Documente Academic
Documente Profesional
Documente Cultură
Name
JUL
: Bharmatisna
AN S. Ked
NIM
: 04033100018
Semester
: XII
Date
Advisor
DEPARTMENT OF NEUROLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ RSMH
PALEMBANG
2009
: Mr I
: 36 years
: Male
: Lr Balai Pengobatan RT 05 RW 10 Banyuasin
: Islam
: August 13th, 2009
Anamnesis
The patient was admitted to Neurology ward RSMH because of the weakness at the left arm
and left leg which happened suddenly.
1 week before admitted to the hospital, the patient suddenly had weakness at his left arm dan
left leg when he was working, followed by losing consciousness. During the attack, he have headache,
nausea, vomitted and seizure. he experienced blurry eyes and the movement of his eyes also become
limitted. he felt that the weakness he had was the same between the arm and the leg. he still could
express her mind by talking, writing and giving sign. The patient understood other peoples mind which
was expressed by talking, writing and giving sign. When he was talking, his lips deviated to the left and
there is disarthria.
During the attack, he doesnt have a heart beat which was followed by shortness of breathing.
he never complained that he had headache at the backside of his head which occurred in the morning
and became less in the afternoon.
The patient experienced these complaints for the first time.
PHYSICAL EXAMINATION
PRESENT STATE
Internal State
Sense
Nutrition
Pulse
Respiratory rate
Blood pressure
: compos mentis
: sufficient
: 90 beats/min
: 20 times/min
: 170/90 mmHg
Lungs
Liver
Spleen
Extremities
Genital
: no abnormality
: no abnormality
: no abnormality
: refer to neurological state
: no abnormality
Psychiatric state
Attention
Attention
: cooperative
: normal
Facial Expression
Psyche contact
: natural
: natural
Neurological state
Head
Shape
: brachiocephaly
Deformity
: no
2
Size
Symetric
Hematome
Tumor
: normal
: yes
: no
: no
Neck
Position
: straight
Torticolis
: no
Nape of neck stiffness : no
Fracture
Fracture pain
Vessel
Pulsation
Deformity
Tumor
Vessels
: no
: no
: no widening
: no disorder
: no
: no
: no widening
CRANIAL NERVES
Olfaktorius nerve
Smelling
Anosmia
Hyposmia
Parosmia
Right
No disorder
No
No
No
Left
No disorder
No
No
No
Opticus nerve
Visual acuity
Campus visi
Right
6/30 PH (-)
V.O.D
Left
6/21 PH (-)
V.O.S
No
No
No
No
No
No
No
No
No
No
Right
No
No
No
Left
No
No
No
No
No
No
No
no abnormality
No
No
No
No
no abnormality
Round
3mm
isochor
No
Round
3mm
isochor
No
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 nerve
Motoric
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 nerve
Whispering
Hour ticking
Weber test
Rinne test
Vestibularis nerve
Nystagmus
Vertigo
Glossopharingeus
nerves
Pharyngeal arch
Uvula
and
Vagus
+
+
+
No
+
+
+
No
Right
No disorder
No
Yes
Left
No disorder
No
Yes
Normal
Normal
Normal
Normal
Normal
Normal
Right
assimetric
Normal
Normal
Normal
Left
assimetric
Normal
angle paralysis
flat
No disorder
Deviation to the left
No disorder
Deviation to the left
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
Right
No disorder
No disorder
Normal
Normal
Left
No disorder
No disorder
Normal
Normal
No
No
No
No
Right
No disorder
No disorder
No
No
Normal
Left
No disorder
No disorder
No
No
Normal
4
Swallowing disorder
Hoarsing/nasalising
Heart beat
Reflex
Vomiting
Coughing
Occulocardiac
Caroticus sinus
Sensory
1/3 posterior tounge
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
Accessorius Nerve
Shoulder Raising
Head Twisting
Right
No disorder
No disorder
Left
No disorder
No disorder
Hypoglossus Nerve
Tounge Showing
Fasciculation
Papil Athrophy
Dysarthria
Right
Deviation to the left
no
no
yes
Left
Deviation to the left
no
no
yes
Right
Sufficient
5
Normal
Left
Lack
2
Increase
Normal
Normal
Normal
Normal
Increase
Increase
Increase
Increase
None
None
None
None
None
None
None
None
Right
Sufficient
5
Normal
Left
Lack
2
Increase
Negative
Negative
Negative
Negative
Normal
Increase
MOTORIC
Arms
Motion
Power
Tones
Physiological Reflex
Biceps
Triceps
Radius
Ulna
Pathological Reflex
Hoffman Tromner
Leri
Meyer
Trofik
LEG
Motion
Power
Tones
Clonus
Tigh
Foot
Physiological reflex
KPR
APR
Pathological reflex
Babinsky
Chaddock
Oppenheim
Gordon
Schaeffer
Rossolimo
Mendel Bechterew
Abdominal skin reflex
Upper
Middle
Lower
Tropik
Normal
Increase
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Positive
Positive
Positive
Positive
Positive
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
SENSORY
Hemihipestesia sinistra (-)
PICTURE
VEGETATIVE FUNCTION
Mictutrion
: normal
Defecation
: normal
Erection
:VERTEBRAL COLUMN
Kyphosis
: no
Lordosis
: no
Gibbus
: no
Deformity
: no
Tumor
Meningocele
Hematome
Tenderness
: no
: no
: no
: no
Right
Negative
Negative
Negative
Left
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
MOTION ABNORMAL
Tremor
: no
Chorea
: no
Athetosis
: no
Ballismus
: no
Dystoni
: no
Myoclonus
: no
LIMBIC FUNCTION
Motoric aphasia
: no
Sensoric aphasia
: no
Apraksia
: no
Agraphia
: no
Alexia
: no
7
Nominal aphasia
: no
LABORATORY FINDINGS
BLOOD
Hb
: 15,5 mg/dl
Leucocyte
: 12600/mm3
Hematocrit
: 40 vol%
Diff Count
: 0/1/0/89/9/10
Thrombocyte : 265000/mm3
LED
: 47
Chol.tot
: 142 mg/dl
HDL cholesterol
: 100 mg/dl
LDL cholesterol
Trygliceride
Uric Acid
Ureum
Creatinin
BSS
Na
K
Ca
: 120 mg/dl
: 50 mg/dl
: 4,6 mg/dl
: 42 mg/dl
: 0,7 mg/dl
: 149 mg/dl
: 137 mmol/l
: 4,8 mmol/l
:2,95 mmol/l
URINE
Colour
Reaction
Protein
Reduction
: not performed
: not performed
: not performed
: not performed
Sediment
Bilirubin
Urobilin
: not performed
: not performed
: not performed
FECES
Consistency
Slime
Blood
Amoeba coli/
Hystolitica
: not performed
: not performed
: not performed
: not performed
: not performed
Erytrocyte
Leucocyte
Worm egg
: not performed
: not performed
: not performed
Protein
Glucose
NaCl
Queckensted
Celloidal
Culture
: not performed
: not performed
: not performed
: not performed
: not performed
: not performed
: not performed
: not performed
: not performed
: not performed
: not performed
: normal
: not performed
: not performed
: ICH Capsula interna dextra
8
RESUME
ANAMNESIS
The patient was admitted to Neurology ward RSMH because of the weakness at the left arm
and left leg which happened suddenly.
1 week before admitted to the hospital, the patient suddenly had weakness at his left arm dan
left leg when he was working, followed by losing consciousness. During the attack, he have headache,
nausea, vomitted and seizure. he experienced blurry eyes and the movement of his eyes also become
limitted. he felt that the weakness he had was the same between the arm and the leg. he still could
express her mind by talking, writing and giving sign. The patient understood other peoples mind which
was expressed by talking, writing and giving sign. When he was talking, his lips deviated to the left and
there is disarthria.
During the attack, he doesnt have a heart beat which was followed by shortness of breathing.
he never complained that he had headache at the backside of his head which occurred in the morning
and became less in the afternoon.
The patient experienced these complaints for the first time.
EXAMINATION
Present State
Sense
Blood pressure
Pulse
Respiratory rate
Temperature
Nutrition
Neurological state
Nn. Craniales
N. VII : Forehead wrinkle is asymmetrical, lagophthalmus (+), right nasolabial fold is flat, rightangle of the mouth paralysis
N. XII : Tongue showing deviated to the right, there is fasiculasi, there is disarthria
Motoric function
Motoric function
Motion
Power
Tones
Clonus
Arm
Right
Sufficient
5
Normal
Leg
Left
Lack
2
Increase
Right
Sufficient
5
Normal
-
Left
Lack
2
Increase
9
Physiological reflex
Pathological reflex
Normal
-
Increase
(+) H,T
Normal
-
Increase
(+) B,C,S
Sensory function
Vegetative function
Limbic function
Abnormal Movement
Gait & Stability
Meningeal Irritation
DIAGNOSIS
Diagnosis clinic
Diagnosis topic
Diagnosis etiology
MANAGEMENT
Treatment
:
Medicine
: IVFD RL gtt xx/mins
Inj citicholine 2 x 250 mg iv
Vitamin B1, B6, B12 tab 3x1
Adona 3 x 100 mg
Captopril 2 x 12,5 mg
Ranitidine amp 2 x 150 mg iv
Fisiotherapy : Active movement
PROGNOSIS :
Quo ad vitam
Quo ad functionam
: bonam
: dubia ad bonam
10
TOPIC :
SUBCORTEX HEMISFERIUM CEREBRI
DEXTRA
Symptoms :
Motoric deficit (hemipleghia / hemiparese dextra central)
Pure afasia motoric
-
TOPIC :
CAPSULA INTERNA HEMISFERIUM
FOR THIS PATIENT
CEREBRI DEXTRA
Symptoms :
Hemiparese Typica
- Hemiparese sinistra spastik + parese N. VII
Parese
N.VII
central
& N. XII sinistra central
contralateral
Parese
N.XII
central
contralateral
THE TOPIC OF CAPSULA INTERNA HEMISFERIUM CEREBRI DEXTRA CAN NOT BE
RULED OUT
Differential Diagnosis Etiology:
ETIOLOGY :
HEMORRHAGIC CEREBRI
Symptoms :
- Loss of consciousness > 30
- Attack in activity
- Initiated by headache, nausea and vomits
ETIOLOGY :
EMBOLI CEREBRI
Symptoms :
- Loss of consciousness < 30
- There is atrial fibrillation
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