IDENTIFICATION Name : Mr. A
Age : 50 years
Sex : Male
Address : Jl. Srijaya Lorong Bersama No 1056, Alang-alang Lebar
Religion : Moslem
Admission date : May 21st, 2012
ANAMNESIS
The patient was admitted to Neurology department of Moh Husein General Hospital because of the weakness on his right arm and lower limb which happened suddenly.
± 21 hours before admission to the hospital, while resting, suddenly he felt weakness on his right arm and lower limb without decrease of consciousness. At that time, he didn’t experience headache, nausea and vomit, stiffness or disturbance of sensibility on the right side. The weakness between his right arm and lower limb was similiar degree. The patient is right handed. He could express by speech, hand writing and geasture. The patient understood other people’s mind which was expressed by talking, writing and giving sign. When he talked, his mouth deviate and experience slurred speech. He had no complain about urination and defecation.
There are no previous history of headache in the morning, history of getting painless lession and self healing in the eksternal genital and his wife has no history of abortion in > 16 weeks. There's no history of hypertension and diabetes mellitus. This illness was the first time for him.
PHYSICAL EXAMINATION
PRESENT STATE
Internal State
Sense : compos mentis
(E4M6V5
) Nutrition : adequate
Pulse : 86 beats/min
Respiratory rate : 20 times/min
Blood pressure : 180/100 mmHg
Temperature : 37,20C
Specific Examination
1. Chest X-Ray : normal chest
2. Brain CT-Scan
Head CT scan without contrast, axial slice, slice thickness 3 mm and 7 mm with brain window is found:
- Slight hypodense lession with uncertainty border in left corona radiata
- Sulci, fissura of sylvii and gyrii in good condition
- Gray and white matter differentiation are clear
- No deviation on midline
- Infrateritorial: pons, cerebellum are in good condition
- Ventricles and cysternae system is not narrow, magna cysternae is prominent
- Air cell pneumatitation for right and left mastoid is good
- Occuli bulbi and left and right retroorbita area are good
Conclusion: Infarct ischemic in left radiate corona.
DIAGNOSIS
A. Clinical Diagnosis :
1. Right hemiparesis spastic type
2. Right VII nerve palsy centre type
3. Right XII nerve palsy centre type
B. Topical Diagnosis :
Left interne capsule hemisphere
C. Etiological Diagnosis :
Cerebral thrombosis
DD: 1. Cerebral hemorrhage
2. Cerebral emboli
3. Cerebral thrombosis
MANAGEMENT
Therapy:
- bed rest
- low salt semi solid diet
- IVFD RL gtt xxx/M
- citicholine 2x250 mg IV
- aspilet 1x80 mg tab
- Vitamine of B1,B6,B12 3x1 tab
PROGNOSIS
Quo ad vitam : bonam
Quo ad functionam : dubia ad bonam
CASE ANALYSIS
A. Topical diagnosis
1. Lession in left cerebral cortex hemisphere
Lession in left cerebral cortex hemisphere, the symtomps:
⁻ Motoric deficit (right hemiparesis)
⁻ Iritative symtomps (seizure on the right side)
⁻ Focal symtomps (The paralysis is not similiar )
⁻ Sensoric deficit on the paralysed side Right hemiparesis spastic type
The symtomps found in the patient
- No seizures on the paralysed side
- The paralysis of right arms and right lower limb are similiar
- No sensibility disorder on the right side body
So, the possibility of lession in left cerebral cortex hemisphere can be excluded.
2. Lession in left cerebral subcortex hemisphere
Lession in left cerebral subcortex hemisphere, the symtomps
⁻ Motoric deficit (hemiparese dextra)
⁻ Motoric aphasia Right hemiparesis spastic type
No pure motoric aphasia found in the patient
So, the possibility of lession in left cerebral subcortex cerebri hemisphere can be excluded.
3. Lession in left interne capsule hemisphere
Lession in left interne capsule hemisphere, the symtomps:
- Hemiparesis/hemiplegi typica
- Right VII nerve palsy centre type
- Right XII nerve palsy centre type
- The weakness in the paralysed side is similiar
The symtomps found in this patient.
So, the possibility of lession in left interne capsule hemisphere can be made.
B. Etiological Diagnosis
Siriraj Stroke Score:
SJ : (2,5 x level of consciousness) + ( 2 x Vomity) + ( 2 x Headache) + (0,1 x diastolic blood pressure) – (3 x atheroma marker) – 12 : (2,5 x 0 ) + ( 2 x 0) + (2 x 0) + (0,1 x 90) – (3 x 0) – 12 : 0 + 0 + 0 + 9 – 0 – 12 : - 3
Conclusion : Non cerebral haemorrhagic
Differential Diagnosis Etiology:
1. Cerebral haemmorhagic
2. Cerebral emboli
3. Cerebral thrombosis
The symtomps found in the patient:
- Without unconsciousness
- Happen in resting time
So, etiological diagnosis cerebral thrombosis can be made.
Conclusion:
Etiological Diagnosis: cerebral thrombosis
No comments:
Post a Comment