Plenary Discussion

7th A

Group 7th A
Rizki Meizikri
Rizka Ananda Putri Fajriah Rosandali

Ismail Fajri
Ayu Annisa VivIt Erdina

Fajar Normansyah
Siti Ubaidah

SCENARIO 6: DIFFICULITY IN WALKING

Tn. Andi, 34 years old was taken to the health center because suddenly he could not walk since two days ago. Along with these legs weakness, there was also uncontrollable urination. No history of previous trauma. After review, the doctors found signs UMN type of paralysis in both legs, and found also hypoesthesia at starting from the 10th thoracic dermatome to downwards. After giving an explanation to the family, Tn. Andi referred to the hospital Dr.M.Djamil for further examination. After the X-ray photo thoracic CV, Tn. Andi was admitted at the neurological ward for lumbar puncture examination and myelography. Right next to Mr. Andi, lay a male patient, 14 years of age because he has difficulty to stand up after sitting or from the bed which couldn't be done alone, but still could walk. This patient was the only boy and his other female siblings are healthy. Earlier when he was two years old, he had normal development. After age two years, he started showing symptoms to fall easily. Initially could stand quickly, but soon had difficulity.

To stand, hands should be on both feet and both hands move slowly to the thigh, then he could be standing. Along with the development of the disease seen leg muscles began to shrink, but both calf is noticeably enlarged. In contrast to Tn. Andi, though difficult to running, this patient can urinate and defecate normally and his sensory has no interference. Mother of the child patient looks very sad because his illness was growing worst day by day, as she was pessimistic. How do you explain what happened to Tn.Andi and patient next to him?

Clarifying unfamiliar terms

Myelography:
a type of radiographic examination that uses a contrast medium to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors. The procedure often involves injection of contrast medium into the cervical or lumbar spine. reduced sense of touch or sensation, or a partial loss of sensitivity to sensory stimuli.
above the Pons.

Hypoesthesia:

UMN: Upper Motor Neuron, located in central nervous system(CNS)

Identifying Problems
1. Why Mr. Andi suddenly could not walk since 2 days ago?
2.

3.
4.

5.
6.

Why leg of Mr. Andi weakened and urinate without realizing whereas before there was no history of trauma? What is the signs of UMN type of paralysis? What is the interpretation of UMN paralysis in both legs and hypoesthesia in dermatome 10th thoracal downward? What is the purpose of lumbar puncture and myelography and what is the indications? What possible diagnosed Mr. Andi and what is the relationship between his gender and age to his symptoms?

Identifying Problems
7.
8. 9. 10. 11. 12.

Why patient B can not stand up and sit down alone by himself, but still able to walk? Why only him who experienced it, while his sister is healthy? Why after the age of 2 years, he showed symptoms of easy falling? Why are urinary incontinence disorders and sensory abnormality absent despite he was also paralyzed? Why his leg muscles shrink and his calf muscles enlarged? What is the prognosis of the child illness?

Identifying Problems
13. What type of examination can be performed on the

child? 14. What treatment should do to both patient? 15. What is the screening ( early detection) that can be performed on the second patient?

Why Mr. Andi suddenly lose his ability of walking two days ago?
There may be abnormalities in the central nervous system

(CNS), peripheral nervous system, or in the muscle ,bones, joints. If the disturbance in the nervous system , can be on the motor nerves, sensory or both or in the pyramidal pathway or extrapyramidal Could also exist in the form of psychomotor disturbance in vestibular disorder.

realizing whereas before there was no history of trauma

Micturition disorders can be due to :
lesion in the spinal cord, because the micturition reflex center

located in the centre of the sacrum (conus,cauda equine) . Can be accompanied by disorders of defecation and sexual function Lesion in the medulla spinalis can cause 3 things
Motor disturbances due to lesions in total, or only in the spinal cord anterior

horn. Back pain symptoms are sudden. Disturbance below the lesion, causing total paralysis Sensory loss due to damage to the posterior horn.

What is of the signsof of UMN type of paralysis? Signs paralysis UMN type
a. Decrease in tendon reflexes b. Positive pathological reflexes -> Babinski, HoffmannTrauner c. Hypertonus muscle d. Not found atrophy in muscles paralyzed e. Clonus positive muscle -> relax, then suddenly contracted f. Hyperreflexia g. Loss of control volunteer / conscious

What is the interpretation of UMN paralysis in both legs and hypoesthesia in dermatome 10th thoracal downward? UMN paralysis -> lesions in the spinal cord (CNS) hypoesthesia as high as 10th torachal to bottom: contained paralysis in limbs (lesion UMN). If hypoesthesia high as lumbo-sacral, then paralysis of the limbs of type LMN.

What is the purpose lumbar puncture and myelography examinations and what indications?
Objectives and indications of inspection: Examined a. Measure intracranial pressure (cerebro spinal fluid). Normal values: 50180 mmH2O. increases when there is intracranial masses such as tumors, bleeding, or the presence of edema; decreased when the spinal canal obstruction above the puncture lumbar puncture. b. Color. Normally clear not colored. Abnormal circumstances could xantocrom colored (yellow), usually indicates the presence of blood that had long or an increase in protein content is very high in the CNS; Cloudy showed the presence of infection (increased white blood cells, proteins, microorganisms) c. Cell count. 0 to 5 leukocyte /mm3. Increased [no active disease such as meningitis, acute infection, abscesses, tumors, infarcts, multiple sclerosis.

- Myelografi: to show whether there are abnormalities in the spinal cord, Indications: a partial block on lumbar puncture, such as a tumor intramedular, intradural tumors, and extradural, myelitis, etc.. - CV torachal: to determine whether there are abnormalities in the spine can cause spinal cord clamping, or whether there is an infection

What possible diagnosed Mr. Andi and what is the relationship between his gender and age to his symptoms?
Diseases that may be suffered: multiple sclerosis (young adults, comparison of men and women 1.5 to 1). Multiple sclerosis is a risk factor for infection myelopathy and myelitis. Multiple sclerosis occurs because of the presence of plaques in the white matter of chronic inflammation that occurs there. Course of their illness: multiple sclerosis - myelopathy - specify the cause. If the cause of the infection -> myelitis. If the cause is unknown -> autoimmune -> transverse myelitis. Another differential diagnosis was radicular syndrome, with a chief complaint of back pain. Because the results are not known, then disease of Mr.Andi certainly could not be determined.

Why only him who experienced it, while his sister is healthy?
Because the disease is associated with X-linked (classic type),

only men who become patients, whereas women are carrier, and although the women affected, the progression is not as severe in men.

Why after the age of 2 years he showed symptoms of easy falling?

Because it runs a chronic progressive disease. At birth up to 2

years, most of the normal child. In the following years new symptoms such as muscle weakness, like falling, and difficulty walking because at that age the child begins to learn to walk. In the next age, the child can not walk. Progression of the disease depends on the individual. The process has begun dystrophy since birth, but symptoms seen when the child learns to walk.

Why are urinary incontinence disorders and sensory abnormality absent despite he was also paralyzed?
Due to interference only occurs in the pelvic floor muscles, and

nervous system remains normal.

Why shrink leg muscles and calf muscles bigger?

Because muscular dystrophy causes the muscles can not contract

normally -> muscles not used in a long time -> atrophy. But the calf was found enlargement called pseudohipertrofi, where enlargement is due to the accumulation of fatty infiltrate between muscle fibers, whereas the fixed muscle atrophy.

What is the prognosis of the child illness?

The poor prognosis of childhood diseases, because most patients

with this disease will die in their teens, around the age of 20 years. Because of the weakness of the respiratory muscles, causing difficulty breathing child. This disease can affect the smooth muscle in some patients, and causes the heart muscle gradually also affected. Muscular dystrophy can also cause kifoskoliosis as compensation body to withstand the body weight, so that the organs in the thoracic disrupted.

What checks can be performed on the child?

Laboratory tests that can be done is genetic testing, see the

deletions / duplications of genes XP21. However, genetic analysis is difficult to do. Could also do an ultrasound to look at the structure of muscle and connective tissue. EMG to see changes in the electrical activity of muscles. Physical examination found Gower sign and pseudohipertrofi.

How do doctors treatment of the second patient and Tn. Andi?

Procedures that can be done in the form of physiotherapy, to

slow the progression of atrophy due to muscle contractures. Physiotherapy can be done for example by immersing the limb in warm water so that the joints remain intact and do not experience muscle contractures. Could be given drugs such as prednisone to prevent contractures. Or treatment of a tendon release surgery iperatif, with the aim of freeing contractures.

Learning Objective
Students are able to explain the definition, classification,

epidemiology, etiology, risk factors, clinical manifestations, diagnosis, investigation, management of a comprehensive, complications, prognosis, and referral indications of disease: 1. Spinal cord lesions 2. neurogenic bladder 3. Muscular dystrophy.