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 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

PROGNOSIS
Quo ad vitam : bonam

Quo ad functionam : dubia ad malam