7/25/2019 Case Kito Fix
1/32
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$mi, S'Ked
NI! % ./000010
0/0000
7/25/2019 Case Kito Fix
2/32
C$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
7/25/2019 Case Kito Fix
4/32
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*
/
7/25/2019 Case Kito Fix
5/32
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
.
7/25/2019 Case Kito Fix
6/32
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*$tive
7/25/2019 Case Kito Fix
7/32
S5h$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
7/25/2019 Case Kito Fix
8/32
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
7/25/2019 Case Kito Fix
9/32
@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$4h % not 4erformed
3
7/25/2019 Case Kito Fix
10/32
C"?S5$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/!).
Recommended