case prof basjir

7/30/2019 Case Prof Basjir

1/9

Case Report Session

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PARKINSONS DISEASE

By:

Athikah Khairunnisa 0810312113 Ade Nurul Chairani 07120018

Afdol Rahmadi 0910313204 Wenny Widyastuti 0810312109

Wahyudi Firmana 0810312127 Feby Andammori 0910312122

Erikha 0810312102 Ridho Forestry 0810312107

Defri Heryadi 0810312099

PRECEPTOR:

Prof. Dr. H. Basjiruddin A, Sp.S (K)

NEUROLOGY DEPARTMENT

FACULTY OF MEDICINE ANDALAS UNIVERSITY

RSUP DR M. DJAMIL

PADANG

2013


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Case Report Session

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Case Illustration

Patient Identity

Name : Mr. A

Age : 65 years old

Occupation : Pensionary

MR No : 05.16.70

A 65 years old male patient came to Neurology Policlinic RSUP Dr. M. Djamil Padang,

on April 1st, 2013 with:

Chief Complain : Trembling of the whole body

Present Illness History:

Trembling of the whole body since 2 months ago. Patient felt trembling in his right upperlimb for the past 1 years. Then left upper limb start to trembling 2 weeks after that. At

first, patient felt the tremble when resting dan decreased when he moves. But for the past

2 months, patient felt the tremble in the whole body continuously so that he has difficulty

to do daily activities.

Patient complain that his step was became shorter for the past 7 months. Patient oftentripped the household furniture when walked and felt hard to start and stop walking.

Patient feels stiffness in his limbs Patient Family tells that patient tends to falls when he was standing.

Past Illness History:

No history of suffering from this disease previously No history of trauma, accident, and falls in sit position No history of hypertension, diabetes, and cardiovascular disease.

Family Illness History:

No family members known to be suffering from this diseaseEmployment, Social Economic, and Habitual History:

Patient is a pensionary with enough physical activity.


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Case Report Session

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No house environtment with pesticide contamination and house near chemical industry.Physical Examination:

General Condition : Moderately ill Awareness : Compos Mentis Cooperative Blood Pressure : 140/90 mmHg Pulse : Easily palpable, regular, 110x/minute. Temperature : 36,8o c Breath : Abdominothoracal pattern, regular, 28x/minute Body weight/height : 80kg/165 cm

Internal Examination :

Lymph nodes : No enlargement

Neck : JVP 5-2 cm H2O. Carotid bruit (-)

Lungs :

Inspection : Symetric in static and dynamic

Palpation : Vocal fremitus right simetris with vocal fremitus left

Percussion : Resonant

Auscultation : Vesicular, ronkhi - / -, wheezing - / -

Cor :

Inspection : Ictus are not visible

Palpation : Ictus cordis palpable 1 finger medial LMCS RIC V

Percussion : With normal limits

Auscultation : Regular, HR= 112x/minute, Murmur (-), Galloup (-)

Abdomen :

Inspection : Distended/flat, mass (-)

Palpation : Liver and spleen no enlargement

Percussion : Tympanic

Auscultation : Bowel sounds (+) normal

Vertebrae corpus

Inspection : deformity (-)

Palpation : tenderness (-), Gibus (-), crepitating (-)


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Case Report Session

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Neurological Examination:

1. GCS: E4M6V5 = 15

2. Meningial signs;

Nuchae Rigidity : (-) Brudzinsky 1 : (-) Brudzinsky 2 : (-) Kernig sign : (-)

3. Increased of intracranial pressure :

Projectile vomiting : (-) Progressive headache : (-)

4. Cranial Nerves

N I : Smelling ability is good

N II : Visual field is good

N III, IV, VI : Pupil round, isocor, 3 mm / 3 mm, light reflex direct and indirect + /+,

ptosis (-), movement of the eye ball is free.

N V : corneal reflex in both eyes (+), spontaneously open the mouth (+), move

the jaw to the right and left

N VII : right nasolabial fold same with the left, wrinkle of the forehead is symme

tric, close the eyes (+)

N VIII : Listening function is good, nistagmus (-)

N IX and X : faringeal arch is symmetric, uvula is in the middle, 1/3 tounge sensation

is good, and Gag reflex (+)

N XI : Can raise his right and left shoulder and turned head to left or right

N XII : there is no tounge deviation, atrophy (-), fasiculation (-).

5. Motor: 555 555 hi pe rt on us wi th Co g Wheele Phenomenon, eut ropi .

555 555 resting tremor (+), rigidity (+)

6. Sensorik :

Exteroceptive : Tactile (+) (+)Pain (+) (+)

Thermis (+) (+)


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Case Report Session

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Propioceptive :Vibration (+) (+)

Position (+) (+)

7. Autonomic Nervous System:

Mixturition : Neurogenic bladder (-) Defecation : good Sweat : hypersecretion

8. Physiological Reflex:

Biceps : ++/++

Triceps : ++/++ KPR : ++/++ APR : ++/++

9. Pathological Reflex:

Babinsky : -/- Chaddock : -/- Oppenheim : -/- Schuffer : -/- Gordon : -/- Hoffman Tromner: -/-

10. Sublime Function : consciousness is good, decreasing in intellectual, emotional reaction is go

od

11. Dementia signs :

Glabella reflex : (-) Snout reflex : (-) Palmomental reflex : (-) Grasping reflex : (-) Sucking reflex : (-)

12. Parkinsons signs:

Tremor : (+)


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Case Report Session

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Rigidity : (+) Bradichinesia : (+) Postural instability : (+) Parkinsons face : (+) Shortening of the footstep : (+)

Diagnosis

Clinical diagnosis : Parkinsons Disease

Topical diagnosis : Substansia Nigra

Etiological diagnosis : Idiopathic

Secondary diagnosis : -

Management

Low salt dietary

Medication given:

Levodopa 100mg per day

Trihexyphenidil 3 x 2 mg (p.o)


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Case Report Session

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Discussion

A 65 years old male patient came to Neurology Policlinic RSUP Dr. M. Djamil Padang,

on April 1st, 2013 diagnosed with Parkinsons disease. The diagnosis of Parkinsons disease is

based on careful history taking and physical examination. There are no laboratory test or imaging

studies that confirm the diagnosis. From history,

Trembling of the whole body since 2 months ago. Patient felt trembling in his right upperlimb for the past 1 years. Then left upper limb start to trembling 2 weeks after that. At

first, patient felt the tremble when resting dan decreased when he moves. But for the past

2 months, patient felt the tremble in the whole body continuously so that he has difficulty

to do daily activities.

Patient complain that his step was became shorter for the past 7 months. Patient oftentripped the household furniture when walked and felt hard to start and stop walking.

Patient feels stiffness in his limbs Patient Family tells that patient tends to falls when he was standing.Parkinsons disease typically develops between the ages of 55 and 65 years and occurs in 1 to

2 % of persons over the age of 60 years. Approximately 0.3 % of the general population is affect

ed, and the prevalence is higher among men than women, with ratio of 1.6 to 1.0. This patient is

a male and 65 years, it is concurrent with that comment. From the physical examination, it is co

ncurrent to the diagnosis, Parkinsons disease. Parkinsons diseases motor manifestation of the d

isorder commonly include resting tremor, a soft voice, small handwriting (micrographia), stiffnes

s (rigidity), slowness of movements (bradykinesia), shuffling steps, difficulties with balance. A cl

assic symptom is resting tremor, although 20% of patients do not have it. Parkinsons disease als

o has a multitude of nonmotor manifestations, including disturbances of mood, cognition, and sle

ep. But, in this patient, he doesnt have nonmotor manifestation. There is a longlist of causes of p

arkinsonism that includes toxins, infections of the central nervous system, structural lesions of th

e brain,metabolic disorders, and other neurologic disorders. Most of these causes are rare and are

generally suggested by atypical features in the history or examination.

Medicine for this patient are levodopa as dopaminergic and trihexyphenidil as antichollinergi

c. Actually the diagnosis of Parkinsons disease is not necessarily cause to begin drug therapy. Dr

ug therapy is warranted when the patient is sufficiently bothered by symptoms to desire treatmen


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t or when the disease is producing disability. If the patient needs treatment for motor symptoms,

efficacious agents for initial therapy include levodopa, dopamine agonist, anticholinergic agents,

amantadine, and selective monoamine oxidase B (MAO-B) inhibitors. Except for comparisons of

individual dopamine agonist with levodopa, there are no robust comparisons of efficacy among t

hese agents, but clinical experience suggest that the dopaminergic agents are more potent than th

e anticholinergic agents, amantadine, and selective MAO-B inhibitors. For this reasons, dopamin

ergic drugs are often the initial therapy recommended for patients with troublesome symptoms.


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Case Report Session

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References

Joesoef, Aboe. Konsensus Tatalaksana Penyakit Parkinson. Kelompok Studi Movement

Disorders PERDOSI. 2003

Okun, Michael. Deep-Brain Stimulation for Parkinons Disease. New England Journal of

Medicine. 2012; 367:1529-38

Nutt, John. Diagnosis and Initial Management of Parkinsons Disease. New England Journal of

Medicine. 2005:353:1021-7

Aragon, Ana. The Professionals Guide to Parkinsons Disease. Parkinsons Disease

Society.2010; London.

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