status neuroooo case my dokter

CASE REPORT

SENIOR CLINICAL CLERKSHIP

Period of August 19th – September 22th , 2008

JUL

DEPARTMENT OF NEUROLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ RSMH

PALEMBANG

2009

1

Name : Bharmatisna AN S. Ked

NIM : 04033100018

Semester : XII

Date : September 26th, 2009

Advisor : Dr. H. A. Rachman Toyo, SpS(K)

NEUROLOGY MEDICAL RECORD

Identification

Name : Mr IAge : 36 yearsSex : MaleAddress : Lr Balai Pengobatan RT 05 RW 10 BanyuasinReligion : IslamAdmission date : 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 people’s 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 doesn’t 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 STATEInternal State

Sense : compos mentisNutrition : sufficientPulse : 90 beats/minRespiratory rate : 20 times/minBlood pressure : 170/90 mmHg

Psychiatric stateAttention : cooperativeAttention : normal

Neurological stateHead Shape : brachiocephaly

Lungs : no abnormalityLiver : no abnormalitySpleen : no abnormalityExtremities : refer to neurological stateGenital : no abnormality

Facial Expression : natural Psyche contact : natural

Deformity : no

2

Size : normalSymetric : yesHematome : noTumor : no

Neck Position : straightTorticolis : noNape of neck stiffness : no

Fracture : noFracture pain : noVessel : no wideningPulsation : no disorder

Deformity : noTumor : noVessels : no widening

CRANIAL NERVESOlfaktorius nerveSmellingAnosmiaHyposmiaParosmia

Opticus nerveVisual acuityCampus visi

Anopsia Hemianopsia

Oculi fundus Edema papil Atrophy papil Retina bleeding

Occulomotorius, Trochlearis and Abducens nerves DiplopiaEyes gapPtosisEyes position

Strabismus Exophtalmus Enophtalmus Deviation conjugae

Eyes movementPupil

Shape Size Isochor/anisochor Midriasis/miosis

Light reflex

RightNo disorder

NoNoNo

Right6/30 PH (-)

V.O.D

NoNo

NoNoNo

RightNoNoNo

NoNoNoNo

no abnormality

RoundØ 3mmisochor

No

LeftNo disorder

NoNoNo

Left6/21 PH (-)

V.O.S

NoNo

NoNoNo

LeftNoNoNo

NoNoNoNo

no abnormality

RoundØ 3mmisochor

No

3

direct consensuil accommodation

Argyl Robertson

Trigeminus nerveMotoric

Biting Trismus Corneal reflex

Sensory Forehead Cheek Chin

Facialis nerveMotoricFrowningEyes closingGigglingNasolabial foldFacial shape

rest Speaking/whistling

Sensory 2/3 anterior tounge

Autonomy Salivation Lacrimation Chvostek’s sign

Statoacusticus nerveCochlearis nerveWhisperingHour tickingWeber testRinne testVestibularis nerveNystagmusVertigo

Glossopharingeus and Vagus nervesPharyngeal archUvulaSwallowing disorderHoarsing/nasalisingHeart beat

+++

No

RightNo disorder

NoYes

NormalNormalNormal

RightassimetricNormal

NormalNormal

No disorderDeviation to the left

No disorder

No disorderNo disorderNo disorder

RightNo disorderNo disorder

Normal Normal

NoNo


NoNo

Normal

+++

No

LeftNo disorder

NoYes

NormalNormalNormal

LeftassimetricNormal

angle paralysis flat

No disorderDeviation to the left

No disorder

No disorder No disorderNo disorder

LeftNo disorderNo disorder

Normal Normal

NoNo


No No

Normal

4

Reflex Vomiting Coughing Occulocardiac Caroticus sinus

Sensory 1/3 posterior tounge

No disorderNo disorderNo disorderNo disorder

No disorder

No disorderNo disorderNo disorderNo disorder

No disorder

Accessorius NerveShoulder RaisingHead Twisting

Hypoglossus NerveTounge ShowingFasciculationPapil AthrophyDysarthria

MOTORICArmsMotionPowerTonesPhysiological Reflex

Biceps Triceps Radius Ulna

Pathological Reflex Hoffman Tromner Leri Meyer Trofik

LEGMotionPowerTonesClonus

Tigh Foot

Physiological reflex K P R A P R

Pathological reflex Babinsky Chaddock


RightDeviation to the left

nonoyes

RightSufficient

5Normal

NormalNormalNormalNormal

NoneNoneNoneNone

RightSufficient

5Normal

Negative Negative

Normal Normal

NegativeNegative


LeftDeviation to the left

nonoyes

LeftLack

2Increase

IncreaseIncreaseIncreaseIncrease

NoneNoneNoneNone

LeftLack

2Increase

NegativeNegative

IncreaseIncrease

PositivePositive

5

Oppenheim Gordon Schaeffer Rossolimo Mendel Bechterew

Abdominal skin reflex Upper Middle Lower Tropik

NegativeNegativeNegativeNegativeNegative

NegativeNegativeNegativeNegative

PositivePositivePositiveNegativeNegative

NegativeNegativeNegativeNegative

SENSORYHemihipestesia sinistra (-)

PICTURE

6

VEGETATIVE FUNCTIONMictutrion : normalDefecation : normalErection : -

VERTEBRAL COLUMNKyphosis : no Tumor : noLordosis : no Meningocele : noGibbus : no Hematome : noDeformity : no Tenderness : no

SYMPTOMS OF MENINGEAL IRRITATION

Nape of neck stiffnessKerniqLassequeBrudzinsky

Neck Cheek Symphisis Leg I Leg II

RightNegativeNegativeNegative


LeftNegativeNegativeNegative


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 confirmedMOTION ABNORMALTremor : noChorea : noAthetosis : noBallismus : noDystoni : noMyoclonus : no

LIMBIC FUNCTIONMotoric aphasia : noSensoric aphasia : noApraksia : noAgraphia : noAlexia : noNominal aphasia : no

7

LABORATORY FINDINGSBLOODHb : 15,5 mg/dl LDL cholesterol : 120 mg/dlLeucocyte : 12600/mm3 Trygliceride : 50 mg/dlHematocrit : 40 vol% Uric Acid : 4,6 mg/dlDiff Count : 0/1/0/89/9/10 Ureum : 42 mg/dlThrombocyte : 265000/mm3 Creatinin : 0,7 mg/dlLED : 47 BSS : 149 mg/dlChol.tot : 142 mg/dl Na : 137 mmol/lHDL cholesterol : 100 mg/dl K : 4,8 mmol/l

Ca :2,95 mmol/l

URINEColour : not performed Sediment : not performedReaction : not performed Bilirubin : not performedProtein : not performed Urobilin : not performedReduction : not performed

FECESConsistency : 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 performed

SPECIFIC 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 : 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 people’s 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 doesn’t 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 StateSense : compos mentis (GCS 15: E4M6V5)Blood pressure : 170 / 90 mmHgPulse : 90x/minuteRespiratory rate : 20x/minuteTemperature : 36,8o CNutrition : sufficient

Neurological stateNn. CranialesN. VII : Forehead wrinkle is asymmetrical, lagophthalmus (+), right nasolabial fold is flat, right-

angle of the mouth paralysisN. XII : Tongue showing deviated to the right, there is fasiculasi, there is disarthria

Motoric functionMotoric function Arm Leg

Right Left Right LeftMotion Sufficient Lack Sufficient LackPower 5 2 5 2Tones Normal Increase Normal IncreaseClonus - -Physiological reflex Normal Increase Normal Increase

9

Pathological reflex - (+) H,T - (+) B,C,S

Sensory function : hemihipestesia sinistra (-)Vegetative function : no abnormalityLimbic function : no abnormalityAbnormal Movement : (-) Gait & Stability : not yet assesed Meningeal Irritation : (-)

DIAGNOSISDiagnosis clinic : Hemiparese sinistra spastik + parese N. VII & N. XII sinistra centralDiagnosis topic : capsula interna dextraDiagnosis etiology : haemorragic cerebri

MANAGEMENTTreatment :Medicine : IVFD RL gtt xx/mins

Inj citicholine 2 x 250 mg ivVitamin B1, B6, B12 tab 3x1Adona 3 x 100 mgCaptopril 2 x 12,5 mgRanitidine amp 2 x 150 mg iv

Fisiotherapy : Active movement

PROGNOSIS : Quo ad vitam : bonamQuo ad functionam : dubia ad bonam

DIFFERENTIAL DIAGNOSIS DISCUSSION

Differential Diagnosis Topic:TOPIC :

CORTEX CEREBRI HEMISFERIUM DEXTRA FOR THIS PATIENT:Symptoms :- Irritate sign (seizure at the weak side/right) - Focal sign (the weakness of the arm and leg is

different)- motoric deficit (hemipleghia/hemiparese dextra

central) - sensoric deficit (at the weak side)

- No seizure at the weak side/right- The weakness he had was the same

between the arm and the leg- Hemiparese sinistra spastic +

ophthalmoplegia bilateral + parese N.VII + N.XII dextra perifer

- There is not sensibility disorder at the side of the weakness

THE TOPIC OF CORTEX CEREBRI HEMISFERIUM DEXTRASHOULD BE RULED OUT

10

TOPIC :SUBCORTEX HEMISFERIUM CEREBRI

DEXTRAFOR THIS PATIENT:

Symptoms :- Motoric deficit (hemipleghia /

hemiparese dextra central) - Pure afasia motoric

- Hemiparese sinistra spastik + parese N. VII & N. XII sinistra central

- The patient understood other people’s mind which was expressed by talking, writing and giving sign.

THE TOPIC OF SUBCORTEX CEREBRI HEMISFERIUM DEXTRASHOULD BE RULED OUT

TOPIC :CAPSULA INTERNA HEMISFERIUM

CEREBRI DEXTRAFOR THIS PATIENT

Symptoms :- Hemiparese Typica - Parese N.VII central

contralateral- Parese N.XII central

contralateral

- Hemiparese sinistra spastik + parese N. VII & N. XII sinistra central

THE TOPIC OF CAPSULA INTERNA HEMISFERIUM CEREBRI DEXTRA CAN NOT BE RULED OUT

Differential Diagnosis Etiology:ETIOLOGY :

HEMORRHAGIC CEREBRI FOR THIS PATIENTSymptoms : - Loss of consciousness > 30‘ - Attack in activity - Initiated by headache, nausea and vomits

- The patient suddenly had weakness at his left arm and left leg when he was working, followed by losing consciousness

- During the attack, he have headache, nausea and vomited.

THE ETIOLOGY OF HEMORRHAGIC CEREBRICAN NOT BE RULED OUT

ETIOLOGY :EMBOLI CEREBRI FOR THIS PATIENT

Symptoms :- Loss of consciousness < 30‘ - There is atrial fibrillation

- The patient suddenly had weakness at his left arm and left leg when he was working, followed by losing consciousness

- During the attack, he doesn’t have a heart beat which was followed by shortness of breathing.

THE ETIOLOGY OF EMBOLI CEREBRI SHOULD BE RULED OUT

11

Etiological Diagnosis: Hemorrhagic Cerebri

12

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