nerve
Cochlearis nerveWhispering
Hour ticking
Weber test
Rinne test
Vestibularis nerveNystagmus
Vertigo
Glossopharingeus and Vagus nerves
Pharyngeal arch
Uvula
Swallowing disorder
Hoarsing/nasalising
Heart beat
Reflex
Vomiting
Coughing
Occulocardiac
Caroticus sinus
Sensory
1/3 posterior toungeRight
No disorder
No
No
No
Right
6/9 PH (-)
V.O.D
No
No
No
No
No
Right
No
No
No
No
No
No
No
no abnormality Round
3mm
isochor
No
+
+
+
No
Right
No disorder
No
Yes
NormalNormal
NormalRight
simetric
Normal Normal
NormalNo disorder
No disorderNo disorder
No disorder
No disorder
No disorder
Right
No disorder
No disorder
Normal
Normal
No
No
RightNo disorderNo disorderNoNoNormalNo disorderNo disorderNo disorderNo disorder
No disorderLeft
No disorder
No
No
No
Left
6/6 PH (-)
V.O.S
No
No
No
NoNo
Left
No
No
No
No
No
No
No
no abnormality Round
3mm
isochor
No
+
+
+
No
Left
No disorder
No
Yes
Normal
Normal
Normal
Left
simetric
Normal
angle paralysis
flatNo disorder
No disorderNo disorder
No disorder
No disorder
No disorder
Left
No disorder
No disorder
Normal
Normal
No
No
LeftNo disorderNo disorder No No Normal No disorder
No disorder
No disorder
No disorder
No disorder
Accessorius Nerve
Shoulder Raising
Head Twisting
Hypoglossus Nerve
Tounge ShowingFasciculationPapil Athrophy
Dysarthria
MOTORIC
Arms
Motion
Power
Tones
Physiological Reflex
Biceps
Triceps
Radius
UlnaPathological Reflex
Hoffman Tromner
Leri
Meyer TrofikLEG
Motion
Power
Tones
Clonus
Tigh
Foot Physiological reflex
K P R
A P R
Pathological reflex
Babinsky Chaddock
Oppenheim Gordon Schaeffer Rossolimo
Mendel BechterewAbdominal skin reflex
Upper
Middle
Lower
Tropik Right
No disorderNo disorder
Right
No deviationnono
noRightSufficient
5
Normal
Normal
Normal
Normal
Normal
None
None
None
None
RightLack1Increase
Negative NegativeIncrease
Increase
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
LeftNo disorder
No disorder
LeftNo deviationnononoLeft
Sufficient5NormalNormal
NormalNormalNormalNone
None
None
None
LeftLack
1Increase
NegativeNegativeIncrease
Increase
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
SENSORYHipestesia below processus xiphoideus to the tips of toes.PICTURE
VEGETATIVE FUNCTIONMicturition
: retention urineDefecation
: retention alviVERTEBRAL COLUMNKyphosis: no Tumor: no
Lordosis: no Meningocele: no
Gibbus: no Hematome: no
Deformity: no Tenderness: no
SYMPTOMS OF MENINGEAL IRRITATIONNape of neck stiffness
Kerniq
Lasseque
Brudzinsky
Neck
Cheek
Symphisis
Leg I
Leg II
Right
Negative
Negative
Negative
Negative
Negative
Negative
Negative
NegativeLeft
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
GAIT AND EQUILIBIRIUMGait
Equilibirium and CoordinationAtaxia
: not confirmed
Romberg
: not confirmedHemiplegic
: not confirmed
Dysmetri
: not confirmedScissor
: not confirmed
finger finger
: normalPropulsion
: not confirmed
finger nose
: normalHisteric
: not confirmed
heel - heel
: not confirmedLimping
: not confirmed
Reboundphenomenon: not confirmedSteppage
: not confirmed
Dysdiadochokinesis: not confirmedAstasia-Abasia: not confirmed
Trunk Ataxia
: not confirmed
Limb Ataxia
: not confirmed
MOTION ABNORMAL
Tremor
: noChorea
: noAthetosis
: noBallismus
: noDystoni
: noMyoclonus
: noLIMBIC FUNCTIONMotoric aphasia: noSensoric aphasia: noApraksia
: noAgraphia
: noAlexia
: noNominal aphasia: noLABORATORY FINDINGSBLOOD
Hb
: 12,6 gr/dl
Ureum
: 146 mg/dl (15-39 mg/dl)Leucocyte: 9600/mm3
Creatinin
: 3,2 mg/dl (0,6-1,0 mg/dl)Hematocrit: 36 vol%
Protein total
: 6,4 g/dl (6-7,8 g/dl)Diff Count: 0/3/0/72/10/4
Albumin
: 3,7 g/dl (3,5-5 g/dl)Thrombocyte: 307000/mm3
Globulin
: 2,7 g/dl
LED
: 47
Na
: 136 mmol/l (135-155)
K
: 3,6 mmol/l (3,5-5,5)URINE
Epithel
: +
Protein
: -Leucocyte: 4-6 /HPF
Glucose
: -Eritocyte: 2-3 /HPF
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 FLUIDColour
: not performed
Protein
: not performedClarity
: not performed
Glucose
: not performedPressure: not performed
NaCl
: not performedCell
: not performed
Queckensted
: not performedNonne
: not performed
Celloidal
: not performedPandy
: not performed
Culture
: not performedSPECIFIC EXAMINATIONCranium X- Ray
: not performedChest X- Ray
: not performedVertebral column X- Ray: not performedElectroencephalography: not performedElectroneuromyography: not performedElectrocardiography
: normal Arteriography
: not performed Pneumography
: not performedCT-Scan
: not performedRESUMEIDENTIFICATIONMrs. R, female, 53 years, admission date 26th of September 2009
ANAMNESISThe patient was admitted to Neurology ward RSMH because of the weakness of both legs which happened gradually.
+ 3 months before admitted to the hospital, the patient felt pain at her left flank that radiating to her back bone. There was no weakness of her legs. The patient had no complain concerning her activity daily living. Patient then felt numbness at the tips of her toes. But she didnt seek medical advice for this complaint. She had no complain concerning defecation and urinating. + 2 weeks before admitted to the hospital, she started to feel weakness of both legs, she felt walking were heavier. Also, numbness at her toes became more frequent and radiating to the upper legs. + 1 week before admitted to the hospital, weakness of both legs worsen and she was unable to walk. She felt numbness at her pelvic down to tip of her toes. She complained that she couldnt defecate and urinate.
There was no history of trauma on her back. History of hipertension is positive, routine medically control. She had chronic cough but history of fever, sweaty at night and decrease of body weight was denied.
The patient suffered from this illness for the first time.
EXAMINATIONPresent StateSense
: compos mentis (GCS 15: E4M6V5)
Blood pressure : 120 / 80 mmHg
Pulse
: 110x/minute
Respiratory rate : 20x/minute
Temperature
: 36,8o C
Nutrition
: sufficientNeurological state
Nn. Craniales
No abnormalityMotoric function
Motoric functionArmLeg
RightLeftRightLeft
Motion SufficientSufficientLackLack
Power 5511
Tones NormalNormalIncreaseIncrease
Clonus--
Physiological reflexNormalNormalIncreaseIncrease
Pathological reflex----
Sensory function: Hipestesia below processus xiphoideus to the tip of the toes.Vegetative function : Retention urine et alviLimbic function: no abnormality
Abnormal Movement: (-)
Gait & Stability: not yet assesed
Meningeal Irritation: (-)
LABORATORY FINDINGS
Hb
: 12,6 gr/dl
Ureum
: 146 mg/dl (15-39 mg/dl)
Leucocyte: 9600/mm3
Creatinin
: 3,2 mg/dl (0,6-1,0 mg/dl)
Hematocrit: 36 vol%
Protein total
: 6,4 g/dl (6-7,8 g/dl)
Diff Count: 0/3/0/72/10/4
Albumin
: 3,7 g/dl (3,5-5 g/dl)
Thrombocyte: 307000/mm3
Globulin
: 2,7 g/dl
LED
: 47
Na
: 136 mmol/l (135-155)
K
: 3,6 mmol/l (3,5-5,5)
UrineEpithel
: +
Protein
: -
Leucocyte: 4-6 /HPF
Glucose
: -
Eritocyte: 2-3 /HPF
DIAGNOSISDiagnosis clinic: Paraparese inferior spastik + Hipestesia below processus xiphoideus to the tip of the toes + Retention urine et alviDiagnosis topic: Total transversal lesion medulla spinalis Th7-8Diagnosis etiology: - Spondylitis TB
- SOLMANAGEMENTTreatment :
Medicine:Diet NBTKTP
Meloxicam tab 1 x 15 mg
Vitamin B1, B6, B12 tab 3x1
Dulcolax supp 1x1
Catheter urinePlanning:P/ Ro Thorax PA
P/ Ro vertebrae thoracal AP/Lat
P/ Lumbal puncture
P/ CT-Scan columna vertebraePROGNOSIS: Quo ad vitam
: bonam
Quo ad functionam : dubia ad bonamCASE ANALYSIS
Differential Diagnosis Etiology:
Paraparesea. Paralysis of UMN lesion
Characteristics:
Hypertonus
Hyperflexi
Patology reflex (+)
Muscle atropy (-)Examples: Spondylitis TB, SOL, trauma, Infection
b. Paralysis of LMN lesion
Characteristics:
Hypotonus, clonus (-)
Hyporeflexy
Atropy degenerative: muscle atropy (+), fast onset 1-2 weeks
Patology reflex (-)
Examples: trauma, carpal tunnel syndrome, Gullain Barre syndrome, radiation, toxin or poison, demyelinating disease.c. Paralysis combination (nuclear lesion + UMN/LMN lesion)
Characteristics:
Fascicular contraction (+)
Muscle atropy
Hypertonus, often clonus (+)
Hyperreflexy
Patology reflex (+)
Examples: ALS, myelin syndrome.
In conclusion, this paralysis case type is UMN lesion.
Etiology :
Space Occupying Lesion (SOL)Symptoms of the patient were:
- Motoric deficit on the level of lesion
- Segmental sensoric deficit
- Deficit symptoms appear slowly Motoric deficit on the level of lesion
Segmental sensoric deficit
Happened slowly
There is possibility of SOL
Etiology :
Tuberculous SpondylitisSymptoms of the patient were:
- History of chronic lung disease- Fever
- Vertebral pain
- Chronic progresive weakness Chronic cough Fever was denied Pain at her back bone Weakness of both legs happened gradually
There is possibility of Tuberculous Spondylitis
Name: Agung Nopriansah, S. Ked
NIM: 04080505041
Semester: XI
Date : September 27th, 2009
Advisor: Dr. H. A. Rachman Toyo, SpS(K)
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