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8/11/2019 Neuro Oohf fwy fggwgyfwy

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Tertaparese flaccid+hipesthesia 4

finger under neck to toe+retensiourine

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


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Identification

Mr. A/ 27 yrs/ P.bungur/ Islam/administered at august 10, 2009


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Anamnesis Patient administered into hospital because of

inability to walk concerning weakness of bothlegs within gradual onset.

4 days before hospitalized, patient feltnumbness on his both legs without weakness on

both legs.and felt that he could not urinated anddefecation.

20 hours before hospitalized, patient felt hisboth legs became weak and felt the numbness

on his both legs ascending up to hisstomach.When Patient administered intohospital, patient felt hard to breath and armweakness with his both legs could not move andnumbness from his stomach to his toe.


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Patient had History of fever and cough 7 daysago, history of trauma on the lower back wasdenied, and history of growing something on thelower back was denied.

Patient suffered from this illness for the firsttime.


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Physical examination

General condition

Conciousness : GCS E4M6V5= 15 Blood Pressure : 110/70 mmHg

Pulse : 68 x/mins

Respiratory Rate : 30x/mins

Temperature : 37,4oC


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Neurological statusCranial nerves:

N. VII : Forehead wrinkle isasymmetrical(right left behind), showing

teeth the right left behind

(parese N VII perifer)


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Motoric Function RA LA RL LL - Movement Lack lack no no

- Strength 4 4 0 0

- Tone de de de de

- Clone - -

- Physiological Refl. de de de de

- Patological Refl. - - - -


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Sensoric Function : Hipesthesia from 4finger under the neck to toe both legs

Vegetative : retensio urine


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Laboratory findingsBlood (august 10th, 2009) Leukosit abnormal 13200/mm3

LCS(august 15th, 2009)

no distosiation cito albumin


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DIAGNOSIS

Clinical diagnosis : tetraparese flaccid+parese n VII dextra perifer + retensio urine+hipestesi 4 finger from neck to toe both legs

Topical diagnosis : total tranversal lesionmedulla spinalis C2-C3

Etilogical diagnosis : gullian Barre

syndrom


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Differential diagnosis

poisonings with organophosphate, poisonhemlock, thallium, or arsenic

botulismwith early loss of pupillary reactivity

diphtheriawith early oropharyngeal dysfunction

Lyme diseasepolyradiculitis and other tick-borne paralyses

porphyriawith abdominal pain, seizures,psychosis

poliomyelitiswith fever and meningeal signs

myasthenia gravis

tranverse myelitis
http://en.wikipedia.org/wiki/Organophosphatehttp://en.wikipedia.org/wiki/Poison_hemlockhttp://en.wikipedia.org/wiki/Poison_hemlockhttp://en.wikipedia.org/wiki/Thalliumhttp://en.wikipedia.org/wiki/Arsenichttp://en.wikipedia.org/wiki/Botulismhttp://en.wikipedia.org/wiki/Diphtheriahttp://en.wikipedia.org/wiki/Lyme_diseasehttp://en.wikipedia.org/wiki/Porphyriahttp://en.wikipedia.org/wiki/Poliomyelitishttp://en.wikipedia.org/wiki/Myasthenia_gravishttp://en.wikipedia.org/wiki/Myasthenia_gravishttp://en.wikipedia.org/wiki/Poliomyelitishttp://en.wikipedia.org/wiki/Porphyriahttp://en.wikipedia.org/wiki/Lyme_diseasehttp://en.wikipedia.org/wiki/Diphtheriahttp://en.wikipedia.org/wiki/Botulismhttp://en.wikipedia.org/wiki/Arsenichttp://en.wikipedia.org/wiki/Thalliumhttp://en.wikipedia.org/wiki/Poison_hemlockhttp://en.wikipedia.org/wiki/Poison_hemlockhttp://en.wikipedia.org/wiki/Organophosphate


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treatment

Dopamine amp in 100 cc Nacl 0,9%

Dobutamin amp in 100 cc Nacl 0,9%

02 3-4 L/ minute(nasal) Inj dexametason 4x2 amp

Inj ceftriaxon 2x I gr

Inj ranitidine 2x 1 amp

Inj bisolvon 2x1 amp

Parasetamol tab 3x 500mg

IVFD RL gtt XX/menit

Vitamin B1, B6, B12 3x1 tab

Diet BB


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Prognosis

Quo ad Vitam: dubia ad bonam Quo ad Functionam: dubia ad bonam


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topic diagnosis

lesion on ms C2-C3 Sign on the patient

Tetraparese /tertaplegia(motoric) tetraparese flaccid

Sensoric deficit according to

dermatom

Hipesthesia from 4 finger under

the neck to toe both legs

Otonomic disorder(retensio urine) Retensio urine

Total lesion (disorder of motoric,

sensoric, otonomic)

Yes


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differential diagnosis of etiologi

swollen clostridium

botulism

no

Contaminated injury no

Paralysis nervus craniales Nervus vII dextra perifer

paralysis descending paralysis ascending

paralysis respiratory muscle Paralysis respiratory muscle

Botulism can be rule out


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diftheria can be rule out

Sore throat no

High fever yes

Pseudomembran on

tonsil

No finding

paralysis respiratory

muscle

Paralysis respiratory

muscle


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Poisoning can be rule out

swollen

organofosfat,nitrofurantoin,dap

sone

no

Disorder of lacrimation,

salivation, incontinensia urine,miosis

no


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porfiria can be rule out

Pain attack no

Mental

disorder(halusinasi,depresi,paran

oid)

no

Vomit with pain in stomach

no

Aritmia of heart no

Sensitive to light no

Muscle weakness Tetraparese weakness


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Tranversal mielitis(segmen c3,4,5) Sign on patient


Progesive weakness yes

Arm with UMN dan LMNlegs with UMN

Arm ang legs flaccid (spinal shock)

fever yes

Spinal shock (all extrimities are flaccid in

the first weak and then return to spastic)

no

LCS with increase of protein and cell

account

no

Deficit sensoric and otonom Yes


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SGB can not rule out

Sindrom Guillain-Barre (SGB) Sign on patient

Tetraparese flaccid/Paraparese

flaccid (ascending type)

Tetraparese flaccid ascending type

History of infection on respiratoy

and gastrointestinal

Yes(respiratory)

Deficit sensoric,disorder of otonom Yes(retensio urine)

N craniales involment especially

nervus fascialis

n VII perifer dextra

No sign of fever on onset There is fever on onset

LCs distosiation of cyto albumin No



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Thank you

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