presentation case kito

Case ReportSENIOR CLINICAL CLERKSHIP

Name : Fitria Koeshardani, S. Ked Intan Meilita, S.Ked Vengky Utami, S.Ked

NIM : 54061001080 04061001017

04061001095Semester : IXDate : December 13th, 2010Advisor : Dr. H. A. Rachman Toyo, SpS(K)

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Spinal Cord Contusion

Case Report

• IdentificationName : Mr. IAge : 25 years oldGender : maleMarital Status : unmarriedReligion : MoslemAddress : outside PalembangAdmission Date : December 1st 2010 3

ANAMNESIS (Auto Anamnesis)

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The patient was admitted in the neurology ward in RSMH Palembang because of paralysis of both legs and he complaints difficulty in urinating and defecation since he fell from the palm tree.

± 2 weeks ago, the patient fell from a tree in the supine position, his back hit first, and the patient immediately unable to move both his legs, he also couldn’t feel sense from the umbilicus to the fingertips of both legs and complaint difficulty in urinating and defecation. There was no impairment of consciousness , he didn’t complain about nausea and vomiting. He was taken to the hospital immediately.

Patient had no history of Hypertension. No history of getting fever. No history of getting head injury. No history of diabetes mellitus. No history of chronic cough, no history of lifting heavy load, no history of spinal bump

This illness was suffered for the first time 

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PHYSICAL EXAMINATION

Sense : E4M6V5Nutrition : sufficientPulse :82beats/minRespiratory rate :18 times/minBlood pressure :110/80 mmHgWeight : 55 kgHeight : 164 cm

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Neurological state

• Nervi cranialesNn. Craniales : no abnormality

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Motoric function

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Motoric function Arm Leg

Right Left Right Left

Motion Sufficient Sufficient Insufficient Insufficient

Power 5 5 0 0

Tones Normal Normal Decrease Decrease

Clonus - -

Physiological reflex

Normal Normal Decrease Decrease

Pathological reflex - - - -

• Sensory function : Hipestesi as high as 2 fingers under umbilicus until the fingertips of both legs.

• Vegetative function : retensio urin and retensio alvi

• Limbic function : No abnormality• Abnormal Movement: (-) • Gait & Stability : not examined• Meningeal Irritation : (-)

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Hb : 11,3 g/dL Total kolesterol :116

mg/dL

Eritrocyte : 4,2 juta/mm3 Kolesterol HDL : 37

mg/dL

Leukosit : 9500 /mm3 Kolesterol LDL : 61

mg/dL

Trombosit : 421.000 /mm3 Trigliseride : 91

mg/dL

Hematocrit: 35 vol% Ureum : 60

mg/dL

CK-NAK : 51 U/I Kreatinin : 1,1

mg/dL

CK-MB : 13 U/I Natrium : 135

mmolL

Diff Count: 0/0/2/81/12/5 Kalium : 4,1

mmol/L

Calsium : 2,4 mmol/L

Additional Examination

Specific examination

• Vertebral column X- Ray :Compressive fracture/burst T.11 and Spondylolistesis T 11-12

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DIAGNOSIS

Clinical Diagnostic : Inferior flacid paraplegia + hipestesi as high as 2 fingers under umbilicus until the fingertips of both legs.

Topical Diagnostic : Total transversal lesion medula spinalis T11-T12

Etiological Diagnostic : Contusio medula spinalis

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TreatmentNon Medication :ImmobilisationUrin catheterisationConsult for operative treatmentConsult to medical rehabilitation Medication :

IVFD RL gtt XX/minMetilprednisolon 5,4 mg/kg BB bolus followed by 30 mg/kgBW/hour infussion for 23 hours Vitamin B1, B6, B12 3x1 tab

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• PROGNOSIS –Quo ad vitam : bonam–Quo ad functionam : dubia ad malam

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• Complication –Urinary tract infection–DVT–Pulmonary embolism–Death

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• From Anamnesis– History of trauma on back of the body– Weakness on both legs– Retensio urin and alvi– Lost of sensation from umbilicus until

fingertips of both leg

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• From Physical Examination– Paraplegia inferior flaccid– Hipestesi from 2 fingers below umbilicus until

fingertips of both legs– Retensio urin et alvi

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• From additional examination– Burst fracture on vertebrae thoracal 11th.– Spondylolistesis T 11-12

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Differential Diagnosis for etiological diagnosis:• Myelitis• Spondylitis TB• Subdural hematom spinalis• Spinal cord contusion

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So, the possibility of myelitis can be ruled out. 22

1. Myelitis Found in patient:

Symptomps: Fever Neck stiffness and pain in posterior of body Asymetric motoric deficit

No feverNo neck stiffness and pain in posterior of bodyParaparese inferior flaccid (symetric)

Case analysis-con't-2

So, the possibility of spondylitis TB can be ruled out..23

2. Spondylitis TB Found on patient:

Chronic coughChronic and progressive weakness

No chronic cough Weakness appear after trauma

Case analysis-con't-4

So, the possibility of subdural hematom spinalis can be ruled out.. 24

3. Subdural Hematom spinalis

Found on patient:

History of traumaChronic and progressive weakness

History of trauma 2 weeks before Weakness appear after trauma

Case analysis-con't-5

So, the possibility of contusio of spinal cord can’t be ruled out.. 25

4. Spinal cord contusion Found on patient:

History of traumaAcute and permanent weakness

History of trauma 2 weeks before Weakness appear after trauma

• From all above, we concluded that this patient suffered from– paraplegi inferior flaccid + hipestesi from 2

fingers below umbilicus until fingertips of both leg + retensio urin et alvi because of spinal cord contusion on thoracal 11th

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