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Case Presentation

Hemiparese sinistra spastik +


parese N.VII sinistra perifer

Department of Neurology RSMH Palembang
Faculty of Medicine University of Sriwijaya

By: M.Andri Junaidi, S.Ked.
Supervisor: Dr. H. A. R. Toyo, Sp.S (K)

IDENTIFICATION
Mr.M/65 years/male/married/islam/
Palembang/ january 5
th
2007
ANAMNESIS
The patient was hospitalized in neurology ward
RSMH because of walking disturbance which was
caused by weakness on his left arm and lower
limb, which happened suddenly.

3 hours before admitted to the hospital, when the
patient was taking wudhu, suddenly he felt weakness on
his his left arm and lower limb without unconsciousness.
At that time, he didnt get headache, nausea and vomit,
without stiffness, and without disturbance of sensibility
on the left side. The weakness between arm and lower
limb was felt same. The patient uses right hand to work.
He could express his mind by talking, writing and giving
sign. The patient understood other peoples mind which
was expressed by talking, writing and giving sign. He
didnt feel throbbed and sorebreath.
ANAMNESIS
History 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 illness was the first time for him.
Physical Examination
Generalis Status
General Condition : moderate sickness
Sens : compos mentis (GCS=E
4
M
6
V
5
)
Nutrition : enough
Temp. : 36,8C
Pulse : 80 x/minute
Respiratory rate : 18 x/minute
Blood Pressure : 130/80 mmHg

Physical Examination
Generalis Status
Heart : HR: 80 x/menit,
murmur(-), gallop(-)
Lung : vesikuler(+) normal,
ronchi (-), wheezing(-)
Liver : not palpable
Spleen : not palpable
Ekstremity : refer to neurological status

Physical Examination
Neurological Status
N. VII sinistra :
- forehead fold : flat
- lagoftalmus (+)
- angle of the mouth
- nasolabialis fold : flat

Physical Examination
Motorik
Fungtion
Arm Leg
Right Left Right Left
Movement enough less enough less
Power 5 4 5 4
Tonus Normal Normal
Klonus - - -
Physiological R. Normal Normal
Patological R. - - - (+) B
Physical Examination
Sensorik function : no abnormality
Vegetatif function : no abnormality
Noble function : no abnormality
MES : no
Abnormal Movement : no
Gait : cant be examined
Balance and coordination : Romberg (+)
Dysmetri finger to finger (+)
Laboratory
Hb : 12,5 g/dl Cholesterol HDL : 55 mg/dl
Leucocyt : 4.200/mm
3
Cholesterol LDL : 172 mg/dl
Diff Count : 0/4/3/60/30/3 Trigliseride : 143 mg/dl
Trombocyt : 180.000/mm
3
Cholesterol total : 256 mg/dl
Hematocryt : 38 vol% Uric Acid : 3,5 mg/dl
BSS : 113 mg/dl Ureum : 45 mg/dl
Creatinin : 1,1 mg/dl

Radiology
Ro Thorax PA:
LVH
CT scan :
Infark in cerebellum sinistra
Diagnosis banding topik

1. Lesion at the cortex of
hemispherium cerebri dextra,
signs:

In the patient, signs :

- motoric deficyt - hemiplegi sinistra type spastic
- 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 type
spastyc

-afasia motoric if the lesion
in dominan hemispherium.
(-)

3. Lesion at Capsula
interna hemispherium
cerebri dextra, signs:
In the patient, signs :

- hemiparese/hemiplegy
typica
- hemiplegi sinistra tipe
spastik

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

Focal sign & iritatif sign (-) Focal sign & iritatif sign (-)
Topical Diagnosis :

Capsula interna hemispherium dextra + cerebellum
Etyological Diff Diagnose :
1. Hemorrhagic cerebri,
signs:
In the patient, signs :
- When activity -mild activity (wudhu)
- 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 -mild activity (wudhu)
- Unconsiousness (-) (-)
- Risk factor for
aterosklerosis (+)
(+)
Siriraj Stroke Score = -2
CVD non Hemorrhagic

Etiological Diagnosis :


Trombosis Cerebri
Diagnosis
Clinical Diagnosis :
Hemiparese sinistra spastik + parese N.VII
sinistra perifer

Topical Diagnosis :
Capsula interna hemispherium dextra +
cerebellum

Etiological Diagnosis :
Trombosis Cerebri

Management
IVFD Ringer Laktat gtt xx/mnt
Diet rice low salt
Brain Act 2 x 250 mg intravenous
Aspilet 1 x 80 mg tab per oral
Grahabion 2 x 1 tab per oral
Physiotherapy : IRR and gait training

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