CASE REPORT

SENIOR CLINICAL CLERKSHIP

Period of August 02
nd
30
th
, 2010
HEMPLEGIA SINISTRA FLACCID +
PARESE N. VII SINISTRA SENTRAL + PARESE
N. XII SINISTRA SENTRAL
Atika Akbari, S. Ked !"!#"$!%!%&'
Fri(k) Ar*i+d, S.Ked !"!#"$!%&&,'
Ad-i./r 0 Dr. H. A. Ra123a+ T/)/, S4SK'
DEPARTMENT OF NE5ROLOG6
FAC5LT6 OF MEDICINE SRI7I8A6A 5NIVERSIT69 RSMH
PALEM:ANG
;!&!
NE5ROLOG6 MEDICAL RECORD
I. Ide+ti<i1ati/+

N!e " #r$ S
Age " %& 'ers
Se( " #)e
Address " *)$ +!n No$ 1%,, #rin, -n'usin
Re)igion " Is)!
Ad!ission dte " August 2
nd
, 2010
II. A+a3+e.i.
+he .tient /s d!itted to Neuro)og' /rd RS#H 0e1use of the /e2ness on )eft r!
nd )o/er )i!0 /hi1h h..ened sudden)'$
3 & d's 0efore d!itted to the hos.it), /hen the .tient /2e u., sudden)' he fe)t
/e2ness on his his )eft r! nd )o/er )i!0 /ithout un1ons1iousness$ At tht ti!e, he didn4t get
hed1he, nuse nd 5o!it, /ithout stiffness, nd /ithout distur0n1e of sensi0i)it' on the )eft
side$ +he /e2ness 0et/een )eft r! nd )o/er )i!0 /s fe)t s!e$ +he .tient 1n6t !o5e )eft
r! nd )o/er )i!0 /s fe)t s!e t ))$ +he .tient uses right hnd to /or2$ He 1ou)d e(.ress
his !ind 0' t)2ing, /riting nd gi5ing sign$ +he .tient understood other .eo.)e4s !ind /hi1h
/s e(.ressed 0' t)2ing, /riting nd gi5ing sign$ 7hen he t)2ing, his !outh de5ite to )eft, nd
.e)o$ He hd no 1o!.)ining 0out urintion nd defe1tion$ +hen, the .tient go to RS Kundur
nd hos.it)i8ed, he /s gi5en & !edi1ines 9the .tient forgot their n!es nd for!s: nd 1
in;e1tion !edi1ine 1iti1ho)in$ -e1use there is no i!.ro5e!ent, the .tient send to RS#H
P)e!0ng$
+here re no histor' of getting hed1he often)', histor' of getting )esion in the e2stern)
genit) /hi1h /s .in)ess nd se)f he)ing, s2in )esion /hi1h /s .in)ess, se)f he)ing, nd his
/ife no histor' of 0ortion in < 1% /ee2s$ +here6s no histor' di0etes !e))itus$
+his i))ness /s the first ti!e for hi!$
III. P2).i1a* E=a3i+ati/+
PRESENT STATE
I+ter+a* State
Sense " 1o!.os !entis
Nutrition " suffi1ient
Pu)se " 100 0ets=!in
Res.irtor' rte " 22 ti!es=!in
-)ood .ressure " 1>0=100 !!Hg
+e!.erture " 3>,?
0
C

CRANIAL NER@ES
A1i)is ner5e
#otori1
Aro/ning
E'es 1)osing
Bigg)ing
Nso)0i) fo)d
A1i) sh.e
Right
si!etri1
Nor!)
Nor!)
Nor!)
Left
si!etri1
Nor!)
ng)e .r)'sis
f)t
2
rest
S.e2ing=/hist)ing
Sensor'
2=3 nterior tounge
No disorder
No disorder
No disorder
No disorder
No disorder
No disorder
H'.og)ossus Ner5e
+ounge Sho/ing
As1i1u)tion
P.i) Athro.h'
C'srthri
#O+ORIC
AR#
#otion
Po/er
+ones
Ph'sio)ogi1) Ref)e(
-i1e.s
+ri1e.s
Rdius
D)n
Ptho)ogi1) Ref)e(
Hoff!n +ro!ner
Leri
#e'er
+rofi2
LEB
#otion
Po/er
+ones
C)onus
+igh
Aoot
Ph'sio)ogi1) ref)e(
K P R
A P R
Ptho)ogi1) ref)e(
-0ins2'
Chddo12
O..enhei!
Bordon
S1heffer
Rosso)i!o
Right
No de5ition
no
no
'es
Right
Enough
,
Nor!)
Nor!)
Nor!)
Nor!)
Nor!)
None
None
None
None
Right
Enough
,
Nor!)
Negti5e
Negti5e
Nor!)
Nor!)

Negti5e
Negti5e
Negti5e
Negti5e
Negti5e
Negti5e
Negti5e
Left
de5ition
no
no
'es
Left
Less
0
Ce1rese
Ce1rese
Ce1rese
Ce1rese
Ce1rese
None
None
None
None
Left
Less
0
Ce1rese
Negti5e
Negti5e
Ce1rese
Ce1rese
Negti5e
Negti5e
Negti5e
Negti5e
Negti5e
Negti5e
Negti5e
Negti5e
3
#ende) -e1htere/
A0do!in) s2in ref)e(
D..er
#idd)e
Lo/er
+ro.i2
Negti5e
Negti5e
Negti5e
Negti5e
Negti5e
Negti5e
Negti5e
SENSORE
No 0nor!)it'$
@EBE+A+I@E ADNC+ION
#i1turition " no 0nor!)it'$
Cefe1tion " no 0nor!)it'$
#ENINBEAL SIBNS" Negti5e$
BAI+, -ALANCE, ANC COORCINA+ION" Cn4t 0e e(!ined
#O+ION A-NOR#AL" Negti5e$
LI#-IC ADNC+ION" Negti5e$
A-NOR#AL #O@E#EN+" No 0nor!)it'$
IV. LA:ORATOR6 FINDINGS
-LOOC 92 Agustus 2010:
H0 " 1&,2 g=d) 9 1& 1> :
Ht " && 9 &0 F &> :
Leu2osit " ,?00=!!
3
9 ,000 F 10$000 :
LEC " 10=!!
3
9 G 10 :
+ro!0osit " 21H$000 9 200$000 ,00$000 :
C1 " 0 = 2 = 2 = %H = 22 = ,
-ss " 11% !g=d)
Cho)estro) tot) " 2>& !g=d) 9 G 200 :
HCL " ,2 !g=d) 9 G ,, :
LCL " 20% !g=d) 9 G 130 :
+rig)iserid " 1,1 !g=d) 9 G 1,0 :
SBO+ " 33 I=) 9 G &0 :
SBP+ " 2% I=) 9 G &1 :
As! Drt " &,, !g=d) 9 3,, ?,1 :
Dreu! " 31 !g=d) 9 1, 3H :
Kretin " 1,3 !g=d) 9 0,H 1,3 :
Protein tot) " ?,& !g=d) 9 %,0 ?,> :
A)0u!in " &,? !g=d) 9 3,0 ,,0 :
B)o0u)in " 2,? !g=d)
&
N " 1&0 !!o)=) 9 13% 1,, :
K " 3,, !!o)=) 9 3,, ,,, :
C " 2,&, !!o)=) 9 2,02 2,%0 :
3 Agustus 2010
Protro!0in .)s! " 13,%& se1onds 912F1>:
AP++ " 2H,,0 se1onds 92,F3,:
Ai0rinogen " %0? !g=d)
eAi0rinogen " 3H0 !g=d)
CP+ " 13,H se1onds
CAP+ " 3>,> se1onds
INR " 0,>?
DRINE 9? Agustus 2010:
E.ithe) " 3 Protein " tr1e J
Leu1o1'te " 0F2 =HPA B)u1ose " F
Erito1'te " 0F1 =HPA
S')inder=1r'st) " F
Rongen +hor( " nor!) thor(
V. DIAGNOSIS
C)ini1) Cignosis "
He!.)egi sinistr f)2sid 3 .rese n$ @II sinistr sentr) 3 .rese n$ KII sinistr sentr)
+o.i1) Cignosis "
L1unr 1ere0r) infr1t 1.su) intern
Etio)ogi1) Cignosis "
+ro!0osis, sere0ri
VI. MANAGEMENT
#edi1ine "
FI@AC RL gtt ((=#
F 1iti1ho)ine 2(2,0 !g I@
F 1.to.ri) 2(2,!g t0
F si!5sttin 1(10 !g t0
F .r1et!o) 3(,00!g PRN
F s.i)et 1(>0 !g t0
F diet .orridge )o/ s)t
Pro C+ s1n hed
Aisioter.i"
F -ed .ositioning
F Infr Red Rdition )eft side e(tre!it'
F -o0th ther.'
VII. PROGNOSIS
Luo d 5it! " 0on!
Luo d fun1tion! " du0i d 0on!
,
CASE ANALESIS
T/4i1a* dia>+/.i.
1$ Lession in 1orte( he!isferiu! 1ere0ri
de(tr, the s'!.to!s"
+he s'!.to!s found in the .tient"
F #otori1 defi1it 9he!i.rese sinistr: F He!i.)egi sinistr f)11id
F Irittif s'!.to! 92e;ng .d sisi 2iri: F No Sei8ures on the .r)'sis side
F Ao1) s'!.to! 9+he .r)'sis is not
s!e :
F +he .r)'sis of )eft r!s nd )eft )o/er )i!0
re s!e
F Sensori1 defi1it on the .r)'sis side F No sensi0i)it' disorder on the )eft side 0od'
So, the .ossi0i)it' of )ession in 1orte( 1ere0ri he!isferiu! de(tr 1n 0e e(1)uded$
So$ the .ossi0i)it' of )ession in su01orte( 1ere0ri he!isferiu! de(tr 1n 0e e(1)uded$
3$ Lession in 1.su) intern he!isferiu!
de(tr, the s'!.to!s"
+he s'!.to!s found in the .tient"
F He!i.rese=he!i.)egi t'.i1 F He!i.)egi sinistr f)11id
F Prese n$@II sinistr 1entr) F Prese n$@II sinistr 1entr)
F Prese n$KII sinistr 1entr) F Prese n$KII sinistr 1entr)
F +he /e2ness in the .r)'sis side is
s!e
F +he /e2ness in the .r)'sis side is s!e
So, the .ossi0i)it'of )ession in 1.su) intern he!isferiu! de(tr 1n 0e !de$
+here re 5rious 1)ssifi1tion s'ste!s for 1ute is1he!i1 stro2e$ +he O(ford
Co!!unit' Stro2e Pro;e1t 1)ssifi1tion 9OCSP, )so 2no/n s the -!ford or O(ford
1)ssifi1tion: re)ies .ri!ri)' on the initi) s'!.to!sM 0sed on the e(tent of the s'!.to!s, the
stro2e e.isode is 1)ssified s tot) nterior 1ir1u)tion infr1t 9+ACI:, .rti) nterior 1ir1u)tion
infr1t 9PACI:, .osterior 1ir1u)tion infr1t 9POCI:, or )1unr infr1t 9LACI:$ +hese four entities
.redi1t the e(tent of the stro2e, the re of the 0rin ffe1ted, the under)'ing 1use, nd the
.rognosis$
A T/ta* A+teri/r Cir1?*ati/+ I+<ar1t 9TACI: is t'.e of 1ere0r) infr1tion ffe1ting
the entire nterior 1ir1u)tion su..)'ing one side of the 0rin$ T/ta* A+teri/r Cir1?*ati/+ Str/ke
S)+dr/3e 9TACS: refers to the s'!.to!s of .tient /ho 1)ini1))' ..ers to h5e suffered
fro! tot) nterior 1ir1u)tion infr1t, 0ut /ho hs not 'et hd n' dignosti1 i!ging 9e$g$ C+
S1n: to 1onfir! the dignosis$ It is dignosed /hen it 1uses )) 3 of the fo))o/ing s'!.to!s"
+he s'!.to!s found in the .tient"
Higher disfun1tion
o C's.hsi
o @isuos.ti) distur0n1es
o Ce1resed )e5e) of
1ons1iousness
No
No
No
No
2$ Lession in su01orte( he!isferiu! 1ere0ri
de(tr, the s'!.to!s"
+he s'!.to!s found in the .tient"
F #otori1 defi1it 9he!i.rese sinistr: F He!i.)egi sinistr f)11id
F #otori1 .hsi F No .ure !otori1 .hsi
%
Ho!on'!ous he!ino.i
#otor nd Sensor' Cefe1ts 9N2=3 of
f1e, r!, )eg:
No sensor' defe1ts
So, the .ossi0i)it' of tot) nterior 1ir1u)tion infr1t 9+ACI: 1n 0e e(1)uded$
Prti) Anterior Cir1u)tion Infr1t 9PACI: is t'.e of 1ere0r) infr1tion ffe1ting .rt of
the nterior 1ir1u)tion su..)'ing one side of the 0rin$ Prti) Anterior Cir1u)tion Stro2e
S'ndro!e 9PACS: refers to the s'!.to!s of .tient /ho 1)ini1))' ..ers to h5e suffered
fro! .rti) nterior 1ir1u)tion infr1t, 0ut /ho hs not 'et hd n' dignosti1 i!ging 9e$g$
C+ S1n: to 1onfir! the dignosis$ It is dignosed 0' n' one of the fo))o/ing"
+he s'!.to!s found in the .tient"
2 out of 3 fetures of
o Higher d'sfun1tion
C's.hsi
@isu)os.ti) distur0n1es
o Ho!on'!ous he!ino.i
o #otor nd Sensor' Cefe1ts 9<2=3 of
f1e, r!, )eg:
Higher d'sfun1tion )one
Prti) #otor or Sensor' Cefe1t
No
No
No
No sensor' defe1ts
No
No
So, the .ossi0i)it' of .rti) nterior 1ir1u)tion infr1t 9PACI: 1n 0e e(1)uded$
A P/.teri/r Cir1?*ati/+ I+<ar1t 9POCI: is t'.e of 1ere0r) infr1tion ffe1ting the
.osterior 1ir1u)tion su..)'ing one side of the 0rin$ P/.teri/r Cir1?*ati/+ Str/ke S)+dr/3e
9POCS: refers to the s'!.to!s of .tient /ho 1)ini1))' ..ers to h5e suffered fro!
.osterior 1ir1u)tion infr1t, 0ut /ho hs not 'et hd n' dignosti1 i!ging 9e$g$ C+ S1n: to
1onfir! the dignosis$ It 1n 1use the fo))o/ing s'!.to!s"
+he s'!.to!s found in the .tient"
Crni) ner5e .)s' ANC 1ontr)ter)
!otor=sensor' defe1t
-i)ter) !otor or sensor' defe1t
E'e !o5e!ent .ro0)e!s 9e$g$n'stg!us:
Cere0e))r d'sfun1tion
Iso)ted ho!on'!ous he!ino.i
It hs )so 0een sso1ited /ith defness$
*ust 1ontr)ter) !otor defe1t
No
No
No
No
No
So, the .ossi0i)it' of .osterior nterior 1ir1u)tion infr1t 9POCI: 1n 0e e(1)uded$
La1?+ar .tr/ke or *a1?+ar i+<ar1t 9LACI: is t'.e of stro2e tht resu)ts fro! o11)usion
of one of the .enetrting rteries tht .ro5ides 0)ood to the 0rin6s dee. stru1tures$ Ptients /ho
.resent /ith s'!.to!s of )1unr stro2e, 0ut /ho h5e not 'et hd dignosti1 i!ging
.erfor!ed !' 0e des1ri0ed s suffering fro! La1?+ar Str/ke S)+dr/3e 9LACS:$
La1?+ar 1erebra* i+<ar1t C*i+i1a* <i+di+>. i+ 4atie+t@. 3edi1a* re1/rd
No 5isu) defi1it No 5isu) defi1it
?
No no0)e disorders No no0)e disorders
No 0rin ste! fun1tion disorders No 0rin ste! fun1tion disorders
He!i.)egi t'.i1
C'sthri nd d's.hgi
No
Cn6t e(!ined 'et$
#(i!) defi1it on one 0rn1h s!)) rter'
C)ini1) fetures"
Pure !otor stro2e 9P#S:
F he!i.resis or he!i.)egi tht
t'.i1))' ffe1ts the f1e, r!, or )eg
of one side$
F C'srthri, d's.hgi, nd trnsient
sensor' s'!.to!s$
Pure sensor' stro2e 9PSS:
#r2ed 0' .ersistent or trnsient nu!0ness,
ting)ing, .in, 0urning, or nother
un.)esnt senstion on one side of
the 0od'$
At2si2 he!i.reses
It dis.)'s 1o!0intion of 1ere0e))r nd
!otor s'!.to!s, in1)uding /e2ness
nd 1)u!siness, on the i.si)ter) side
of the 0od'$ It usu))' ffe1ts the )eg
!ore thn it does the r!M hen1e, it is
2no/n )so s ho!o)ter) t(i nd
1rur) .resis$ +he onset of
s'!.to!s is often o5er hours or
d's$
So, the .ossi0i)it' of )1unr infr1t 9LACI: 1n 0e !de, /ith )o1tion t 4/.teri/r *i3b of
the i+ter+a* 1a4.?*e$
Con1)usion"
+o.i1) dignosis " LACI 1.su) intern he!isferiu! de(tr
Eti/*/>i1a* dia>+/.i.
Sirir; Stro2e S1ore"
S* " 92,, ( )e5e) of 1ons1iousness: 3 9 2 ( @o!it': 3 9 2 ( Hed1he: 3 90,1 ( disto)i1
0)ood .ressure: 93 ( thero! !r2er: 12
" 92,, ( 0 : 3 9 2 ( 0: 3 92 ( 0: 3 90,1 ( 100: 93 ( 1: 12
" 0 3 0 3 0 3 10 3 12
" F ,
Con1)usion " Non he!orrgi1 1ere0ri
Di<<ere+tia* Dia>+/.i. Eti/*/>)0
1. Hemmoragic cerebri
2. Emboli cerebri
3. Trombosis cerebri
1$ He!!orgi1 1ere0ri, the s'!.to!s" Pd .enderit dite!u2n ge;)"
F Dn1on1iusness < 30 !inutes
F He!i.rese 2ontr)ter) sentr)
No
No
>
So, etio)og' he!!orgi1 1ere0ri 1n 0e e()uded$
E!0o)i 1ere0ri, the s'!.to!s" +he s'!.to!s found in the .tient"
F Dn1ons1iousness G 30 !inutes No
F Arteri) fi0ri)si No
So, etio)og' e!0o)i 1ere0ri 1n 0e e()uded$
+ro!0osis 1ere0ri, the s'!.to!s" +he s'!.to!s found in the .tient"
F No un1ons1iousness F No un1ons1iousness
So, etio)og' tro!0osis 1ere0ri 1n 0e !de$
C/+1*?.i/+0
Eti/*/>i1a* Dia>+/.i.0 Tr/3b/.i. 1erebri
H