CASE REPORT

SENIOR CLINICAL CLERKSHIP

Period of August 02nd 30th , 2010

HEMPLEGIA SINISTRA FLACCID +

PARESE N. VII SINISTRA SENTRAL + PARESE
N. XII SINISTRA SENTRAL

Atika Akbari, S. Ked (04094705051)

Frizky Arlind, S.Ked (04094705118)

Advisor

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

DEPARTMENT OF NEUROLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ RSMH
PALEMBANG

2010ENDORSEMENT PAGE
Case Report

Hemplegia sinistra flaccid + parese n. VII sinistra sentral + parese n. XII sinistra sentral

Presented by:
Atika Akbari, S. Ked (04094705051)
Frizky Arlind, S.Ked (04094705118)
Has been accepted as one of requirements in undergoing senior clinical clerkship period of
August 2nd 30th 2010 in Department of Neurology Faculty of Medicine Sriwijaya University /
RSMH Palembang.
Palembang, August 2010
Advisor

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

NEUROLOGY MEDICAL RECORD

I. Identification
Name

: Mr. S

Age

: 64 years

Sex

: Male

Address

: Jl. Taman No. 165, Mariana, Banyuasin

Religion

: Islam

Admission date

: August 2nd, 2010

II. Anamnesis
The patient was admitted to Neurology ward RSMH because of the weakness on left arm
and lower limb which happened suddenly.
+ 4 days before admitted to the hospital, when the patient wake up, suddenly he felt
weakness on his his left arm and lower limb without unconsciousness. At that time, he didnt get
headache, nausea and vomit, without stiffness, and without disturbance of sensibility on the left
side. The weakness between left arm and lower limb was felt same. The patient can't move left
arm and lower limb was felt same at all. The patient uses right hand to work. He could express
his mind by talking, writing and giving sign. The patient understood other peoples mind which
was expressed by talking, writing and giving sign. When he talking, his mouth deviate to left, and
pelo. He had no complaining about urination and defecation. Then, the patient go to RS Kundur
and hospitalized, he was given 4 medicines (the patient forgot their names and forms) and 1
injection medicine citicholin. Because there is no improvement, the patient send to RSMH
Palembang.
There are no 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, and his
wife no history of abortion in > 16 weeks. There's no history diabetes mellitus.
This illness was the first time for him.

III. Physical Examination

PRESENT STATE
Internal State
Sense

: compos mentis

Lungs

: no abnormality

Nutrition

: sufficient

Liver

: no abnormality

Pulse

: 100 beats/min

Spleen

: no abnormality

Respiratory rate

: 22 times/min

Extremities

: see neurological state

Blood pressure

: 180/100 mmHg

Genital

: no abnormality

Temperature

: 38,70C
Facial Expression

: natural

Psyche contact

: natural

Deformity

: no

Psychiatric state
Attention

: cooperative

Attention

: normal

Neurological state
Head
Shape

: brachiocephaly

Fracture

: no

Size

: normal

Fracture pain

: no

Symetric

: yes

Vessel

: no widening

Hematome

: no

Pulsation

: no disorder

Tumor

: no
Deformity

: no
: no

Neck
Position

: straight

Tumor

Torticolis

: no

Vessels

: no widening

Nape of neck stiffness : no

CRANIAL NERVES
Olfaktorius nerve

Right

Left

Smelling

No disorder

No disorder

Anosmia

No

No

Hyposmia

No

No

Parosmia

No

No
4

Opticus nerve

Right

Left

Visual acuity

6/6 PH (-)

6/6 PH (-)

Campus visi

V.O.D

V.O.S

Anopsia

No

No

Hemianopsia

No

No

Oculi fundus

Edema papil

No

No

Atrophy papil

No

No

Retina bleeding

No

No

Right

Left

No

No

No

No

No

No

No

No

No

No

No

No

No

No

no abnormality

no abnormality

Round

Round

Occulomotorius, Trochlearis and

Abducens nerves
Diplopia
Eyes gap
Ptosis
Eyes position

Strabismus

Exophtalmus

Enophtalmus

Deviation conjugae

Eyes movement
Pupil

Shape

3mm

3mm

Size

isochor

isochor

Isochor/anisochor

No

No

Midriasis/miosis
+

Light reflex

direct

consensuil

accommodation

No

No

Right

Left

No disorder

No disorder

No

No

Yes

Yes

Normal

Normal

Normal

Normal

Normal

Normal

Argyl Robertson
Trigeminus nerve
Motoric

Biting

Trismus

Corneal reflex

Sensory

Forehead

Cheek

Chin
Right

Left

Facialis nerve

simetric

simetric

Motoric

Normal

Normal

Frowning

Normal

angle paralysis

Eyes closing

Normal

flat

Nasolabial fold

No disorder

No disorder

Facial shape

No disorder

No disorder

No disorder

No disorder

No disorder

No disorder

No disorder

No disorder

No disorder

No disorder

Right

Left

Giggling

rest

Speaking/whistling

Sensory

2/3 anterior tounge

Autonomy

Salivation

Lacrimation

Chvosteks sign
6

No disorder

No disorder

No disorder

No disorder

Cochlearis nerve

Normal

Normal

Whispering

Normal

Normal

Weber test

No

No

Rinne test

No

No

Right

Left

No disorder

No disorder

No disorder

No disorder

nerves

No

No

Pharyngeal arch

No

No

Normal

Normal

Hoarsing/nasalising

No disorder

No disorder

Heart beat

No disorder

No disorder

Reflex

No disorder

No disorder

No disorder

No disorder

No disorder

No disorder

Accessorius Nerve

Right

Left

Shoulder Raising

No disorder

No disorder

Head Twisting

No disorder

No disorder

Statoacusticus nerve

Hour ticking

Vestibularis nerve
Nystagmus
Vertigo
Glossopharingeus

and

Uvula

Vagus

Swallowing disorder

Vomiting

Coughing

Occulocardiac

Caroticus sinus

Sensory

1/3 posterior tounge

Hypoglossus Nerve
Tounge Showing

Right
No deviation

Left
deviation
7

Fasciculation

no

no

Papil Athrophy

no

no

Dysarthria

yes

yes

Right

Left

Motion

Enough

Less

Power

Tones

Normal

Decrease

MOTORIC
ARM

Physiological Reflex

Biceps

Normal

Decrease

Triceps

Normal

Decrease

Radius

Normal

Decrease

Ulna

Normal

Decrease

None

None

None

None

None

None

None

None

Right

Left

Enough

Less

Normal

Decrease

Negative

Negative

Negative

Negative

Physiological reflex

Normal

Decrease

KPR

Normal

Decrease

APR

Pathological Reflex

Hoffman Tromner

Leri

Meyer

Trofik

LEG
Motion
Power
Tones
Clonus

Tigh

Foot

Pathological reflex

Babinsky

Negative
Negative

Negative
8

Chaddock

Negative

Negative

Oppenheim

Negative

Negative

Gordon

Negative

Negative

Schaeffer

Negative

Negative

Rossolimo

Negative

Negative

Mendel Bechterew

Abdominal skin reflex

Upper

Middle

Lower

Tropik

Negative
Negative
Negative

Negative

Negative

Negative

Negative

Negative

Negative

SENSORY
No abnormality.
PICTURE

VEGETATIVE FUNCTION
Micturition

: no abnormality.

Defecation

: no abnormality.

MENINGEAL SIGNS
Right

Left

Nape of neck stiffness

Negative

Negative

Kerniq

Negative

Negative

Lasseque

Negative

Negative

Brudzinsky

Neck

Negative

Negative

Cheek

Negative

Negative

Symphisis

Negative

Negative

Leg I

Negative

Negative

Leg II

Negative

Negative

GAIT, BALANCE, AND COORDINATION

Cant be examined
Gait

Equilibirium and Coordination

Ataxia

: not confirmed

Romberg

: not confirmed

Hemiplegiac

: not confirmed

Dysmetri

: not confirmed

Scissor

: not confirmed

finger finger

: normal

Propulsion

: not confirmed

finger nose

: normal

Histeric

: not confirmed

heel - heel

: not confirmed

Limping

: not confirmed

Reboundphenomenon: not confirmed

Steppage

: not confirmed

Dysdiadochokinesis : not confirmed

Astasia-Abasia

: not confirmed

Trunk Ataxia

: not confirmed

Limb Ataxia

: not confirmed

MOTION ABNORMAL
Tremor

: no

Chorea

: no
10

Athetosis

: no

Ballismus

: no

Dystoni

: no

Myoclonus

: no

LIMBIC FUNCTION
Motoric aphasia

: no

Sensoric aphasia

: no

Apraksia

: no

Agraphia

: no

Alexia

: no

Nominal aphasia

: no

ABNORMAL MOVEMENT
No abnormality.
VERTEBRAL COLUMN
Kyphosis

: no

Tumor

: no

Lordosis

: no

Meningocele

: no

Gibbus

: no

Hematome

: no

Deformity

: no

Tenderness

: no

IV. LABORATORY FINDINGS

BLOOD (2 Agustus 2010)
Hb

: 14,2 g/dl

( 14 18 )

Ht

: 44

( 40 - 48 )

Leukosit

: 5700/mm3

( 5000 - 10.000 )

LED

: 10/mm3

( < 10 )

Trombosit

: 219.000

( 200.000 500.000 )

Dc

: 0 / 2 / 2 / 69 / 22 / 5

Bss

: 116 mg/dl

Cholestrol total

: 284 mg/dl

( < 200 )
11

HDL

: 52 mg/dl

( < 55 )

LDL

: 206 mg/dl

( < 130 )

Trigliserida

: 151 mg/dl

( < 150 )

SGOT

: 33 /l

( < 40 )

SGPT

: 26 /l

( < 41 )

Asam Urat

: 4,5 mg/dl

( 3,5 7,1 )

Ureum

: 31 mg/dl

( 15 39 )

Kreatin

: 1,3 mg/dl

( 0,9 1,3 )

Protein total

: 7,4 mg/dl

( 6,0 7,8 )

Albumin

: 4,7 mg/dl

( 3,0 5,0 )

Globulin

: 2,7 mg/dl

Na

: 140 mmol/l

( 136 155 )

: 3,5 mmol/l

( 3,5 5,5 )

Ca

: 2,45 mmol/l

( 2,02 2,60 )

3 Agustus 2010
Protrombin plasma

: 13,64 seconds (12-18)

APTT

: 29,50 seconds (25-35)

Fibrinogen

: 607 mg/dl

eFibrinogen

: 390 mg/dl

CPT

: 13,9 seconds

CAPT

: 38,8 seconds

INR

: 0,87

URINE (7 Agustus 2010)

Epithel

:+

Protein

: trace

Leucocyte

: 0-2 /HPF

Glucose

:-

Eritocyte

: 0-1 /HPF

Sylinder/crystal : Rongen Thorax

: normal thorax

12

V. DIAGNOSIS

Clinical Diagnosis :
Hemplegia sinistra flaksid + parese n. VII sinistra sentral + parese n. XII sinistra sentral

Topical Diagnosis :
Lacunar cerebral infarct capsula interna

Etiological Diagnosis :
Trombosis, serebri

VI. MANAGEMENT

Medicine

-IVFD RL gtt xx/M

- citicholine 2x250 mg IV
- captopril 2x25mg tab
- simvastatin 1x10 mg tab
- paracetamol 3x500mg PRN
- aspilet 1x80 mg tab
- diet porridge low salt

Pro CT scan head

Fisioterapi:
- Bed positioning
- Infra Red Radiation left side extremity
- Bobath therapy

VII. PROGNOSIS
Quo ad vitam

: bonam

Quo ad functionam

: dubia ad bonam

13

CASE ANALYSIS
Topical diagnosis
1. Lession in cortex hemisferium cerebri
dextra, the symptoms:
- Motoric deficit (hemiparese sinistra)
- Iritatif symptom (kejang pada sisi kiri)
- Focal symptom (The paralysis is not

The symptoms found in the patient:

- Hemiplegia sinistra flaccid
- No Seizures on the paralysis side
- The paralysis of left arms and left lower limb

same )
are same
- Sensoric deficit on the paralysis side
- No sensibility disorder on the left side body
So, the possibility of lession in cortex cerebri hemisferium dextra can be excluded.
2. Lession in subcortex hemisferium cerebri

The symptoms found in the patient:

dextra, the symptoms:

- Motoric deficit (hemiparese sinistra)
- Hemiplegia sinistra flaccid
- Motoric aphasia
- No pure motoric aphasia
So. the possibility of lession in subcortex cerebri hemisferium dextra can be excluded.
3. Lession in capsula interna hemisferium
dextra, the symptoms:
- Hemiparese/hemiplegi typica
- Parese n.VII sinistra central
- Parese n.XII sinistra central
- The weakness in the paralysis side is

The symptoms found in the patient:

- Hemiplegi sinistra flaccid
- Parese n.VII sinistra central
- Parese n.XII sinistra central
- The weakness in the paralysis side is same

same
So, the possibilityof lession in capsula interna hemisferium dextra can be made.
There are various classification systems for acute ischemic stroke. The Oxford
Community Stroke Project classification (OCSP, also known as the Bamford or Oxford
classification) relies primarily on the initial symptoms; based on the extent of the symptoms, the
stroke episode is classified as total anterior circulation infarct (TACI), partial anterior circulation
infarct (PACI), posterior circulation infarct (POCI), or lacunar infarct (LACI). These four entities
predict the extent of the stroke, the area of the brain affected, the underlying cause, and the
prognosis.
A Total Anterior Circulation Infarct (TACI) is a type of cerebral infarction affecting
the entire anterior circulation supplying one side of the brain. Total Anterior Circulation Stroke
14

Syndrome (TACS) refers to the symptoms of a patient who clinically appears to have suffered
from a total anterior circulation infarct, but who has not yet had any diagnostic imaging (e.g. CT
Scan) to confirm the diagnosis. It is diagnosed when it causes all 3 of the following symptoms:
The symptoms found in the patient:

Higher disfunction
o

Dysphasia

Visuospatial disturbances

No
No
No
No

Decreased level of

No sensory defects

consciousness

Homonymous hemianopia

Motor and Sensory Defects (2/3 of

face, arm, leg)

So, the possibility of a total anterior circulation infarct (TACI) can be excluded.

Partial Anterior Circulation Infarct (PACI) is a type of cerebral infarction affecting part of
the anterior circulation supplying one side of the brain. Partial Anterior Circulation Stroke
Syndrome (PACS) refers to the symptoms of a patient who clinically appears to have suffered
from a partial anterior circulation infarct, but who has not yet had any diagnostic imaging (e.g.
CT Scan) to confirm the diagnosis. It is diagnosed by any one of the following:
The symptoms found in the patient:

2 out of 3 features of
o

Higher dysfunction

Dysphasia

No
No
No
No sensory defects

Visulospatial disturbances
No
15

No
o

Homonymous hemianopia

Motor and Sensory Defects (>2/3 of

face, arm, leg)

Higher dysfunction alone

Partial Motor or Sensory Defect

So, the possibility of a partial anterior circulation infarct (PACI) can be excluded.
A Posterior Circulation Infarct (POCI) is a type of cerebral infarction affecting the
posterior circulation supplying one side of the brain. Posterior Circulation Stroke Syndrome
(POCS) refers to the symptoms of a patient who clinically appears to have suffered from a
posterior circulation infarct, but who has not yet had any diagnostic imaging (e.g. CT Scan) to
confirm the diagnosis. It can cause the following symptoms:

The symptoms found in the patient:

Cranial nerve palsy AND contralateral Just contralateral motor defect
motor/sensory defect

Bilateral motor or sensory defect

No

Eye movement problems (e.g.nystagmus)

No

Cerebellar dysfunction

Isolated homonymous hemianopia

No
No

No
It has also been associated with deafness.
So, the possibility of a posterior anterior circulation infarct (POCI) can be excluded.
Lacunar stroke or lacunar infarct (LACI) is a type of stroke that results from occlusion
of one of the penetrating arteries that provides blood to the brain's deep structures. Patients who
present with symptoms of a lacunar stroke, but who have not yet had diagnostic imaging
performed may be described as suffering from Lacunar Stroke Syndrome (LACS).
Lacunar cerebral infarct
No visual deficit
No noble disorders

Clinical findings in patients medical record

No visual deficit
No noble disorders
16

No brain stem function disorders

Maximal deficit on one branch small artery
Clinical features:

No brain stem function disorders

Pure motor stroke (PMS)

-

hemiparesis

or

hemiplegia

that

typically affects the face, arm, or leg

-

Hemiplegia typica

of one side.
Dysarthria, dysphagia, and transient

Dysathria and dysphagia

sensory symptoms.
Pure sensory stroke (PSS)
Marked by persistent or transient numbness,
tingling, pain, burning, or another
unpleasant sensation on one side of

No

the body.
Ataksik hemipareses
It displays a combination of cerebellar and
motor symptoms, including weakness
and clumsiness, on the ipsilateral side Can't examined yet.
of the body. It usually affects the leg
more than it does the arm; hence, it is
known also as homolateral ataxia and
crural

paresis.

The

onset

of

symptoms is often over hours or

days.
So, the possibility of a lacunar infarct (LACI) can be made, with location at posterior limb of
the internal capsule.
Conclusion:
Topical diagnosis : LACI capsula interna hemisferium dextra

17

Etiological diagnosis
Siriraj Stroke Score:
SJ

: (2,5 x level of consciousness) + ( 2 x Vomity) + ( 2 x Headache) + (0,1 x diastolic

blood pressure) (3 x atheroma marker) 12
: (2,5 x 0 ) + ( 2 x 0) + (2 x 0) + (0,1 x 100) (3 x 1) 12
: 0 + 0 + 0 + 10 3 12
:-5

Conclusion : Non hemorragic cerebri

Differential Diagnosis Etiology:
1. Hemmoragic cerebri
2. Emboli cerebri
3. Trombosis cerebri
1. Hemmoragic cerebri, the symptoms:
- Unconciusness > 30 minutes

Pada penderita ditemukan gejala:

No

- Hemiparese kontralateral sentral

So, etiology hemmoragic cerebri can be exluded.

No

Emboli cerebri, the symptoms:

- Unconsciousness < 30 minutes
- Arterial fibrilasi
So, etiology emboli cerebri can be exluded.

The symptoms found in the patient:

No
No

Trombosis cerebri, the symptoms:

- No unconsciousness
So, etiology trombosis cerebri can be made.

The symptoms found in the patient:

- No unconsciousness

Conclusion:
Etiological Diagnosis: Trombosis cerebri

REFERENCES
1. Guidelines Stroke 2004. Seri Ketiga. Kelompok Studi Serebrovaskuler PERHIMPUNAN
DOKTER SPESIALIS DOKTER SPESIALIS SARAF INDONESIA PERDOSSI.
18

2. Stroke, Ischemic. Joseph U Becker, Charles R Wira, and Jeffrey L

Arnold. 2010.
3. STROKE. Misbach, J. Fakultas Kedokteran Indonesia.

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