Leg Paralysis

8/13/2019 Leg Paralysis

1/12

MORNING REPORTMonday, November 25th2013

STUDENT INCHARGE:Coass in charge :

Adma Febri

Achmad Arrizal

Supervisor : dr. Sri Sunarti, Sp.PD


2/12

Summary of Data BaseMr. Utomo / 33 yo

Chief complain: Legs and upper arm cantbe moved

Patient couldnt move his legs and upper arm since 6

months ago, it was intermittently. Last two days, they were

paralized, especially his thighs. Paralysis has been worsenedsince yesterday night (November 23rd 2013), his legs

couldnt be moved. He couldnt move so that he came to

ER. He felt he couldntmove from his legs until his back.

Fever (-), cough (-), cold (-), nausea (-), vomiting (-). Hefelt the increasing body weight, his appetite was not

changed (3-4 times a day), every day he eats vegetables and

fruits. His defecation and urination is in normal limit.


3/12

Past medical history: he patient was suffered

from Guillain Barre Syndrome at RSSA 6

months ago with the same complaints. He was

hospitalized for a week, but he forced to go

home. After that, he never controlled and

took a medication. He went to midwive and

was given injection. Family history: no family has the same

complaints


4/12

SUMMARY OF DATA BASE

History of social living : he is married, has one 4-year-children. He is mechanic. He is smoking since

elementary school, 1-2 packs a day. He drank alcohol

since 17 years old but stopped since 7 years ago. He

has chicken poultry.


5/12

Physical examinationBP: 110/70 mmHg PR: 66 bpm regular

strong

RR: 18 tpm Tax: 36.5C

General appearance looked moderately ill GCS: 456

Head Pale conjunctiva -

Icterus Sclera -

Neck JVP R + 0 cmH2O 30 degree, lymphnode enlargement -

Chest Heart: Ictus invisible and palpable at ICS V MCL Sinistra

LHM ictus

RHM: SL D

S1, S2 single, murmur -

Lung: Symetric, SF D= S s s Rh - - Wh - -

s s - - - -s s - - - -

Abdomen Flat, soefl, liver span 8 cm, traube space tympani, bowel sound (+) normal

Extremities Sensoric: normal, edema (-), warm acral

motoric 554 | 455

432 | 234


6/12

Laboratory findingsLAB VALUE (NORMAL) LAB VALUE (NORMAL)

Hb 17.00 11,0-16,5 g/dL RBS 123 < 200 mg/dlMCV 77.10 80-96 fl Ureum 20.60 10-50 mg/dL

MCH 28.20 26,5-33,5 pg Creatinine 0.86 0,7-1,5 mg/dL

Leucocyte 12,950 3.500-10.000/L SGOT 27 11-41U/L

Eos / Bas / Neu / Limf / Mon SGPT 8 10-41U/L

0.5/ 0.1/ 79.2/ 13.7/6.3 % T3 0.83 0.8-2 mg/dL

Ht 46.40 38-42% T4 1.10 0.93-1.7 mg/dL

Plt 329.000 150.000-390.000/L TSH 1.33 0.270-4.2 mg/dL

Natrium 138 136-145 mmol/L

Kalium 2.05 3,5-5,0 mmol/L

Chlorida 108 98-106 mmol/L


7/12

Blood Gas Analysis

Lab Value

pH 7.45 7.357.45

pCO2 31.9 mmHg 35 - 45

pO2 87.2 mmHg 80 - 100

HCO3 22.5 mmol/L 21 - 28

Base Excess -1.7 mmol/L (-3)(+3)

O2Saturation 97.0% > 95%

Conclussion: Normal limit


8/12

URINALISIS

Result Result

Color, Turbidity Yellow, Clear10 x

SG 1,010Epithelia +

PH 6,5Cylinder Negative

Leucocyte NegativeHyaline -

Nitrite NegativeGranular

-

Protein Negative 40 x

Glucose Negative Eritrosit 0.1

Erythrocyte NegativeLeukocyte 3.6

Keton urine Negative Chrystal -

Urobilinogen Negative Bacteria -

Bilirubin Negative


9/12

CXR (March, 13th 2013)

AP position, symmetric, enough KV, less inspiration

Trachea : in the middle

Soft tissue and bone : normal

Right & left phrenico-costalis angle : sharp

Right & Left hemidiaphragm : dome-shaped

Lung : BV pattern normal Cor : Site normal, Shape: Normal, CTR : 48%

Conclusion: Normal

CUE AND CLUE PL IDx PDx PTx Pmo PED

Male/33yo/25

A:

Paralysis 3 days

History of paralysis 6

months ago

History of GBS 6

months ago

PE:

BP: 110/70 mmHg

PR: 66 strong, regulerRR: 18x/min

Tax: 36.5

Extremity:

Sensoric: normal

Motorik:

5-5-4 | 4-5-5

4-3-2 | 2-3-4

LAB:

K: 2.05 mmol/L

1. Tetraparese 1.1 dt

Hipokalemia

1.2 dt GBS

- Bed rest

Diet 1500

ccal/day

IVFD NaCl 0.9%

20 dpm

Drip KCl 20

mEq/hours

If K post

correction > 2.5

mmol/Ldrip

stop, change toPO KSR 3x1 tab

and fruit diet

especially green

banana

Consult to

Neurologic

Department

S, V S, SE

4h post

correctio

n,

Muscle

strength,

ROM

Conditio

n, Green

banana

consum

ption


10/12

CUE AND CLUE PL IDx PDx PTx Pmo PED

Male/33yo/25

A:

Paralysis 3 days

History of paralysis

6 months ago

History of GBS 6

months ago

PE:

BP: 110/70 mmHg

PR: 66 strong,reguler

RR: 18x/min

Tax: 36.5

Extremity:

Sensoric: normal

Motorik:

5-5-4 | 4-5-5

4-3-2 | 2-3-4

LAB:

K: 2.05 mmol/L

2. Hipokalemia 2.1 dt

Hiperaldoste

ronemia

primer

1.2 dt

Aldos

teron

level

Kaliu

m

urine

Bed rest

Diet 1500

ccal/day

IVFD NaCl 0.9%

20 dpm

Drip KCl 20

mEq/hours

If K post

correction > 2.5

mmol/Ldrip

stop, change toPO KSR 3x1 tab

and fruit diet

especially green

banana

Consult to

Neurologic

Department

S, V S, SE

4h post

correctio

n,

Muscle

strength,

ROM

Conditio

n, Green

banana

consum

ption


11/12

Condition this morning


12/12

Thank you

Leg Paralysis

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