Case Kito Fix

7/25/2019 Case Kito Fix

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CASE REPORT

SENIOR CLINICAL CLERKSHIP

Period of November 22th Desember 20nd, 200

DEPARTMENT OF NEUROLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ RSMH

PALEMBANG

2010

ENDORSE!EN" PA#E

N$me % &itri$ Koesh$rd$ni, S' Ked

Int$n !ei(it$, S'Ked

)en*+ -t$mi, S'Ked

NI! % ./000010

0/0000


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C$se Re4ort

Contu!on o" S#!n$% Co&'

Presented b%

&itri$ Koesh$rd$ni, S' Ked ./000010

Int$n !ei(it$, S'Ked 0/0000

)en*+ -t$mi, S'Ked 0/00003.

H$s been $55e4ted $s one of re67irements in 7nder*oin* senior 5(ini5$( 5(er+shi4

4eriod of November 22th De5ember 20nd, 200 in De4$rtment of Ne7ro(o*

&$57(t of !edi5ine Sri8i9$$ -niversit : RS!H P$(emb$n*'

P$(emb$n*, De5ember 200

Advisor

Dr' H' A' R$5hm$n "oo, S4S;Kt f ee( sense from the 7mbi(i57s to the fin*erti4s of both (e*s $nd

5om4($int diffi57(t in 7rin$tin* $nd defe5$tion'' Im4$irment of 5ons5io7sness ;?t 5om4($in $bo7t n$7se$ $nd vomitin*' He 8$s t$+en to the hos4it$(

immedi$te('

P$tient h$d no histor of H4ertension' No histor of *ettin* fever' Nohistor of *ettin* he$d in97r' No histor of di$betes me((it7s' No histor of

5hroni5 5o7*h, no histor of (iftin* he$v (o$d, no histor of s4in$( b7m4

"his i((ness 8$s s7ffered for the first time

PHYSICAL E,AMINATION

PRESENT STATE

Int*&n$% St$t*

Sense % E/!).

N7trition % s7ffi5ient

P7(se %12be$ts:min

Res4ir$tor r$te %1 times:min

@(ood 4ress7re %0:10 mmH*

ei*ht % .. +*

Hei*ht % / 5m

P-.!$t&!. t$t*

L7n*s % no $bnorm$(it

Liver % no $bnorm$(it

S4(een % no $bnorm$(it

EBtremities % no edem$

#enit$( % no $bnorm$(it


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Attit7de %5oo4er$tive

Attention %norm$(

N*u&o%o!.$% t$t*

Head

Sh$4e % br$5hio5e4h$(

Sie % normo5e4h$(

Smetri5 % es

Hem$tome % no

"7mor % no

Neck

Position % str$i*ht"orti5o(is % no

N$4e of ne5+ stiffness % no

&$5i$( EB4ression % n$t7r$(

Phsi5$( 5ont$5t % norm$(

Deformit % no

&r$5t7re % no

&r$5t7re 4$in % no

)esse( % no 8idenin*

P7(s$tion % no disorder

Deformit % no"7mor % no

)esse(s % no 8idenin*

/


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CRANIAL NER)ES

O(f$5tori7s nerve

Sme((in*

Anosmi$

H4osmi$

P$rosmi$

O4ti57s nerve

)is7$( $57it

C$m47s visi

Ano4si$

Hemi$no4si$

O57(i f7nd7s

Edem$ 4$4i(

Atro4h 4$4i(

Retin$ b(eedin*

O557(omotori7s, "ro5h(e$ris

$nd Abd75ens nerves

Di4(o4i$

Ees *$4

Ptosis

Ees 4osition

Str$bism7s

EBo4ht$(m7s

Eno4ht$(m7s

Devi$tion 5on97*$e

Ees movement

P74i(

Sh$4e

Sie

Iso5hor:$niso5hor

!idri$sis:miosis

Li*ht ref(eB

dire5t 5onsens7i(

Ri*ht

No disorder

No

No

No

Ri*ht

Not eB$mined

)'O'D

No

No

No

No

No

Ri*ht

No

simetris

No

No

No

No

No

no $bnorm$(it

Ro7nd

mm

iso5hor

No

F

FF

Left

No disorder

No

No

No

Left

Not eB$mined

)'O'S

No

No

No

No

No

Left

No

simetris

No

No

No

No

No

no $bnorm$(it

Ro7nd

mm

iso5hor

No

F

FF

.


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A55essori7s Nerve

Sho7(der R$isin*

He$d "8istin*

H4o*(oss7s Nerve

"o7n*e Sho8in*

&$s5i57($tion

P$4i( Athro4h

Ds$rthri$

!O"ORIC

Arms

!otion

Po8er"ones

Phsio(o*i5$( Ref(eB

@i5e4s

"ri5e4s

R$di7s

-(n$

P$tho(o*i5$( Ref(eB

Hoffm$n "romner

Leri

!eer

"rofi+

LE#

!otion

Po8er

"ones

C(on7s

"i*h &oot

Phsio(o*i5$( ref(eB

K P R

A P R

P$tho(o*i5$( ref(eB

@$bins+

Ch$ddo5+

O44enheim

#ordon

Ri*ht

simetris

No disorder

No devi$tion

no

no

no

Ri*ht

S7ffi5ient

.Norm$(

Norm$(

Norm$(

Norm$(

Norm$(

None

NoneNone

None

Ri*ht

Ins7ffi5ient

0

de5re$sin*

Ne*$tive

Ne*$tive

de5re$sin*

de5re$sin*

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Left

simetris

No disorder

Left

S7ffi5ient

.Norm$(

Norm$(

Norm$(

Norm$(

Norm$(

None

NoneNone

None

Left

Ins7ffi5ient

0

de5re$sin*

Ne*$tive

Ne*$tive

de5re$sin*

de5re$sin*

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive


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S5h$effer

Rosso(imo

!ende( @e5htere8

Abdomin$( s+in ref(eB -44er

!idd(e

Lo8er

Crem$ster ref(eB

Ne*$tive

Ne*$tive

No $bnorm$(it

No $bnorm$(it

No $bnorm$(it

Not eB$mined

Ne*$tive

Ne*$tive

SENSORG

Hi4estesi $s hi*h $s 2 fin*ers 7nder 7mbi(i57s 7nti( the fin*erti4s of both (e*s'

PIC"-RE

)E#E"A"I)E &-NC"ION

!i5t7rition % retensio 7rin

Defe5$tion % retensio $(vi

Ere5tion % not eB$mined

)ER"E@RAL COL-!N

K4hosis % no "7mor % no

Lordosis % no !enin*o5e(e % no

#ibb7s % no Hem$tome % no

Deformit % es "enderness % no


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SG!P"O!S O& !ENIN#EAL IRRI"A"ION

N$4e of ne5+ stiffness

Kerni6

L$sse67e

@r7dins+

Ne5+

Chee+

Sm4hisis

Le* I

Le* II

Ri*ht

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Left

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

Ne*$tive

#AI" AND E-ILI@IRI-!

#$it E67i(ibiri7m $nd Coordin$tion

At$Bi$ % not eBemined Romber* % ne*$tif

Hemi4(e*i5 % not eBemined Dsmetri % ne*$tif

S5issor % not eBemined fin*er fin*er % norm$(

Pro47(sion % not eBemined fin*er nose % norm$(

Histeri5 % not eBemined hee( ? hee( % not eBemined

Lim4in* % not eBemined Rebo7nd4henomenon % not eBemined

Ste44$*e % not eBemined Dsdi$do5ho+inesis % ne*$tive

Ast$si$?Ab$si$ % ne*$tive "r7n+ At$Bi$ % ne*$tiveLimb At$Bi$ % ne*$tive

!O"ION A@NOR!AL

"remor % no

Chore$ % no

Athetosis % no

@$((ism7s % no

Dstoni % no

!o5(on7s % no

LI!@IC &-NC"ION

!otori5 $4h$si$ % no

Sensori5 $4h$si$ % no

A4r$+si$ % no

A*r$4hi$ % no

A(eBi$ % no

Nomin$( $4h$si$ % no

LA@ORA"ORG &INDIN#S

1


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@LOOD

Hb % , *:dL "ot$( +o(estero( % m*:dL

Eritro5te % /,2 97t$:mm Ko(estero( HDL % m*:dL

Le7+osit % 3.00 :mm Ko(estero( LDL % m*:dL

"rombosit % /2'000 :mm "ri*(iseride % 3 m*:dL

Hem$to5rit % . vo( -re7m % 0 m*:dL

CK?NAK % . -:I Kre$tinin % , m*:dL

CK?!@ % -:I N$tri7m % . mmo(L

Diff Co7nt % 0:0:2:1:2:. K$(i7m % /, mmo(:L

C$(si7m % 2,/ mmo(:L

-RINE

E4ithe( % not 4erformed Protein % not 4erformed

Le75o5te % not 4erformed #(75ose % not 4erformedErito5te % not 4erformed

&ECES

Consisten5 % not 4erformed Ertro5te % not 4erformed

S(ime % not 4erformed Le75o5te % not 4erformed

@(ood % not 4erformed orm e** % not 4erformed

Amoeb$ 5o(i: % not 4erformed

Hsto(iti5$ % not 4erformed

CERE@RO SPINAL &L-ID

Co(o7r % not 4erformed Protein % not 4erformed

C($rit % not 4erformed #(75ose % not 4erformed

Press7re % not 4erformed N$C( % not 4erformed

Ce(( % not 4erformed 7e5+ensted % not 4erformed

Nonne % not 4erformed Ce((oid$( % not 4erformed

P$nd % not 4erformed C7(t7re % not

4erformed

SPECI&IC EJA!INA"ION

Cr$ni7m J? R$ % not 4erformed

Chest J? R$ % norm$( thor$B

)ertebr$( 5o(7mn J? R$ %Com4ressive fr$5t7re:b7rst "'II $nd

S4ond(osetesis " ?2

E(e5troen5e4h$(o*r$4h % not 4erformed

E(e5trone7romo*r$4h % not 4erformed

E(e5tro5$rdio*r$4h % not 4erformed

Arterio*r$4h % not 4erformed

Pne7mo*r$4h % not 4erformed

3


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C"?S5$n % not 4erformed

RESUME

IDENTIFICATION

!r' I: 2. e$rs o(d: m$(e: 7nm$rried: !os(em: st$ in to8n: De5ember th

200

ANAMNESIS (Auto An$)n*!+

"he 4$tients 8$s hos4it$(ied in ne7ro(o* 8$rd of RS!H P$(emb$n*

be5$7se 4$r$(sis of both (e*s $nd he h$s 4rob(ems in 7rin$tion $nd defe5$tion

sin5e he f$(( from the 4$(m tree'

= 2 8ee+s $*o, 8hen he 8$s 5(imbin* 4$(m trees, the 4$tient fe(( from $

tree in the s74ine 4osition, his b$5+ hit first, $nd dire5t( the 4$tient 5$n not moveboth his (e*s, 4$tients $(so fee( (ess sense on the 4$rt of 7mbi(i57s to the fin*erti4s

of both (e*s , he h$s 4rob(ems in 7rin$tion $nd defe5$tion'' Im4$irment of

5ons5io7sness ;?t 5om4($in $bo7t n$7se$ $nd vomitin*' P$tients $re

t$+en dire5t( to hos4it$('

P$tient h$d no histor of H4ertension' No histor of *ettin* fever' No

histor of *ettin* he$d in97r' No histor of di$betes me((it7s' No histor of

5hroni5 5o7*h, no histor of (iftin* he$v (o$d, no histor of s4in$( b7m4

"his i((ness 8$s s7ffered for the first time

EJA!INA"ION

Present St$te

Sense % 5om4os mentis ;#CS .% E/!).

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Case Kito Fix