CLINICAL CONFRENCE

NEUROLOGY DIVISION
(New Case )
JUNE 25 th , 2021

dr. Sukma Susanti / Presenter

dr. Cut Wirdatusa‘adah / Madya Divisi
dr. Amelia / Senior Divisi
 PATIENT IDENTITY
FR, 17 Year 10 month ( male)
MR Number 938982
Date of Birth August 22th, 2003
Admission Date June 23nd, 2021

MEDICAL DIAGNOSIS
Neurology Division : Paraplegia Inferior et causa Suspect Lower Motor
Neuron Lession
PATIENT PICTURE
 HISTORY TAKING
Chief Complaint
weakness in the both legs
History of Present Illness
A 17-year-old boy was admitted to the hospital with complaints of weakness in the lower limbs that has been
experienced since 1 month before entering the hospital
There is swelling and pain in the right leg experienced since 1 month before admission to the hospital. Worse since 1
week before admission to the hospital.
There is an enlarged stomach experienced since 1 week before admission to the hospital.
No fever, no seizure
No cough, no shortness of breath
No vomiting
Children want to eat and drink
Defecation: not yet 2 days
Urination: via a catheter
 HISTORY TAKING
History of Past Illness
There was history of pain in the right waist radiating to the legs accompanied by the
appearance of weakness in the right leg experienced 6 months before admission to the
hospital. Then swelling on the right leg up to the thigh.
There was history of falling in a sitting position experienced 1 month before admission to
the hospital and after that the patient was unable to move both legs.
History of being treated at Bone Hospital for 10 days
History of being treated at Primaya Hospital for 2 days and receiving ceftriaxone therapy (3
days), paracetamol, 3 units of PRC transfusion, 100 cc albumin transfusion
No history of seizures.
No history of frequent fever.

Vital Sign
GCS 15 E4 M6 V5
Blood Pressure : 110 / 70 mmhg
Heart Rate : 90 bpm
Temperature : 36,5 °C
Respiration Rate : 24 times/min
Pain scale : 3 NRS
SpO2 : 99 %
PHYSICAL EXAMINATION
Antropomethry
Body weight : 49 kg
Length : 160 cm
Head Circumference : 53,3 cm (49,5 cm – 52,5 cm )
Weight for Length : 18/23 x 100% = 78 %
Weight for Age : 18/28 x 100% = 64,2 %9
Length for Age : 122/133 x 100 % = 91,7 %
Head Circumference : 53,3 cm
( Normocephal)
N = 53-58
BB/TB = 49/47 x 100% = 104 %

TB/U = 165/175 x 100 % = 94,2 %

BB/U = 49/64 x 100% = 76,5 %

 PHYSICAL EXAMINATION
History of Vaccine
Vaccine 1 2 3 4 Mark
Hep B √ √ √ √
BCG √ - - -
DPT √ √ √
POLIO √ √ √ √
MR / CAMPAK √ √ - -
OTHER - - - -

History of Growth and Development

Observe the hand : not remember One syllables : not remember
Grabbing object : not remember Pointing the object : not remember
Prone position by self : not remember First tooth : not remember
 •PHYSICAL EXAMINATION
Neurological status:
 Nerve I: there was normal
 Nerve II: positive light reflex
Round and isochoric pupils, diameter of 2.5mm/2.5mm
 Nerve III, IV, VI: movement of the eyeball in all directions normally
 Nerve V: positive corneal reflex
 Nerve VII: there was no fascial nerve parese
 Nerve VIII: normal hearing. Balance is difficult to evaluate
 Nerve IX, X, X: normal swallow reflex
 Nerve XII: there was no tongue deviation
 •PHYSICAL EXAMINATION
 Motorik: strength: 5/5, 0/0
Tonus: normal/normal, decrease / decrease
• Physiological reflexes : upper extremity normal/normal, lower
extremity difficult to assess
 Pathological reflexes : Babinski negatif
 Sensibility: there was normal
 signs of meningeal excitability: difficult to assess
 PHYSICAL EXAMINATION
No pale, no jaundice, no stomatitis Abdomen
no lymphadenopathy No distension
Normal peristaltic sound
Chest and pulmo Hepar and spleen difficult to evaluate
Vesicular breath sounds.
There were no Ronkhi and wheezing.

Cardiovascular
I / II heart sound, Regular rhythm
no murmur
 LABORATORY FINDING
Laboratory June 23nd 2021 Normal Value

Hb 10.5 12.0 – 16.0 gr/dL

WBC 19.300 4.0 – 10.0 x 103/μL

PLT 420.000 150 - 400 /mm3

MCV 82 80 -100 μm3

MCH 27 27 - 32 Pg

MCHC 33 31.5 – 35.0 gr/dl

 LABORATORY FINDING
Laboratory June 23nd 2021 Normal Value

GDS 84 140

Ureum 33 10 - 50 mg/dl
Creatinine 0.47 <1.3 mg/dl
SGOT 249 < 38 u/l
SGPT 167 < 41 u/l

Albumin 3.1 3.5 – 5.0 mg/dl

Natrium 129 136-145

Kalium 3.5 3.5-5.1

chlorida 94 97-111
 LABORATORY FINDING
Peripheral blood analysis RSWS (23/6/2021)
• Erytrocytes : Normochromic normocytic, anisocytosis,ovalocytes (+), inclusion
bodies (-),normoblast (-)
• Leukocytes : Increased number, PMN>Lymphocytes,toxic granulation (+),
vacuolization (+), cellsyoung (-)
• Platelets : Adequate number, normal morphology

Impression/Suggestion : Normochromic normocytic anemia suspected cause of

infection
 •RADIOLOGI FINDING
Chest x ray 03-06-2021
Impression :
There is no radiological abnormality on
the chest X-ray at this time

CT scan Lumbosacral 05-04-2021 (in

palopo medica hospital
impression :
No radiographic abnormalities were
seen in the lumbosacral vertebrae
 Assesment
- Paraparese inferior et causa suspected acute myelitis
transverse dd GBS
- Iron deficiency anemia differential diagnosis of anemia of
chronic disease
- Electrolyte imbalance
- Leukocytosis
- Hypoalbuminemia
- Reactive thrombocytosis
- Melena
 Planning
- KAEN 3B infusion / intravenous
- Correction of hypokalemia
Quick correction : 0.75 x BB = 0.75 x 18 = 13 meq
KCL 7.4% 13 cc in 5% dextrose 400 cc discharged in 8 hours
(speed 50cc/hour)
Continued infusion of Kaen 3B 20 drops/minute
- Check electrolytes / 24 hours after correction
- Correction of hyponatremia (130-123) x 0.6 + (2 x 18) = 40.2 meq
Correction of hyponatremia is adequate with infusion of Kaen 3B
20 drops/minute
 Planning
- Meropenem / intravenous
- VIP albumin / oral
- Watch for signs of neurological deficit
- Anemia tracking-
- Examination permit: MRI spine with Contrast, EMG and lumbar
puncture
- Watch for signs of infection
- Consular license for gastroenterohepatologist
THANK YOU