Case Bersama - TTH Edit

8/13/2019 Case Bersama - TTH Edit

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Presented by :

NATASHA ASTAR

Pembimbing:

Prof. Dr. H. Basjiruddin A, Sp. S (K)



A 56 years old male presented with right upperand lower limb weakness since 4 days beforeadmitted to hospital,

•Right upper and lower limb

weakness

Chief Complaint



•

Right upper and lower limb weakness since 4 daysbefore admitted to Dr M Djamil Hospital. Earlier

patient were brought to a general practitioner and

then were admitted to Sijunjung Hospital for 2

days and then were refered here from SijunjungHospital. Weakness are seen suddenly during

activity (lifting farming items), and fall. Conscious

after attack. The upper and lower limb weakness

are equal. Now patient are unable to lift anything

and have to be hold by family to walk. He also

have difficulty in eating and drinking.

Current Illness History



This complain are accompanied with wrymouth and patient cannot speak. Patientcannot understand conversation and cannotsay any words.

No complain of headache, vomiting,decreased consciousness, and seizures.

No complain in sensing, miction and

defecation



• Known hypertensive since 3 years ago. No regular

checkup to doctor.•No previous history of stroke.

•No history of diabetes.

Past Illness History

•No family history of hypertension, diabetes, heart

disease and stroke.

Family History of Illness

• Patient is a farmer, smoke 12 stick of cigarette a

day since 30 years ago.

Socioeconomic Background



•General Appearance: Moderately Ill

•Level of Consciousness: compos mentiscooperative

•Pulse : 72 x/menit

•Respiratory Rate : 20 x/menit

•Blood Pressure : 180/120 mmHg

•Temperature : 36,7oC

General



GCS 15 : E4 M6 Aphasia



•Neck stiffness: (-) Brudzinsky II : (-)

•Brudzinsky I : (-) Kernig Sign : (-)

Meningeal SIgn

•Vomiting (-)

•Progressive headache (-)

Intracranial Pressure Examination



N. I : Difficult to evaluate N. II : Difficult to evaluate

N. III, IV, VI : Light reflex +/+

Doll eye movement N. V : difficult to evaluate

N. VII : Right Nasolabial plica flatter

than the left side, EyelashesReflex +/+

N VIII : difficult to evaluate



N IX : Vomitting Reflex +, capableto swallow

N X : Pharinx arch symmetric, Uvulaon the midline

N XI : difficult to evaluate

N XII difficult to evaluate



Motor Function Test Upper Limb Right

Left Movement Limited

active Strength 0/0/0

5/5/5 Tonus eutonus

eutonus Trophy eutrophy

eutrophy Fall Test Right side

lateralisation



Lower Limb Right Left

Movement Limited active Strength 0/0/0 5/5/5

Tonus eutonus eutonus

Trophy eutrophy eutrophy Fall test Right side lateralisation



Sensibility Test Pain Sensibility +, Tactil Sensibility +.



•

Mixturition : neurogenic bladder (-)•Defecation : normal

• Sweat secretion : normal

Autonomous Nervous System



Reflex Right Left

Biceps +++ ++

Triceps +++ ++APR +++ ++

KPR +++ ++



Hemoglobin : 14.7gr/dl Leukocyte : 10,500/mm3 Hematocryte : 42% Thrombocyte : 140 000/mm3 Sodium : 148mmol/L Potassium : 3.5mmol/L Chloride : 104mmol/L Random Blood Glucose : 125gr/dl Urea : 60mg/dl Creatinine : 1.4mg/dl



EKG : Atrial Fibrilation Normoventricular

response



Clinical Diagnosis Right Hemiparesis+RightNVII and NXII Paresiscentral type +Globalaphasia

Topic Diagnosis Right brain hemisphere,

Subcortical

Etiology Diagnosis Cerebral Thromboemboli

Secondary Diagnosis Emergency Hypertension,Atrial Fibrillation Normoventricular Response



•Right Hemiparesis+Right NVII and NXII Paresis

central type +Global aphasia

Clinical Diagnosis

•Right brain hemisphere, Subcortical

Topic Diagnosis

•Cardiooemboli

Etiology

•Emergency Hypertension, Atrial Fibrillation

•Normoventricular Response

Secondary Diagnosis



•Head elevation 30degree

•Oxygen 2L/minute

•IVFD RL 12hour/kolf

•

Catheter (fluid balance)•Diet Soft Food, Low Sodium II

Supportive



•Piracetam 4x3gr (IV)

•Bisoporolol 1x2.5mg (Oral)

•Aspilet 2x 80mg

•Herbesser Drip 50mg in 50cc Ringer

lactate via syringe pump 50cc/hour

Medicinal Therapy



Dietary control Physical Therapy

Family education and prevention onhypertension and stroke

Medicinal Therapy



A 26 years old male visited NeurologyAmbulatory Service with pain in the head anddiagnosed Frequent episodic tension typeheadache associated with pericarnial

tenderness.

Diagnosed made by anamnesis and physical

examination that associated with AmericanHeadache Society diagnostic criteria.



The exact cause or causes of tension

headache are unknown.

Experts used to think that the pain of tensionheadache stemmed from muscle contractionin the face, neck and scalp, perhaps as aresult of heightened emotions, tension orstress.

But research suggests that there doesn'tappear to be a significant increase in muscletension in people diagnosed with tensionheadache.



The most common theories support

interference or "mixed signals" involvingnerve pathways to the brain, which isdemonstrated by a heightened sensitivity topain in people who have tension headaches.

Increased muscle tenderness, a commonsymptom of tension headache, may be theresult of overactive pain receptors.



It's likely other factors also contribute to the

development of tension headaches. Potential

triggers may include

•stress, depression and anxiety, poor posture.

•working in awkward positions or holding one position

for a long time, and

• jaw clenching

Some people with tension headaches don't

seek medical attention and try to treat the

pain on their own. The problem with that isthat repeated use of over-the-counter (OTC)

pain relievers can actually cause overuse

headaches.



A variety of medications, both OTC and

prescription, are available to stop orreduce the pain of an existing headache

attack, including pain reliever and

combination medications. Also there arepreventive medications include tricyclic

antidepressants, selective serotonin

reuptake inhibitors (SSRIs), andanticonvulsants and muscle relaxants.



For this patient

•we choose combination aspirin and caffeine to relief

the pain, and also give muscle relaxants based on

the theory.

•manage his stress

•

According to his behavior and job, he has to perfecthis posture. Good posture can help keep your

muscles from tensing up.

•Massage can help reduce stress and relieve tension.

It's especially effective for relieving tight, tendermuscles in the back of your head, neck and

shoulders.

Case Bersama - TTH Edit

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