Upload
senida-ayu-rahmadika
View
13
Download
1
Embed Size (px)
DESCRIPTION
neuro
Citation preview
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