power point case kontusio medula
TRANSCRIPT
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Case Presentation
Paraplegi Inferior Flaksid +hipestesia 1 finger above
umbilicus start from tiptoe +
Retensio Urine
By: Ferawati, S.Ked.
Supervisor: Dr. H. A. R. Toyo, Sp.S (K)
Department of NeurologyRSMH Palembang
Faculty of Medicine University of Sriwijaya
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IDENTIFICATION
Mr.Y/17 tahun/male/not yet
married/Islam/suburban/Desember 19st
2006
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ANAMNESIS
History of fever (-), history of long
cough (-), history bump in backbone (-)
This illness was the first time for him.
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Physical Examination
Generalis Status
General Condition: average sickness
Sens : compos mentis (GCS=E4M6V5)
Nutrition : lack of nutrition
Temp. : 36,8C
Pulse : 80 x/minute
Respiratory rate : 20 x/minute
Blood Pressure : 120/80 mmHg
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Physical Examination
Generalis Status
Heart : HR: 80 x/menit,
murmur(-), gallop(-)Lung : vesikuler(+) normal,
ronkhi (-), wheezing(-)
Liver : not palpableSpleen : not palpable
Ekstremity : refer to neurological status
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Physical Examination
Neurological Status
Nn. Craniales : no abnormality
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Physical Examination
Motorik
Fungtion
Arm Leg
Right Left Right Left
Movement enough enough less less
Power 5 5 0 0
Tonus Normal Normal
Klonus - -
Physiological R. Normal Normal
Patological R. - - (-) (-)
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Physical Examination
Sensorik function : hipestesia (+) 1 finger above
umbilicus start from tiptoe
Vegetatif function : retensio urineLuhur function : no abnormality
Abnormal Movement : no
Gait & Stability : no abnormalityGRM : tidak ada
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Additional Examination
Ro Thoracolumbal:
Compression frakture V. Th 12 and
V.L 1
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Etiological Differential Diagnosis
1. Myelitis Symptoms on the patientwere:
Symptoms:History of fever
Neck Stiffness and pain on the back
Asymetrical motoric abnormality
There is no fever
There was no neck stiffness
and pain on the back
Paraplegi inferior flaksid(simetric)
So the possibility of myelitis can be rejected
Working Diagnosis of Etiology: contussio medullae
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DIAGNOSIS BANDING ETIOLOGI
So the possibility of hematomyelia can be rejected
2. Hematomyelia Symptoms on the patientwere:
Symptoms:
History of trauma
Weakness was acute and getting
better by the time
History of trauma (+) 2
days before admitted to
RSMH, fall in buttockposition.
Weakness was acute but
permanent
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DIAGNOSIS BANDING ETIOLOGI
So the possibility of spinal subdural hematome
can be rejected
3. Spinal subdural
hematome
Symptoms on the patient were:
Symptoms:History of trauma
Weakness was chronic
progressif and not
permanent
History of trauma (+) 2 days
before admitted to RSMH, fall inbuttock position.
Weakness was acute andpermanent
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DIAGNOSIS BANDING ETIOLOGI
So the possibility of contussio medullae cant yet
be rejected
4. Contussio medullae Symptoms on the patientwere:
Symptoms:
History of trauma
Weakness was acute and
permanent
History of trauma (+) 2
days before admitted to
RSMH, fall in buttockposition.
Weakness was acute
and permanent
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DIAGNOSIS
Clinical Diagnosis :
Paraplegi Inferior Flaksid + hipestesia 1 finger above
umbilicus start from tiptoe + Retensio Urine
Topical Diagnosis :
Transversal totally lesion at Th.9
Etiological Diagnosis :
Contussio medullae
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MANAGEMENT
IVFD RL gtt xx/m
Catheter + urine bag
Vit B1, B6, B12 2 x 1 tablet
Diet NB Pro CT-Myelografi
Consult to spinal orthopedic surgery
Consult to rehabilitation medic
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PROGNOSIS
Quo ad vitam : bonam
Quo ad functionam : dubia ad malam
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