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)
IDENTIFICATION Mr.M/65 years/male/married/islam/ Palembang/ january 5 th 2007 ANAMNESIS The patient was hospitalized in neurology ward RSMH because of walking disturbance which was caused by weakness on his left arm and lower limb, which happened suddenly.
3 hours before admitted to the hospital, when the patient was taking wudhu, 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 arm and lower limb 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 peoples mind which was expressed by talking, writing and giving sign. He didnt feel throbbed and sorebreath. 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. Physical Examination Generalis Status General Condition : moderate sickness Sens : compos mentis (GCS=E 4 M 6 V 5 ) Nutrition : enough Temp. : 36,8C Pulse : 80 x/minute Respiratory rate : 18 x/minute Blood Pressure : 130/80 mmHg
Physical Examination Generalis Status Heart : HR: 80 x/menit, murmur(-), gallop(-) Lung : vesikuler(+) normal, ronchi (-), wheezing(-) Liver : not palpable Spleen : not palpable Ekstremity : refer to neurological status
Physical Examination Neurological Status N. VII sinistra : - forehead fold : flat - lagoftalmus (+) - angle of the mouth - nasolabialis fold : flat
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 Physical Examination Sensorik function : no abnormality Vegetatif function : no abnormality Noble function : no abnormality MES : no Abnormal Movement : no Gait : cant be examined Balance and coordination : Romberg (+) Dysmetri finger to finger (+) Laboratory Hb : 12,5 g/dl Cholesterol HDL : 55 mg/dl Leucocyt : 4.200/mm 3 Cholesterol LDL : 172 mg/dl Diff Count : 0/4/3/60/30/3 Trigliseride : 143 mg/dl Trombocyt : 180.000/mm 3 Cholesterol total : 256 mg/dl Hematocryt : 38 vol% Uric Acid : 3,5 mg/dl BSS : 113 mg/dl Ureum : 45 mg/dl Creatinin : 1,1 mg/dl
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
PROGNOSIS Quo ad Vitam : bonam Quo ad Functionam : dubia ad bonam