Case Report

Spastic dextra hemiplegi +

N.XII dextra parese
Sri Noviyanti Yusuf
Ira Laurentika
Advisor: Dr. H. A. R. Toyo, Sp.S (K)
Department of Neurology RSMH Palembang
Faculty of Medicine Sriwijaya University

IDENTIFICATION
Ms.C/85 years/female/married/islam/
Palembang/ September 29th 2008

ANAMNESIS
The patient was hospitalized in neurology ward
RSMH because of walking disturbance which was
caused by weakness on his right arm and leg arm,
which happened suddenly.

1 day before admitted to the hospital, when the patient

was taking rest, suddenly he felt weakness on his right
arm and right leg without unconsciousness. At that time,
he didnt get headache, nausea and vomit, without
stiffness, and without sensiblity disturbances. The
weakness between arm and leg was felt same. The patient
uses right hand to work. Afasia was not found. The
patient 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 disease was the first time to her.

Physical Examination
General State
General Condition : moderate sickness
Sens
: compos mentis (GCS=E4M6V5)
Nutrition
: enough
Temp.
: 36,8C
Pulse
: 82 x/minute
Respiratory rate : 22 x/minute
Blood Pressure
: 160/80 mmHg

Physical Examination
Internal state
Heart
Lung
Liver
Spleen
Ekstremity

: HR: 82 x/menit,
murmur(-), gallop(-)
: vesiculer(+) normal,
ronchi (-), wheezing(-)
: not palpable
: not palpable
: see neurological state

Physical Examination
Neurological State
N. XII :
- Tongue showing: deviation to the right
- fasiculation (-)
- papil athropy(-)
- dysarthria (-)

Physical Examination
Motorik
Function
Movement
Power
Tonus
Klonus
Physiological R.
Pathological R.

Arm
Right
Left
less
2

enough
5
Normal
Normal
-

Leg
Right
Left
less
3
+B

enough
5
Normal
Normal
-

Physical Examination
Sensorik function
: no abnormality
Vegetatif function
: no abnormality
Limbic function : no abnormality
Meningial irritation
: no
Abnormal Movement : no
Gait
: cant be examined
Equilibrium and coordination : no abnormality

Laboratory Findings

Hb
: 12 mg/dl
WBC
: 6.800/mm3
Diff Count : 0/4/1/71/24/0
Trombocyt : 206.000/mm3
Hematocryt : 36 vol%
BSS
: 113 mg/dl
Sodium
: 142 mg/dl
Potassium : 4,6 mg/dl

Cholesterol HDL : 49 mg/dl

Cholesterol LDL : 169 mg/dl
Trigliseride
: 125 mg/dl
Cholesterol total : 243 mg/dl
Uric Acid
: 5,5 mg/dl
Ureum
: 67 mg/dl
Creatinin
: 1,2 mg/dl
Calcium
: 2,37 mg/dl

Radiological Findings
CT scan :

Diagnosis banding topik

1. Lesion at the cortex of
hemispherium cerebri sinistra,
signs:
- motoric deficyt
- iritation sign
- focal sign

-sensoric deficyt

In the patient, signs :

- hemiplegi dextra, spastic type

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

2. Lesion at the subcortex

hemispherium cerebri
dextra, signs:
- motoric deficyt
-afasia motoric if the lesion
in dominan hemispherium.

In the patient, signs :

- hemiplegy sinistra, spastic

type
(-)

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

In the patient, signs :

- hemiparese/hemiplegy
typica

-hemiplegi
spastic type

weakness in the left arm and

lower limb was felt same

- weakness in the left arm and

Focal sign & iritatif sign (-)

Focal sign & iritatif sign (-)

sinistra,

lower limb was felt same

Topical Diagnosis :
Capsula

interna hemispherium sinistra

Etyological Diff Diagnose :

1. Hemorrhagic cerebri,
signs:

In the patient, signs :

- When activating

- when resting

- 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

- When resting

- Unconsiousness (-)

(-)

- Risk factor for

aterosklerosis (+)

(+)

Siriraj Stroke Score = -4

CVD non Hemorrhagic

Etiological Diagnosis :
Trombosis Cerebri

Diagnosis
Clinical Diagnosis :
Hemiparese dextra spastik + parese N.XII dextra
Topical Diagnosis :
Capsula interna hemispherium sinistra
Etiological Diagnosis :
Trombosis Cerebri

Management
IVFD

Ringer Laktat gtt xx/mnt

Diet rice low salt
Citicholoine injection, 2x250mg
Simvastatin 1x1
Neuorobion injection, 1x5000mg
Physiotherapy : IRR and gait training

PROGNOSIS
Quo ad Vitam
Quo ad Functionam

: dubia ad bonam
: dubia ad bonam