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Case Presentation

Hemiparese sinistra spastik +

parese N.VII sinistra perifer

Department of Neurology –  RSMH Palembang

Faculty of Medicine University of Sriwijaya

By: M.Andri Junaidi, S.Ked.

Supervisor: Dr. H. A. R. Toyo, Sp.S (K)

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IDENTIFICATION

Mr.M/65 years/male/married/islam/

Palembang/ january 5th 2007

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 ANAMNESIS

The patient was hospitalized in neurology wardRSMH because of walking disturbance which wascaused by weakness on his left arm and lower

limb, which happened suddenly.

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 ±  3 hours before admitted to the hospital, when the

 patient was taking wudhu’, suddenly he felt weakness onhis his left arm and lower limb without unconsciousness.

At that time, he didn’t  get headache, nausea and vomit,

without stiffness, and without disturbance of sensibility

on the left side. The weakness between arm and lowerlimb was felt same. The patient uses right hand to work.

He could express his mind by talking, writing and giving

sign. The patient understood other people’s mind which

was expressed by talking, writing and giving sign. Hedidn’t feel throbbed and sorebreath.

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 ANAMNESIS

History of getting headache oftenly (-)

History of getting lesion in the eksternal genital

which was painless and self healing (-)Skin lesion which was painless, self healing (-)

His wife history of abortion in > 16 weeks (-)

This illness was the first time for him.

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Physical Examination

Generalis Status

General Condition : moderate sickness

Sens : compos mentis (GCS=E4M6V5)

 Nutrition : enough

Temp. : 36,8ºC

Pulse : 80 x/minute

Respiratory rate : 18 x/minute

Blood Pressure : 130/80 mmHg

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Physical Examination

Generalis Status

Heart : HR: 80 x/menit,

murmur(-), gallop(-)Lung : vesikuler(+) normal,

ronchi (-), wheezing(-)

Liver : not palpableSpleen : not palpable

Ekstremity : refer to neurological status

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Physical Examination

Neurological Status

 N. VII sinistra :

- forehead fold : flat

- lagoftalmus (+)

- angle of the mouth

- nasolabialis fold : flat

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Physical Examination

Motorik

Fungtion

Arm Leg

Right Left Right Left

Movement enough less enough less

Power 5 4 5 4

Tonus Normal Normal

Klonus - - -

Physiological R. Normal Normal

Patological R. - - - (+) B

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Physical Examination

Sensorik function : no abnormality

Vegetatif function : no abnormality

 Noble function : no abnormality

MES : no

Abnormal Movement : no

Gait : can’t be examined 

Balance and coordination : Romberg (+)Dysmetri finger to finger (+)

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Radiology

Ro Thorax PA:

LVHCT scan :

Infark in cerebellum sinistra

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Diagnosis banding topik

1. Lesion at the cortex of

hemispherium cerebri dextra,signs:

In the patient, signs :

- motoric deficyt - hemiplegi sinistra type spastic

- iritation sign (-)

- focal sign - weakness in the left arm and

lower limb was felt same

-sensoric deficyt (-)

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  2. Lesion at the subcortex

hemispherium cerebridextra, signs:

In the patient, signs :

- motoric deficyt - hemiplegy sinistra typespastyc

-afasia motoric if the lesion

in dominan hemispherium.

(-)

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3. Lesion at Capsula

interna hemispherium

cerebri dextra, signs:

In the patient, signs :

- hemiparese/hemiplegy

typica

- hemiplegi sinistra tipe

spastik

weakness in the left arm and

lower limb was felt same- weakness in the left arm and

lower limb was felt same

Focal sign & iritatif sign (-) Focal sign & iritatif sign (-)

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Topical Diagnosis :

Capsula interna hemispherium dextra + cerebellum

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Etyological Diff Diagnose :

1. Hemorrhagic cerebri,

signs:

In the patient, signs :

- When activity -mild activity (wudhu’) 

- Unconsiousness > 30 menit (-)

- headache, nausea, vomit before (+)

(-)

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2. Emboli cerebri, signs: In the patient, signs :

- arterial fibrilation (+) (-)

- Unconsiousness < 30 menit (-)

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3. Trombosis cerebri,

signs:

In the patient, signs :

- When taking a rest -mild activity (wudhu’) 

- Unconsiousness (-) (-)

- Risk factor foraterosklerosis (+)

(+)

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Siriraj Stroke Score = -2

 CVD non Hemorrhagic 

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Etiological Diagnosis :

Trombosis Cerebri

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Diagnosis

Clinical Diagnosis :Hemiparese sinistra spastik + parese N.VIIsinistra perifer

Topical Diagnosis :

Capsula interna hemispherium dextra +cerebellum

Etiological Diagnosis :

Trombosis Cerebri

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Management

IVFD Ringer Laktat gtt xx/mnt

Diet rice low salt

Brain Act 2 x 250 mg intravenous

Aspilet 1 x 80 mg tab per oral

Grahabion 2 x 1 tab per oral

Physiotherapy : IRR and gait training

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PROGNOSIS

Quo ad Vitam : bonam

Quo ad Functionam : dubia ad bonam