A MAN 19 YEARS OLD WITH LOWER

EXTRIMITIES PARAPHARESIS AND

LEFT LOWER EXTRIMITY
HYPERESTHESIA ON DERMATOME L1

Oleh :
Fardiansyah D. 22010116210077
Nina Huwaida Zunnur
22010116220257
Mentor Senior :
dr. Dody Priambada, Sp.BS (K)
Identity
Name : Tn. SS
Age : 19 years old
Gender : Male
Religion : Christian
Address : Batam city, Riau
Hospitalized : April 6th 2017
Medical Record Number : C631575
No Active Problem Date No Passive Date
Problem
1 Tenderness 17/04/201
back on 7
Thoracal
Vertebrae 11
2 Lower 17/04/201
extrimities 7
parapharesis
3 Hyperesthesia 17/04/201
on dermatome 7
L1
 Anamnesis
Autoanamnesis with patient in Rajawali 2.B on April 17th 2017 at 5
pm
Main Complaint : Difficult to move left and right legs

History of present illness :

14 days before hospitalized, The patient had a traffic
accident while driving the motorcycle at night. Motorcycle
driven by a patient, crashed into a truck that was stopped.
The patient fell on the right side with face down position,
then the patient was hit by another motorcycle from behind
and the patient's back dropped the other motorcycle hit.
When the incident the patient was wearing a helmet. The
patient was still conscious at the time of the incident.
Unconscious (-), dizziness (-), vomiting (-), injuries and
bleeding from the head (-), double vision (-). The patient
feels pain in the back area and both legs are difficult to
In Emergency departments Kariadi Hospital, The
patient performed an x-ray and was transferred to
the inpatient room. Defecate and Urinate wnl,
nausea (-), vomiting (-), dizziness (-). The patient
complains that it is still difficult to move the right
and left legs, and it feels pain when the left leg
starts from the waist until the toe is touched or
exposed to something like a tisue or blanket.
Patients are scheduled for surgery on Tuesday, April
18th 2017.
Past illness :
Previous history of trauma is denied
Previous history of operation is denied
A history of high blood pressure is denied
Allergy history is denied

Family history :
A history of high blood pressure is denied
Allergy history is denied
Social Economy :
The patients is A college student of Salatiga
University. Parents of the patients work by selling
in the market in the city of Batam. Financing with
non-PBI JKN
Impression: social economy is enough
 PHYSICAL EXAMINATION
Physical examination in Rajawali 2B on April 17th 2017 at 5.30 pm
General condition : Weak
Consciousness : Compos mentis, GCS E4M6V5 = 15

Vital Signs :
Frequency of breath : 20x/min
Frequency of pulse : 78x/min regular
Temperature : 37,4oC axiller
Blood Pressure : 120/70 mmHg
VAS : 3-4
Weight : 75 Kg
Height : 170 cm
BMI : 25.95 (overweight)
General State
Head : Mesocephal, hair loss (-), lesion (-)
Eyes : Ptosis (-/-), conjungtiva palpebra pale (-/-), sclera
icteric (-/-), Light Reflex (+/+), pupil isokor 3mm.
Ears : Discharge (-/-).
Nose : Discharge (-/-).
Mouth : Cyanosis (-), Dry mucosa (-).
Neck : Symmetrical, enlargement of the lymph nodes (-/-),
No tracheal deviation, JVP in normal range.
Chest :
Heart
Inspection : Ictus cordis cannot be seen
Palpation : Ictus cordis palpable on SIC V LMCS
Percussion: configuration wnl
Auscultation : Basic Sound wnl, regular, bising (-), gallop (-)
Lungs
Inspection : Symmetrical when static and dynamic
Palpation : Tactile fremitus right and left are equal
Percussion: Sonor all around areas
Auscultation : Vesicular basic sound (+/+) , additional sound
(-/-)
 Abdomen :
Inspection : Flat, lump (-), venectation (-)
Auscultation : Bowel sound (+) normal
Percussion: Tympanic, liver dullness (+), flank dullness (+) N,
shifting dullness (-)
Palpation :Supel, tenderness (-),muscular defance (-), Liver
and lien are not palpable

Extremities : superior inferior

Cyanotic -/- -/-
Oedem -/- -/-
Cold acral -/- -/-
Capp.refill <2/<2 <2/<2
Neurological State
N I (Olfaktorius) Right Left
Subjective + +
Objective + +

N II (Optikus)
Sharp eyesight 2/60 2/60
Field vision no obstacles no obstacles
Seeing color good good
Fundus oculi not done not done
 N III (Okulomotor) Right Left
Sela mata 1,5 cm 1,5 cm
Eyes movement free free
Strabismus - -
Exophtalmus - -
Pupil :
-diameter 3mm 3mm
-form round round
Light Reflex + +
Convergency Reflex + +
Consensual Reflex + +
Double vision - -
 N IV (Trochlearis) Right Left
Eyes Movement Free Free
Bulbus position central central
Double vision - -
N V (Trigeminus)
Open mouth +
Chewing +
Biting +
Right Left
Cornea Reflex + +
Cornea Sensibility + +
 N VI (Abducens) kanan kiri
Eyes movement to lateral + +
Bulbus position central central
Double vision - -

N VII (Facialis)
Closing Eyes + +
Showing teeth + +
Whistling + +
Feelings of tounge 2/3 anterior not done not
done
 N VIII (Vestibulocochlearis) Right Left
Friction fingers + +
Sound whisper + +
Seconds watch + +
Rinne Test not done not done
Weber Test not done not done
Swabach Test not done not done

N IX (Glossopharyngeus)
Tongue tasting 1/3 posterior : not done
Pharynx sensibility : +
 N X (Vagus)
Arcus Pharynx : Symmetrical
Uvula : +
Speak : Normal, fluently
Swallowing : +
Oculocardiac : Normal

N XI (Acsesorius) right left

Turn away face : + +
Shrug : + +

N XII (Hipoglossus)
Tongue movement : free
Tremor :-
Articulation : clearly
Deviation :-
A. Body dan Limbs
1. Body
Motoric
Respiration : Thoracoabdominal
Sitting : cannot sit
columna vertebralis form : straight
columna vertebralis movement : fixed
2. Upper
Motoric Right Left
Extremities
Movement : + +
Strenght : 5/5/5/5/5 5/5/5/5/5
Tonus : Normotonus Normotonus
Trophy : Eutrophy Eutrophy
Sensibility
Tactile Sensibility + +
Temperature : not done not done
Discrimination 2 : + +
points : + +
Feelings of pain : + +
Localized feeling : + +
Position feeling : not done not done
Vibrating :
Reflex Right Left

Biceps Reflex : ++ ++

Triceps Reflex : ++ ++

Radius Reflex : ++ ++

Ulna Reflex : ++ ++

Hoffman Reflex : Neg Neg

Tromner Reflex : Neg Neg

3. Lower Extremities
Motoric Right Left
Movement : limited limited
Strenght : 3/3/3/3/3 1/1/1/1/1
Tonus : Hipotonus Hipotonus
Trophy : Eutrophy Eutrophy
Sensibility
Hyperesthesia on
Tactile Sensibility + normal L1
Temperature : not done not done
Discrimination 2 points : + +
Feelings of pain : + +
Localized feeling : + +
Position feeling : + +
Vibrating : not done not done
Reflex Right Left

Patellar Reflex : ++ ++++

Achilles Reflex : ++ ++++

Babinsky Reflex : Neg Neg

Chaddock Reflex : Neg Neg

Schaefer Reflex : Neg Neg

Oppenheim Reflex : Neg Neg

Gordon Reflex : Neg Neg

Thigh Clone : Neg +

Clonus Legs : Neg +

E. Coordination, Gait, and
Balance
How to walk : Not able to walk

Romberg Test : not done

Ataxia : not done

Disdiadokinesia : Neg

Rebound Phenomen : Neg

Dysmetri : Neg

F. Vegetative tool
Miction : (+)
Defecation, flatus : (+) , (+)
Localized State
Back:
Inspection : not seen a lesion on the back
Palpation : tenderness around vertebrae thoracal
11

Rectal Toucher:
Inspection : Hyperemic (-), fistulas (-), bleeding (-)
Palpation : Enough sphincter tone, slippery
mucosa, mass (-), collapsible collapses (-), enlarged
prostate (-), bulbovernosus reflex (+)
Gloves : feces (+), mucus (-), blood (-)
Supporting Examination
April 4th 2017
April 11 2017
RESUME
A man 19-years-old with lower
extrimities movements is limited, An
abnormal increased in sensitivity
touched on the left lower extremity of
the upper body as high as the L1
dermatome, Right muscle strength
3/3/3/3/3 and left 1/1/1/1/1, Left
Patellar reflex +4, left achilles reflex
+4, left thigh clone +, left leg clonus +.
 DIAGNOSIS
Clinic Diagnosis:
Paraparese inferior
Hyperesthesia of left lower extremity
Topical Diagnosis:
Medulla spinalis segment lumbal 1
Etiologic Diagnosis:
Spondilolisthesis vertebrae thoracal 11
e.c trauma
INITIAL PLAN
Diagnosa:
S :-
O : Pro-laminectomy + posterior fusion
Treatment:
Sleeping flat bed
Infus RL 20 tpm
Proper body positioning
Neurosurgical consul for surgery program
Rehabilitation medic consul
Fasting before surgery
Monitoring:
General state, Consciousness, Vital
signs(RR, HR, BP, T)
Urine output and defecate
Neurological deficit
Patients complaint
Education:
Explain the patient's condition to the
patient and family that the possible cause
of the patient's complaint is due to a spinal
cord injury due to suspicion of trauma due
to an accident on the spine
Explain to patients and families to restrict
spinal movements in order not to aggravate
complaints
Explain about the supporting examination
that needs to be done
Explain to patients and families to switch
over every 2 hours by log roll to prevent
decubitus ulcers
Explain to the patient about the prognosis
of this disease
Post Operation (Tuesday, April
18th 2017)
Diagnosa:
S :-
O :-
Treatment:
Sleeping flat bed
Proper body positioning
Rehabilitation Medic consul for physiotherapy
Alih baring tiap 2 jam
Infus RL 20 tpm
Ceftriaxone injection 2x1 gr
Metronidazol injection 500 mg/12 jam
Tramadol injection 1 mg/8 jam
Ranitidin injection 1 mg/8 jam
MST 15 mg/8 jam (bila nyeri)
Monitoring:
General state, consciousness, vital signs (RR, HR, BP, T)
Urin output and defecate
Neurological deficit
Patients complaint
Education:
Explain the patient and family situation that the possible
complications of the surgical action have been
performed
Explain to patients and families to switch over every 2
hours by log roll to prevent decubitus ulcers
Explain to the patient about the prognosis of this
disease
Thankyou