CASE REPORTTRIGEMINAL NEURALGIA

Rizka Dana PrastiwiG4A014099

PEMBIMBING dr. Untung Gunarto, Sp.S

IDENTITYName : Mrs. KAge : 60 years oldGender : femalaeAdress : Margasana Jatilawang RT

04/02Job : housewifeReligion : Islam

SUBYEKTIFMAIN COMLAINT

Pain on right cheekRIWAYAT PENYAKIT SEKARANGe

Patient came to Policlinic RSMS withpain on right cheek since 1 year ago. The pain feels everyday, suddenly, uncertain. The character of pain is sharp like to be stabbed, hot duration about 5 minute and self recovery. The pain increase when fatique and when be touched, the pain better when eat drugns from doctor.Other complaint is back neck feels rigid, right hand usually hipestesi, and weary body. Pasien routine control to poliklinik Neuro since 6 month ago.

KUANTITYshe fells pain evryday suddenly, duration about 5 minute

KUALITYThe pain is shap like to be stabbed, hot, verry distrub activity VAS 8

OTHER COMLAINTback neck rigis, right hand hipestesi, and weary body

BETTER FACTOReat drugs from doctor

INCREASE FACTORFatique, when be touched

HISTORY OF ILLNESSthe same symptom since 1 yearhipertension +tooth extraction +

FAMILY HISTORY OF ILNESSSame symptom : -Diabetes Melitus : -Hipertensi : +

SOCIAL ECONOMYpatient is a housewife

FAMILY RELATIONSHIPGood

NUTRITION STATUSgood

PSYCHOLOGYgood

SPIRITUALITYmoslem

OBJEKTIFKU/Kes: good/ GCS E4M6V5vital sign: BP: 140/90 HR: 84 RR: 20 T: 36,1 weight: 85 kg height : 157 cmSt. generalis :

eye : CA -/- SI-/- RC +/+ pupil isokorneck : kaku kuduk (-)Pulmo : SD vesikuler +/+ rh -/- wh -/-cor : S1>S2 regulerAbdomen : supel, BU (+)Ekstremitas : warm +/+

st.neurologis:N. cranialis: normalsensibilitas: normal

MotorikSuperior Inferior

Movement

Motoric power

Trofi

Tonus

RF

RP

klonus

free/free

5555/5555

Eutrofi/eutrofi

Normo/normo

Normo/normo

-/-

-/-

free/free

5555/5555

Eutrofi/eutrofi

Normo/normo

Normo/normo

-/-

-/-

ASSESMENTDK: facial pain (neuralgia)

TTHMyalgiaHipertensi grade 1

DT: n. trigeminal

DE: neuralgia trigeminaldd: post herpetik neuralgia

PLANNINGTherapy:

PO carbamazepin 2x200mgPO trmadol 50 mg k/pPO codein 20mg k/pPO vitamin B12 1x50 mg

Monitoring: Monitoring symtom and effectivity of therapyPatient’s obedient of therapyAdverse event

Planning of diagnostic: MRI

EDUKASIEdukasi penyakit neuralgia trigeminalEdukasi pilihan terapiEdukasi rutin kontrol ke poli saraf

PROGNOSISAd vitam : ad bonamAd fungsionam : dubia ad bonamAd sanationam : dubia ad bonam

THANK YOU