CASE REPORT

SENIOR CLINICAL CLERKSHIP

Period of August 19th September 22th , 2008

Name

JUL
: Bharmatisna
AN S. Ked

NIM

: 04033100018

Semester

: XII

Date

: September 26th, 2009

Advisor

: Dr. H. A. Rachman Toyo, SpS(K)

DEPARTMENT OF NEUROLOGY
FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY/ RSMH
PALEMBANG
2009

NEUROLOGY MEDICAL RECORD

Identification
Name
Age
Sex
Address
Religion
Admission date

: Mr I
: 36 years
: Male
: Lr Balai Pengobatan RT 05 RW 10 Banyuasin
: Islam
: August 13th, 2009

Anamnesis
The patient was admitted to Neurology ward RSMH because of the weakness at the left arm
and left leg which happened suddenly.
1 week before admitted to the hospital, the patient suddenly had weakness at his left arm dan
left leg when he was working, followed by losing consciousness. During the attack, he have headache,
nausea, vomitted and seizure. he experienced blurry eyes and the movement of his eyes also become
limitted. he felt that the weakness he had was the same between the arm and the leg. he still could
express her mind by talking, writing and giving sign. The patient understood other peoples mind which
was expressed by talking, writing and giving sign. When he was talking, his lips deviated to the left and
there is disarthria.
During the attack, he doesnt have a heart beat which was followed by shortness of breathing.
he never complained that he had headache at the backside of his head which occurred in the morning
and became less in the afternoon.
The patient experienced these complaints for the first time.

PHYSICAL EXAMINATION
PRESENT STATE
Internal State
Sense
Nutrition
Pulse
Respiratory rate
Blood pressure

: compos mentis
: sufficient
: 90 beats/min
: 20 times/min
: 170/90 mmHg

Lungs
Liver
Spleen
Extremities
Genital

: no abnormality
: no abnormality
: no abnormality
: refer to neurological state
: no abnormality

Psychiatric state
Attention
Attention

: cooperative
: normal

Facial Expression
Psyche contact

: natural
: natural

Neurological state
Head
Shape

: brachiocephaly

Deformity

: no
2

Size
Symetric
Hematome
Tumor

: normal
: yes
: no
: no

Neck
Position
: straight
Torticolis
: no
Nape of neck stiffness : no

Fracture
Fracture pain
Vessel
Pulsation
Deformity
Tumor
Vessels

: no
: no
: no widening
: no disorder
: no
: no
: no widening

CRANIAL NERVES
Olfaktorius nerve
Smelling
Anosmia
Hyposmia
Parosmia

Right
No disorder
No
No
No

Left
No disorder
No
No
No

Opticus nerve
Visual acuity
Campus visi

Right
6/30 PH (-)
V.O.D

Left
6/21 PH (-)
V.O.S

No
No

No
No

No
No
No

No
No
No

Right
No
No
No

Left
No
No
No

No
No
No
No
no abnormality

No
No
No
No
no abnormality

Round
3mm
isochor
No

Round
3mm
isochor
No

Anopsia
Hemianopsia
Oculi fundus
Edema papil
Atrophy papil
Retina bleeding
Occulomotorius, Trochlearis and
Abducens nerves
Diplopia
Eyes gap
Ptosis
Eyes position
Strabismus
Exophtalmus
Enophtalmus
Deviation conjugae
Eyes movement
Pupil
Shape
Size
Isochor/anisochor
Midriasis/miosis

Light reflex
direct
consensuil
accommodation
Argyl Robertson
Trigeminus nerve
Motoric
Biting
Trismus
Corneal reflex
Sensory
Forehead
Cheek
Chin
Facialis nerve
Motoric
Frowning
Eyes closing
Giggling
Nasolabial fold
Facial shape
rest
Speaking/whistling
Sensory
2/3 anterior tounge
Autonomy
Salivation
Lacrimation
Chvosteks sign
Statoacusticus nerve
Cochlearis nerve
Whispering
Hour ticking
Weber test
Rinne test
Vestibularis nerve
Nystagmus
Vertigo
Glossopharingeus
nerves
Pharyngeal arch
Uvula

and

Vagus

+
+
+
No

+
+
+
No

Right
No disorder
No
Yes

Left
No disorder
No
Yes

Normal
Normal
Normal

Normal
Normal
Normal

Right
assimetric
Normal
Normal
Normal

Left
assimetric
Normal
angle paralysis
flat

No disorder
Deviation to the left

No disorder
Deviation to the left

No disorder

No disorder

No disorder
No disorder
No disorder

No disorder
No disorder
No disorder

Right
No disorder
No disorder
Normal
Normal

Left
No disorder
No disorder
Normal
Normal

No
No

No
No

Right
No disorder
No disorder
No
No
Normal

Left
No disorder
No disorder
No
No
Normal
4

Swallowing disorder
Hoarsing/nasalising
Heart beat
Reflex
Vomiting
Coughing
Occulocardiac
Caroticus sinus
Sensory
1/3 posterior tounge

No disorder
No disorder
No disorder
No disorder

No disorder
No disorder
No disorder
No disorder

No disorder

No disorder

Accessorius Nerve
Shoulder Raising
Head Twisting

Right
No disorder
No disorder

Left
No disorder
No disorder

Hypoglossus Nerve
Tounge Showing
Fasciculation
Papil Athrophy
Dysarthria

Right
Deviation to the left
no
no
yes

Left
Deviation to the left
no
no
yes

Right
Sufficient
5
Normal

Left
Lack
2
Increase

Normal
Normal
Normal
Normal

Increase
Increase
Increase
Increase

None
None
None
None

None
None
None
None

Right
Sufficient
5
Normal

Left
Lack
2
Increase

Negative
Negative

Negative
Negative

Normal

Increase

MOTORIC
Arms
Motion
Power
Tones
Physiological Reflex
Biceps
Triceps
Radius
Ulna
Pathological Reflex
Hoffman Tromner
Leri
Meyer
Trofik
LEG
Motion
Power
Tones
Clonus
Tigh
Foot
Physiological reflex

 KPR
APR
Pathological reflex
Babinsky
Chaddock
Oppenheim
Gordon
Schaeffer
Rossolimo
Mendel Bechterew
Abdominal skin reflex
Upper
Middle
Lower
Tropik

Normal

Increase

Negative
Negative
Negative
Negative
Negative
Negative
Negative

Positive
Positive
Positive
Positive
Positive
Negative
Negative

Negative
Negative
Negative
Negative

Negative
Negative
Negative
Negative

SENSORY
Hemihipestesia sinistra (-)
PICTURE

VEGETATIVE FUNCTION
Mictutrion
: normal
Defecation
: normal
Erection
:VERTEBRAL COLUMN
Kyphosis
: no
Lordosis
: no
Gibbus
: no
Deformity
: no

Tumor
Meningocele
Hematome
Tenderness

: no
: no
: no
: no

SYMPTOMS OF MENINGEAL IRRITATION

Nape of neck stiffness
Kerniq
Lasseque
Brudzinsky
Neck
Cheek
Symphisis
Leg I
Leg II
GAIT AND EQUILIBIRIUM
Gait
Ataxia
: not confirmed
Hemiplegic
: not confirmed
Scissor
: not confirmed
Propulsion
: not confirmed
Histeric
: not confirmed
Limping
: not confirmed
Steppage
: not confirmed
Astasia-Abasia
: not confirmed

Right
Negative
Negative
Negative

Left
Negative
Negative
Negative

Negative
Negative
Negative
Negative
Negative

Negative
Negative
Negative
Negative
Negative

Equilibirium and Coordination

Romberg
: not confirmed
Dysmetri
: not confirmed
finger finger
: normal
finger nose
: normal
heel - heel
: not confirmed
Reboundphenomenon: not confirmed
Dysdiadochokinesis : not confirmed
Trunk Ataxia
: not confirmed
Limb Ataxia
: not confirmed

MOTION ABNORMAL
Tremor
: no
Chorea
: no
Athetosis
: no
Ballismus
: no
Dystoni
: no
Myoclonus
: no
LIMBIC FUNCTION
Motoric aphasia
: no
Sensoric aphasia
: no
Apraksia
: no
Agraphia
: no
Alexia
: no
7

Nominal aphasia

: no

LABORATORY FINDINGS
BLOOD
Hb
: 15,5 mg/dl
Leucocyte
: 12600/mm3
Hematocrit
: 40 vol%
Diff Count
: 0/1/0/89/9/10
Thrombocyte : 265000/mm3
LED
: 47
Chol.tot
: 142 mg/dl
HDL cholesterol
: 100 mg/dl

LDL cholesterol
Trygliceride
Uric Acid
Ureum
Creatinin
BSS
Na
K
Ca

: 120 mg/dl
: 50 mg/dl
: 4,6 mg/dl
: 42 mg/dl
: 0,7 mg/dl
: 149 mg/dl
: 137 mmol/l
: 4,8 mmol/l
:2,95 mmol/l

URINE
Colour
Reaction
Protein
Reduction

: not performed
: not performed
: not performed
: not performed

Sediment
Bilirubin
Urobilin

: not performed
: not performed
: not performed

FECES
Consistency
Slime
Blood
Amoeba coli/
Hystolitica

: not performed
: not performed
: not performed
: not performed
: not performed

Erytrocyte
Leucocyte
Worm egg

: not performed
: not performed
: not performed

Protein
Glucose
NaCl
Queckensted
Celloidal
Culture

: not performed
: not performed
: not performed
: not performed
: not performed
: not performed

CEREBRO SPINAL FLUID

Colour
: not performed
Clarity
: not performed
Pressure
: not performed
Cell
: not performed
Nonne
: not performed
Pandy
: not performed
SPECIFIC EXAMINATION
Cranium X- Ray
Chest X- Ray
Vertebral column X- Ray
Electroencephalography
Electroneuromyography
Electrocardiography
Arteriography
Pneumography
CT-Scan

: not performed
: not performed
: not performed
: not performed
: not performed
: normal
: not performed
: not performed
: ICH Capsula interna dextra
8

RESUME
ANAMNESIS
The patient was admitted to Neurology ward RSMH because of the weakness at the left arm
and left leg which happened suddenly.
1 week before admitted to the hospital, the patient suddenly had weakness at his left arm dan
left leg when he was working, followed by losing consciousness. During the attack, he have headache,
nausea, vomitted and seizure. he experienced blurry eyes and the movement of his eyes also become
limitted. he felt that the weakness he had was the same between the arm and the leg. he still could
express her mind by talking, writing and giving sign. The patient understood other peoples mind which
was expressed by talking, writing and giving sign. When he was talking, his lips deviated to the left and
there is disarthria.
During the attack, he doesnt have a heart beat which was followed by shortness of breathing.
he never complained that he had headache at the backside of his head which occurred in the morning
and became less in the afternoon.
The patient experienced these complaints for the first time.

EXAMINATION
Present State
Sense
Blood pressure
Pulse
Respiratory rate
Temperature
Nutrition

: compos mentis (GCS 15: E4M6V5)

: 170 / 90 mmHg
: 90x/minute
: 20x/minute
: 36,8o C
: sufficient

Neurological state
Nn. Craniales
N. VII : Forehead wrinkle is asymmetrical, lagophthalmus (+), right nasolabial fold is flat, rightangle of the mouth paralysis
N. XII : Tongue showing deviated to the right, there is fasiculasi, there is disarthria
Motoric function
Motoric function
Motion
Power
Tones
Clonus

Arm
Right
Sufficient
5
Normal

Leg
Left
Lack
2
Increase

Right
Sufficient
5
Normal
-

Left
Lack
2
Increase
9

Physiological reflex
Pathological reflex

Normal
-

Increase
(+) H,T

Normal
-

Increase
(+) B,C,S

Sensory function
Vegetative function
Limbic function
Abnormal Movement
Gait & Stability
Meningeal Irritation

: hemihipestesia sinistra (-)

: no abnormality
: no abnormality
: (-)
: not yet assesed
: (-)

DIAGNOSIS
Diagnosis clinic
Diagnosis topic
Diagnosis etiology

: Hemiparese sinistra spastik + parese N. VII & N. XII sinistra central

: capsula interna dextra
: haemorragic cerebri

MANAGEMENT
Treatment
:
Medicine
: IVFD RL gtt xx/mins
Inj citicholine 2 x 250 mg iv
Vitamin B1, B6, B12 tab 3x1
Adona 3 x 100 mg
Captopril 2 x 12,5 mg
Ranitidine amp 2 x 150 mg iv
Fisiotherapy : Active movement
PROGNOSIS :

Quo ad vitam
Quo ad functionam

: bonam
: dubia ad bonam

DIFFERENTIAL DIAGNOSIS DISCUSSION

Differential Diagnosis Topic:
TOPIC :
CORTEX CEREBRI HEMISFERIUM DEXTRA
Symptoms :
- Irritate sign (seizure at the weak side/right)
- Focal sign (the weakness of the arm and leg is different)
- motoric deficit (hemipleghia/hemiparese dextra central)
- sensoric deficit (at the weak side)
-

FOR THIS PATIENT:

No seizure at the weak side/right

The weakness he had was the same
between the arm and the leg
Hemiparese
sinistra
spastic
+
ophthalmoplegia bilateral + parese N.VII +
N.XII dextra perifer
There is not sensibility disorder at the side
of the weakness
THE TOPIC OF CORTEX CEREBRI HEMISFERIUM DEXTRA
SHOULD BE RULED OUT

10

TOPIC :
SUBCORTEX HEMISFERIUM CEREBRI
DEXTRA
Symptoms :
Motoric deficit (hemipleghia / hemiparese dextra central)
Pure afasia motoric
-

FOR THIS PATIENT:

Hemiparese sinistra spastik + parese N. VII

& N. XII sinistra central
The patient understood other peoples mind
which was expressed by talking, writing
and giving sign.
THE TOPIC OF SUBCORTEX CEREBRI HEMISFERIUM DEXTRA
SHOULD BE RULED OUT

TOPIC :
CAPSULA INTERNA HEMISFERIUM
FOR THIS PATIENT
CEREBRI DEXTRA
Symptoms :
Hemiparese Typica
- Hemiparese sinistra spastik + parese N. VII
Parese
N.VII
central
& N. XII sinistra central
contralateral
Parese
N.XII
central
contralateral
THE TOPIC OF CAPSULA INTERNA HEMISFERIUM CEREBRI DEXTRA CAN NOT BE
RULED OUT
Differential Diagnosis Etiology:
ETIOLOGY :
HEMORRHAGIC CEREBRI
Symptoms :
- Loss of consciousness > 30
- Attack in activity
- Initiated by headache, nausea and vomits

FOR THIS PATIENT

- The patient suddenly had weakness at his
left arm and left leg when he was working,
followed by losing consciousness
- During the attack, he have headache,
nausea and vomited.
THE ETIOLOGY OF HEMORRHAGIC CEREBRI
CAN NOT BE RULED OUT

ETIOLOGY :
EMBOLI CEREBRI

FOR THIS PATIENT

- The patient suddenly had weakness at his
left arm and left leg when he was working,
followed by losing consciousness
- During the attack, he doesnt have a heart
beat which was followed by shortness of
breathing.
THE ETIOLOGY OF EMBOLI CEREBRI SHOULD BE RULED OUT

Symptoms :
- Loss of consciousness < 30
- There is atrial fibrillation

11

Etiological Diagnosis: Hemorrhagic Cerebri

12