Case ReportSpastic dextra hemiplegi + N.XII dextra parese

Department of Neurology RSMH PalembangFaculty of Medicine Sriwijaya University

Sri Noviyanti YusufIra Laurentika

Advisor: Dr. H. A. R. Toyo, Sp.S (K)

IDENTIFICATIONMs.C/85 years/female/married/islam/ Palembang/ September 29th 2008

ANAMNESISThe patient was hospitalized in neurology ward RSMH because of walking disturbance which was caused by weakness on his right arm and leg arm, which happened suddenly.

1 day before admitted to the hospital, when the patient was taking rest, suddenly he felt weakness on his right arm and right leg without unconsciousness. At that time, he didnt get headache, nausea and vomit, without stiffness, and without sensiblity disturbances. The weakness between arm and leg was felt same. The patient uses right hand to work. Afasia was not found. The patient didnt feel throbbed and sorebreath.

ANAMNESISHistory 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 disease was the first time to her.

Physical ExaminationGeneral StateGeneral Condition : moderate sicknessSens : compos mentis (GCS=E4M6V5)Nutrition: enoughTemp.: 36,8CPulse: 82 x/minuteRespiratory rate : 22 x/minuteBlood Pressure : 160/80 mmHg

Physical ExaminationInternal stateHeart : HR: 82 x/menit, murmur(-), gallop(-)Lung: vesiculer(+) normal, ronchi (-), wheezing(-)Liver : not palpableSpleen: not palpableEkstremity: see neurological state

Physical ExaminationNeurological StateN. XII : - Tongue showing: deviation to the right - fasiculation (-) - papil athropy(-) - dysarthria (-)

Physical Examination

Physical ExaminationSensorik function : no abnormalityVegetatif function : no abnormalityLimbic function : no abnormalityMeningial irritation : noAbnormal Movement : noGait : cant be examinedEquilibrium and coordination : no abnormality

Laboratory FindingsHb: 12 mg/dlCholesterol HDL : 49 mg/dl WBC: 6.800/mm3Cholesterol LDL : 169 mg/dlDiff Count: 0/4/1/71/24/0Trigliseride : 125 mg/dlTrombocyt: 206.000/mm3Cholesterol total : 243 mg/dlHematocryt: 36 vol%Uric Acid : 5,5 mg/dlBSS: 113 mg/dlUreum : 67 mg/dlSodium: 142 mg/dlCreatinin : 1,2 mg/dlPotassium: 4,6 mg/dlCalcium : 2,37 mg/dl

Radiological FindingsCT scan :

Diagnosis banding topik

1. Lesion at the cortex of hemispherium cerebri sinistra, signs:In the patient, signs :

- motoric deficyt - hemiplegi dextra, spastic type- iritation sign (-)

- focal sign - weakness in the left arm and lower limb was felt same

-sensoric deficyt (-)

2. Lesion at the subcortex hemispherium cerebri dextra, signs:In the patient, signs :

- motoric deficyt - hemiplegy sinistra, spastic type-afasia motoric if the lesion in dominan hemispherium. (-)

Topical Diagnosis :

Capsula interna hemispherium sinistra

Etyological Diff Diagnose :

1. Hemorrhagic cerebri, signs:In the patient, signs :- When activating- when resting- Unconsiousness > 30 menit(-)- headache, nausea, vomit before (+)(-)

2. Emboli cerebri, signs:In the patient, signs :

- arterial fibrilation (+)(-)- Unconsiousness < 30 menit(-)

3. Trombosis cerebri, signs:In the patient, signs :- When taking a rest- When resting- Unconsiousness (-)(-)- Risk factor for aterosklerosis (+)(+)

Siriraj Stroke Score = -4 CVD non Hemorrhagic

Etiological Diagnosis :

Trombosis Cerebri

DiagnosisClinical Diagnosis :Hemiparese dextra spastik + parese N.XII dextra Topical Diagnosis :Capsula interna hemispherium sinistra

Etiological Diagnosis :Trombosis Cerebri

ManagementIVFD Ringer Laktat gtt xx/mntDiet rice low saltCiticholoine injection, 2x250mgSimvastatin 1x1Neuorobion injection, 1x5000mgPhysiotherapy : IRR and gait training

PROGNOSIS Quo ad Vitam: dubia ad bonamQuo ad Functionam: dubia ad bonam