Case Repor Neurologi

Case ReportHerniated Disc

Senida Ayu Rahmadika030.09.230

NeurologyRSAL dr.Mintohardjo

Patient Id

• MR No : 14.60• Name : Ny. H • Gender : Female• Age : 48 y.o• Address : Jl. KPBB

II RT 017/007 Cengkareng

• Religion : Moslem

• Marital status: Married• Occupation : Housewive• Educational : High

School• Date of hospital

admission:31 December 2015

• Room : P. Numfoor

• Prolonged pain her low back for the past 2 years before admission to hospitalChief

complaint

Also currently complains of:

Pain in her right groinContinous headacheUncomfortable sensation in her stomachWeakness in her extremity

History of Present illness• Prolonged pain her low back for the past 2 years

-She felt pain in her lower back to the right groin worsened after her upper arm broken two months ago

-Numbness in her left leg and foot-She cant move her right leg because of the pain-No complaint of Loss of bladder or bowel control

• History: – Had miomektomy in 2012– Had mastectomy on her left breast in 2013.– After the surgery, she recieved Chemotherapy 3 times and stop. Patient didnt

want to continue treatment– Two months before getting into the hospital, she fell and broke her upper arms.

She went into alternative therapy but patient still couldnt move her arm– So she went into the doctor and been dignosed as malunion

Past Medical History:• Hypertension (-), Diabetes Mellitus (-), Asthma

(+), Allergies (-),Upper respiratory infection (-)

Family Medical History:Hypertension (-), DM (-), Asthma (-), Allergies

(-)Upper respiratory infection (-)

Personal life History:No tobacco, drug, or alcohol use

Physical Exam

Compos MentisModerate painGCS :15Vital signs

BP : 160/100 mmHgPulse : 84x/minRR : 18x/minTemp : 36,9 C

• Status Generalis: Normal

• Neurological examination

Meningeal sign

-

Head normal

Neck normal

Aphasia/disartria

-

Cranial nerve ResultN.I Not checkedN.II Not checkedN.III Opening of eyelids: symmetric, good eye

movement, pupil isocoria, direct light reflex +/+, indirect rightreflex +/+, nistagmus (-)

N.IV Eye movement: good, diplopia (-)N.V Mouth opening;good, biting;good, cornea reflex

(+)N.VI Eye movement: good, diplopia (-)N.VII Fascial: Asymmetric weaknes on the left side, eye

opening +/+N.VIII Auditory:not checked. Balance: finger to nose +/-,

finger to finger normal, dysdiadokinesia: normal. N.IX Not checkedN.X Arcus pharynx symmetricN.XI normalN.XII normal

Neurological Examination: Upper extremity

Motoric Right Left

Muscle strength 5555 Not checked

Reflex

Biceps ++

Triceps +

Pathological Reflex

Hoffman-Tromer - -

Sensoric

Pin-Prick Test - -

Neurological Examination: Lower extremity

Motoric Right Left

Muscle strength Not checked 3333

Reflex

Patella + ++Achilles + ++

Pathological Reflex

Babinsky - -

Chadock - -

Sensoric

Pin-Prick Test - +

LabResult Normal

Leukocyte 18.100 /uL 5000-10.000

Eritrocyte 2.060.000 /dL 4.000.000-5.4000.000

Hb 6.7 g/dL 12 -14

Ht 23 % 37-42

LED 73 mm/hour <20

Trigliserid 319 mg/dL 60 - 170

Total Choresterol 248 mg/dL <200

AST 128 U/I <34

Albumin 3.1 g/dL 3.5 - 5.2

Uric Acid 16.1 g/dL 2.6 - 6

Kalium 2.40 mmol/L 3.4 - 4.3

Ax1 K: Low back pain Lesion n.VII central sinistra

E: Hernia Nucleus PulposusT: Lumbal

Ax2 : Tummor Mammae sinistra

Ax3 : Dyslipidemia

Ax4 : Hipokalemi

Ax5 : Anemia

Ax6 : Hiper uricemia

Diagnosis

Treatment

• Ketorolac • Gabapentin • Amitriptilin • Diazepam • Simvastatin • Gemfibrosil • Allopurinol • Omeprazole • Transfusion PRC

3 x 1amp3 x 300mg2 x 12,5mg3 x 1 tab1 x 10mg2 x 1 tab3 x 100mg1 x 1 vial300cc

Thankyou