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Case Report

SENIOR CLINICAL CLERKSHIP

Name

: Fitria Koeshardani, S. Ked


Intan Meilita, S.Ked
Vengky Utami, S.Ked
NIM
: 54061001080
04061001017
04061001095
Semester : IX
Date
: December 13th, 2010
Advisor : Dr. H. A. Rachman Toyo, SpS(K)

Spinal Cord
Contusion

Case Report
Identification
Name
Age
old
Gender
Marital Status
Religion
Address
Palembang
Admission Date

: Mr. I
: 25 years
: male
: unmarried
: Moslem
: outside
: December 31st 2010

ANAMNESIS (Auto Anamnesis)


The patient was admitted in the neurology ward
in RSMH Palembang because of paralysis of both
legs and he complaints difficulty in urinating and
defecation since he fell from the palm tree.
2 weeks ago, the patient fell from a tree in the
supine position, his back hit first, and the patient
immediately unable to move both his legs, he also
couldnt feel sense from the umbilicus to the fingertips
of both legs and complaint difficulty in urinating and
defecation.
There
was
no
impairment
of
consciousness , he didnt complain about nausea and
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vomiting. He was taken to the hospital immediately.

Patient had no history of Hypertension.


No history of getting fever. No history of getting
head injury. No history of diabetes mellitus. No
history of chronic cough, no history of lifting
heavy load, no history of spinal bump
This illness was suffered for the first time

PHYSICAL EXAMINATION
Sense
Nutrition
Pulse
Respiratory rate
Blood pressure
Weight
Height

: E4M6V5
: sufficient
:82beats/min
:18 times/min
:110/80 mmHg
: 55 kg
: 164 cm
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Neurological state
Nervi craniales
Nn. Craniales

: no abnormality

Motoric function
Motoric function

Arm

Leg

Right

Left

Right

Motion

Sufficient

Sufficient

Power

Tones

Normal

Normal

Decrease

Decrease

Decrease

Decrease

Insufficient Insufficient

Clonus
Physiological
reflex
Pathological reflex

Normal

Normal

Left

Sensory function

: Hipestesi as high as

2 fingers under umbilicus until the fingertips


of both legs.

Vegetative function : retensio urin and


retensio alvi

Limbic function : No abnormality


Abnormal Movement: (-)
Gait & Stability : not examined
Meningeal Irritation : (-)
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Hb

: 11,3 g/dL

Total kolesterol :116 mg/dL

Additional Examination
Kolesterol HDL

Eritrocyte : 4,2 juta/mm3

: 37

mg/dL
Leukosit : 9500 /mm3

Kolesterol LDL : 61

mg/dL
Trombosit: 421.000 /mm3 Trigliseride

: 91

mg/dL
Hematocrit: 35 vol%

Ureum

: 60 mg/dL

CK-NAK : 51 U/I

Kreatinin

: 1,1 mg/dL

CK-MB

Natrium

: 135 mmolL

: 13 U/I

Diff Count: 0/0/2/81/12/5


mmol/L

Kalium

: 4,1
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Specific examination
Vertebral column X- Ray:Compressive
fracture/burst T.11 and Spondylolistesis T
11-12

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DIAGNOSIS
Clinical Diagnostic
: Inferior flacid paraplegia +
hipestesi as high as 2 fingers under umbilicus until
the fingertips of both legs.
Topical Diagnostic
: Total transversal lesion
medula spinalis T11-T12
Etiological Diagnostic :

Contusio medula spinalis

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Treatment
Non Medication :
Immobilisation
Urin catheterisation
Consult for operative treatment
Consult to medical rehabilitation
Medication
:
IVFD RL gtt XX/min
Metilprednisolon 5,4 mg/kg BB bolus
followed by 30 mg/kgBW/hour infussion for
23 hours
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Vitamin B1, B6, B12 3x1 tab

PROGNOSIS
Quo ad vitam
: bonam
Quo ad functionam : dubia ad malam

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Complication
Urinary tract infection
DVT
Pulmonary embolism
Death
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From Anamnesis
History of trauma on back of the body
Weakness on both legs
Retensio urin and alvi
Lost of sensation from umbilicus until
fingertips of both leg

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From Physical Examination


Paraplegia inferior flaccid
Hipestesi from 2 fingers below umbilicus until
fingertips of both legs
Retensio urin et alvi

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From additional examination


Burst fracture on vertebrae thoracal 11th.
Spondylolistesis T 11-12

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Differential Diagnosis for etiological diagnosis:


Myelitis
Spondylitis TB
Subdural hematom spinalis
Spinal cord contusion

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1. Myelitis

Found in patient:

Symptomps:
Fever
Neck stiffness and pain in
posterior of body
Asymetric motoric deficit

No fever
No neck stiffness
and
pain
in
posterior of body
Paraparese inferior
flaccid (symetric)

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So, the possibility of myelitis can be ruled
out.

Case analysis-con't-2

2. Spondylitis TB

Found on patient:

Chronic cough
No chronic cough
Chronic
and Weakness appear after
progressive weakness trauma

So, the possibility of spondylitis TB can be ruled out..


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Case analysis-con't-4

3. Subdural Hematom
spinalis
History of trauma
Chronic
and
progressive weakness

Found on patient:
History of trauma 2
weeks before
Weakness appear after
trauma

So, the possibility of subdural hematom spinalis can be


ruled out..
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Case analysis-con't-5

4. Spinal cord contusion Found on patient:


History of trauma
History of trauma 2
Acute and permanent weeks before
weakness
Weakness appear after
trauma

So, the possibility of contusio of spinal cord cant be ruled


out..
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From all above, we concluded that this


patient suffered from
paraplegi inferior flaccid + hipestesi from 2
fingers below umbilicus until fingertips of
both leg + retensio urin et alvi because of
spinal cord contusion on thoracal 11th

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