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 Neurology RSMH Palembang Faculty of Medicine University of Sriwijaya
IDENTIFICATION Mr.Y/17 tahun/male/not yet married/Islam/suburban/Desember 19 st
2006 ANAMNESIS The patient was hospitalized in neurology ward RSMH because cannot walk which was caused by weakness on his both legs, which happened suddenly. 2 days before admitted to the hospital, the patient climbing mango tree, patient fallen down from height 6 metre, fall in buttock position and direct cannot move second of his both leg accompanied by the trouble sensibilitas in the form feel hipestesi in his both leg. The patient cant urinate, but defecate as usually. These complains was remained until he was admitted to RSMH.
ANAMNESIS History of fever (-), history of long cough (-), history bump in backbone (-) This illness was the first time for him. 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
Physical Examination Generalis Status Heart : HR: 80 x/menit, murmur(-), gallop(-) Lung : vesikuler(+) normal, ronkhi (-), wheezing(-) Liver : not palpable Spleen : not palpable Ekstremity : refer to neurological status
Physical Examination Neurological Status Nn. Craniales : no abnormality
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. - - (-) (-) Physical Examination Sensorik function : hipestesia (+) 1 finger above umbilicus start from tiptoe Vegetatif function : retensio urine Luhur function : no abnormality Abnormal Movement : no Gait & Stability : no abnormality GRM : tidak ada
Additional Examination Ro Thoracolumbal: Compression frakture V. Th 12 and V.L 1 Etiological Differential Diagnosis 1. Myelitis Symptoms on the patient were: 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 DIAGNOSIS BANDING ETIOLOGI So the possibility of hematomyelia can be rejected 2. Hematomyelia Symptoms on the patient were: Symptoms: History of trauma
Weakness was acute and getting better by the time History of trauma (+) 2 days before admitted to RSMH, fall in buttock position. Weakness was acute but permanent 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 in buttock position.
Weakness was acute and permanent DIAGNOSIS BANDING ETIOLOGI So the possibility of contussio medullae cant yet be rejected 4. Contussio medullae Symptoms on the patient were: Symptoms: History of trauma
Weakness was acute and permanent
History of trauma (+) 2 days before admitted to RSMH, fall in buttock position. Weakness was acute and permanent 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 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