CASE REPORT

TRIGEMINAL NEURALGIA
Rizka Dana Prastiwi
G4A014099
PEMBIMBING
dr. Untung Gunarto, Sp.S

IDENTITY
Name
Age
Gender
Adress
Job
Religion

:
:
:
:
:

Mrs. K
60 years old
femalae
Margasana Jatilawang RT 04/02
housewife
: Islam

SUBYEKTIF
MAIN COMLAINT

Pain on right cheek

RIWAYAT PENYAKIT SEKARANGe
Patient came to Policlinic RSMS withpain on right cheek
since 1 year ago. The pain feels everyday, suddenly,
uncertain. The character of pain is sharp like to be
stabbed, hot duration about 5 minute and self
recovery. The pain increase when fatique and when be
touched, the pain better when eat drugns from doctor.
Other complaint is back neck feels rigid, right hand
usually hipestesi, and weary body. Pasien routine
control to poliklinik Neuro since 6 month ago.

KUANTITY

she fells pain evryday suddenly, duration about 5 minute

KUALITY
The pain is shap like to be stabbed, hot, verry distrub
activity VAS 8
OTHER COMLAINT
back neck rigis, right hand hipestesi, and weary body
BETTER FACTOR
eat drugs from doctor
INCREASE FACTOR
Fatique, when be touched

HISTORY OF ILLNESS

the same symptom since 1 year

hipertension +
tooth extraction +
FAMILY HISTORY OF ILNESS
Same symptom : Diabetes Melitus : Hipertensi
:+

SOCIAL ECONOMY

patient is a housewife
FAMILY RELATIONSHIP
Good
NUTRITION STATUS
good
PSYCHOLOGY
good
SPIRITUALITY
moslem

OBJEKTIF
KU/Kes: good/ GCS E4M6V5
vital sign: BP: 140/90 HR:
84
weight: 85 kgheight : 157 cm
St. generalis :
eye

RR: 20 T: 36,1

: CA -/- SI-/- RC +/+ pupil isokor

neck : kaku kuduk (-)
Pulmo
: SD vesikuler +/+ rh -/- wh -/cor
: S1>S2 reguler
Abdomen : supel, BU (+)
Ekstremitas : warm +/+

st.neurologis:
N. cranialis: normal
sensibilitas: normal

Motorik
Movement

Superior
free/free

Inferior
free/free

Motoric power

5555/5555

5555/5555

Trof

Eutrof/eutrof

Eutrof/eutrof

Tonus

Normo/normo

Normo/normo

RF

Normo/normo

Normo/normo

RP

-/-

-/-

klonus

-/-

-/-

ASSESMENT
DK: facial pain (neuralgia)
TTH
Myalgia
Hipertensi

grade 1

DT: n. trigeminal
DE: neuralgia trigeminal

dd: post herpetik neuralgia

PLANNING
Therapy:

PO carbamazepin 2x200mg
PO trmadol 50 mg k/p
PO codein 20mg k/p
PO vitamin B12 1x50 mg
Monitoring:
Monitoring symtom and effectivity of therapy
Patients obedient of therapy
Adverse event
Planning of diagnostic: MRI

EDUKASI
Edukasi penyakit neuralgia trigeminal
Edukasi pilihan terapi
Edukasi rutin kontrol ke poli saraf
PROGNOSIS
Ad vitam : ad bonam
Ad fungsionam : dubia ad bonam
Ad sanationam : dubia ad bonam

THANK YOU