CASE REPORTSENIOR CLINICAL CLERKSHIP

Period of September 7th October 12th , 2009

JULDEPARTMENT OF NEUROLOGYFACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ RSMH

PALEMBANG

2009ENDORSEMENT PAGECase ReportParaparese inferior spastik + Hipestesia below processus xiphoideus to the tips of the toes + Retention urine et alviPresented by:

Agung Nopriansah

04080505041Has been accepted as one of requirements in undergoing senior clinical clerkship period of September 7th 2009 October 12th 2009 in Department of Neurology Faculty of Medicine Sriwijaya University / RSMH Palembang.Palembang, September 2009AdvisorDr. H. A. Rachman Toyo, SpS(K)NEUROLOGY MEDICAL RECORDIdentificationName

: Mrs RAge

: 53 years

Sex

: Female

Address

: Jl. Gajah Mati Sungai Lilin Musi BanyuasinReligion

: Islam

Admission date: September 26th, 2009AnamnesisThe patient was admitted to Neurology ward RSMH because of the weakness of both legs which happened gradually.+ 3 months before admitted to the hospital, the patient felt pain at her left flank that radiating to her back bone. There was no weakness of her legs. The patient had no complain concerning her activity daily living. Patient then felt numbness at the tips of her toes. But she didnt seek medical advice for this complaint. She had no complain concerning defecation and urinating. + 2 weeks before admitted to the hospital, she started to feel weakness of both legs, she felt walking were heavier. Also, numbness at her toes became more frequent and radiating to the upper legs. + 1 week before admitted to the hospital, weakness of both legs worsen and she was unable to walk. She felt numbness at her pelvic down to tip of her toes. She complained that she couldnt defecate and urinate.There was no history of trauma on her back. History of hipertension is positive, routine medically control. She had chronic cough but history of fever was denied.The patient suffered from this illness for the first time.

PHYSICAL EXAMINATIONPRESENT STATEInternal State

Sense: compos mentisNutrition: sufficient

Pulse : 110 beats/min

Respiratory rate: 20 times/minBlood pressure : 120/80 mmHgPsychiatric state

Attention: cooperative

Attention : normalNeurological state

Head

Shape: brachiocephalySize : normalSymetric: yes

Hematome: no

Tumor: no

Neck

Position : straightTorticolis: noNape of neck stiffness: noLungs

: no abnormalityLiver

: no abnormalitySpleen

: no abnormalityExtremities

: see neurological stateGenital

: no abnormalityFacial Expression: natural

Psyche contact

: natural

Deformity

: no

Fracture

: no

Fracture pain

: no

Vessel

: no widening

Pulsation

: no disorder

Deformity

: no

Tumor

: no

Vessels

: no widening

CRANIAL NERVESOlfaktorius nerveSmelling

Anosmia

Hyposmia

Parosmia

Opticus nerveVisual acuity

Campus visi

Anopsia

Hemianopsia

Oculi fundus

Edema papil

Atrophy papil

Retina bleeding

Occulomotorius, Trochlearis and Abducens nerves

Diplopia

Eyes gap

Ptosis

Eyes position

Strabismus

Exophtalmus

Enophtalmus

Deviation conjugae

Eyes movement

Pupil

Shape

Size

Isochor/anisochor

Midriasis/miosis

Light reflex

direct

consensuil

accommodation

Argyl Robertson

Trigeminus nerveMotoric

Biting

Trismus

Corneal reflex

Sensory

Forehead

Cheek

Chin

Facialis nerve

Motoric

Frowning

Eyes closing

Giggling

Nasolabial fold

Facial shape

rest

Speaking/whistling

Sensory

2/3 anterior tounge

Autonomy

Salivation

Lacrimation

Chvosteks sign

Statoacusticus nerve

Cochlearis nerveWhispering

Hour ticking

Weber test

Rinne test

Vestibularis nerveNystagmus

Vertigo

Glossopharingeus and Vagus nerves

Pharyngeal arch

Uvula

Swallowing disorder

Hoarsing/nasalising

Heart beat

Reflex

Vomiting

Coughing

Occulocardiac

Caroticus sinus

Sensory

1/3 posterior toungeRight

No disorder

No

No

No

Right

6/9 PH (-)

V.O.D

No

No

No

No

No

Right

No

No

No

No

No

No

No

no abnormality Round

3mm

isochor

No

+

+

+

No

Right

No disorder

No

Yes

NormalNormal

NormalRight

simetric

Normal Normal

NormalNo disorder

No disorderNo disorder

No disorder

No disorder

No disorder

Right

No disorder

No disorder

Normal

Normal

No

No

RightNo disorderNo disorderNoNoNormalNo disorderNo disorderNo disorderNo disorder

No disorderLeft

No disorder

No

No

No

Left

6/6 PH (-)

V.O.S

No

No

No

NoNo

Left

No

No

No

No

No

No

No

no abnormality Round

3mm

isochor

No

+

+

+

No

Left

No disorder

No

Yes

Normal

Normal

Normal

Left

simetric

Normal

angle paralysis

flatNo disorder

No disorderNo disorder

No disorder

No disorder

No disorder

Left

No disorder

No disorder

Normal

Normal

No

No

LeftNo disorderNo disorder No No Normal No disorder

No disorder

No disorder

No disorder

No disorder

Accessorius Nerve

Shoulder Raising

Head Twisting

Hypoglossus Nerve

Tounge ShowingFasciculationPapil Athrophy

Dysarthria

MOTORIC

Arms

Motion

Power

Tones

Physiological Reflex

Biceps

Triceps

Radius

UlnaPathological Reflex

Hoffman Tromner

Leri

Meyer TrofikLEG

Motion

Power

Tones

Clonus

Tigh

Foot Physiological reflex

K P R

A P R

Pathological reflex

Babinsky Chaddock

Oppenheim Gordon Schaeffer Rossolimo

Mendel BechterewAbdominal skin reflex

Upper

Middle

Lower

Tropik Right

No disorderNo disorder

Right

No deviationnono

noRightSufficient

5

Normal

Normal

Normal

Normal

Normal

None

None

None

None

RightLack1Increase

Negative NegativeIncrease

Increase

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Negative

LeftNo disorder

No disorder

LeftNo deviationnononoLeft

Sufficient5NormalNormal

NormalNormalNormalNone

None

None

None

LeftLack

1Increase

NegativeNegativeIncrease

Increase

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Negative

SENSORYHipestesia below processus xiphoideus to the tips of toes.PICTURE

VEGETATIVE FUNCTIONMicturition

: retention urineDefecation

: retention alviVERTEBRAL COLUMNKyphosis: no Tumor: no

Lordosis: no Meningocele: no

Gibbus: no Hematome: no

Deformity: no Tenderness: no

SYMPTOMS OF MENINGEAL IRRITATIONNape of neck stiffness

Kerniq

Lasseque

Brudzinsky

Neck

Cheek

Symphisis

Leg I

Leg II

Right

Negative

Negative

Negative

Negative

Negative

Negative

Negative

NegativeLeft

Negative

Negative

Negative

Negative

Negative

Negative

Negative

Negative

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 confirmed

MOTION ABNORMAL

Tremor

: noChorea

: noAthetosis

: noBallismus

: noDystoni

: noMyoclonus

: noLIMBIC FUNCTIONMotoric aphasia: noSensoric aphasia: noApraksia

: noAgraphia

: noAlexia

: noNominal aphasia: noLABORATORY FINDINGSBLOOD

Hb

: 12,6 gr/dl

Ureum

: 146 mg/dl (15-39 mg/dl)Leucocyte: 9600/mm3

Creatinin

: 3,2 mg/dl (0,6-1,0 mg/dl)Hematocrit: 36 vol%

Protein total

: 6,4 g/dl (6-7,8 g/dl)Diff Count: 0/3/0/72/10/4

Albumin

: 3,7 g/dl (3,5-5 g/dl)Thrombocyte: 307000/mm3

Globulin

: 2,7 g/dl

LED

: 47

Na

: 136 mmol/l (135-155)

K

: 3,6 mmol/l (3,5-5,5)URINE

Epithel

: +

Protein

: -Leucocyte: 4-6 /HPF

Glucose

: -Eritocyte: 2-3 /HPF

FECES

Consistency: 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 performedSPECIFIC 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

: not performedRESUMEIDENTIFICATIONMrs. R, female, 53 years, admission date 26th of September 2009

ANAMNESISThe patient was admitted to Neurology ward RSMH because of the weakness of both legs which happened gradually.

+ 3 months before admitted to the hospital, the patient felt pain at her left flank that radiating to her back bone. There was no weakness of her legs. The patient had no complain concerning her activity daily living. Patient then felt numbness at the tips of her toes. But she didnt seek medical advice for this complaint. She had no complain concerning defecation and urinating. + 2 weeks before admitted to the hospital, she started to feel weakness of both legs, she felt walking were heavier. Also, numbness at her toes became more frequent and radiating to the upper legs. + 1 week before admitted to the hospital, weakness of both legs worsen and she was unable to walk. She felt numbness at her pelvic down to tip of her toes. She complained that she couldnt defecate and urinate.

There was no history of trauma on her back. History of hipertension is positive, routine medically control. She had chronic cough but history of fever, sweaty at night and decrease of body weight was denied.

The patient suffered from this illness for the first time.

EXAMINATIONPresent StateSense

: compos mentis (GCS 15: E4M6V5)

Blood pressure : 120 / 80 mmHg

Pulse

: 110x/minute

Respiratory rate : 20x/minute

Temperature

: 36,8o C

Nutrition

: sufficientNeurological state

Nn. Craniales

No abnormalityMotoric function

Motoric functionArmLeg

RightLeftRightLeft

Motion SufficientSufficientLackLack

Power 5511

Tones NormalNormalIncreaseIncrease

Clonus--

Physiological reflexNormalNormalIncreaseIncrease

Pathological reflex----

Sensory function: Hipestesia below processus xiphoideus to the tip of the toes.Vegetative function : Retention urine et alviLimbic function: no abnormality

Abnormal Movement: (-)

Gait & Stability: not yet assesed

Meningeal Irritation: (-)

LABORATORY FINDINGS

Hb

: 12,6 gr/dl

Ureum

: 146 mg/dl (15-39 mg/dl)

Leucocyte: 9600/mm3

Creatinin

: 3,2 mg/dl (0,6-1,0 mg/dl)

Hematocrit: 36 vol%

Protein total

: 6,4 g/dl (6-7,8 g/dl)

Diff Count: 0/3/0/72/10/4

Albumin

: 3,7 g/dl (3,5-5 g/dl)

Thrombocyte: 307000/mm3

Globulin

: 2,7 g/dl

LED

: 47

Na

: 136 mmol/l (135-155)

K

: 3,6 mmol/l (3,5-5,5)

UrineEpithel

: +

Protein

: -

Leucocyte: 4-6 /HPF

Glucose

: -

Eritocyte: 2-3 /HPF

DIAGNOSISDiagnosis clinic: Paraparese inferior spastik + Hipestesia below processus xiphoideus to the tip of the toes + Retention urine et alviDiagnosis topic: Total transversal lesion medulla spinalis Th7-8Diagnosis etiology: - Spondylitis TB

- SOLMANAGEMENTTreatment :

Medicine:Diet NBTKTP

Meloxicam tab 1 x 15 mg

Vitamin B1, B6, B12 tab 3x1

Dulcolax supp 1x1

Catheter urinePlanning:P/ Ro Thorax PA

P/ Ro vertebrae thoracal AP/Lat

P/ Lumbal puncture

P/ CT-Scan columna vertebraePROGNOSIS: Quo ad vitam

: bonam

Quo ad functionam : dubia ad bonamCASE ANALYSIS

Differential Diagnosis Etiology:

Paraparesea. Paralysis of UMN lesion

Characteristics:

Hypertonus

Hyperflexi

Patology reflex (+)

Muscle atropy (-)Examples: Spondylitis TB, SOL, trauma, Infection

b. Paralysis of LMN lesion

Characteristics:

Hypotonus, clonus (-)

Hyporeflexy

Atropy degenerative: muscle atropy (+), fast onset 1-2 weeks

Patology reflex (-)

Examples: trauma, carpal tunnel syndrome, Gullain Barre syndrome, radiation, toxin or poison, demyelinating disease.c. Paralysis combination (nuclear lesion + UMN/LMN lesion)

Characteristics:

Fascicular contraction (+)

Muscle atropy

Hypertonus, often clonus (+)

Hyperreflexy

Patology reflex (+)

Examples: ALS, myelin syndrome.

In conclusion, this paralysis case type is UMN lesion.

Etiology :

Space Occupying Lesion (SOL)Symptoms of the patient were:

- Motoric deficit on the level of lesion

- Segmental sensoric deficit

- Deficit symptoms appear slowly Motoric deficit on the level of lesion

Segmental sensoric deficit

Happened slowly

There is possibility of SOL

Etiology :

Tuberculous SpondylitisSymptoms of the patient were:

- History of chronic lung disease- Fever

- Vertebral pain

- Chronic progresive weakness Chronic cough Fever was denied Pain at her back bone Weakness of both legs happened gradually

There is possibility of Tuberculous Spondylitis

Name: Agung Nopriansah, S. Ked

NIM: 04080505041

Semester: XI

Date : September 27th, 2009

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

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