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8/11/2019 Power Point Case Kontusio Medula

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Case Presentation

Paraplegi Inferior Flaksid +hipestesia 1 finger above

umbilicus start from tiptoe +

Retensio Urine

By: Ferawati, S.Ked.

Supervisor: Dr. H. A. R. Toyo, Sp.S (K)

Department of NeurologyRSMH Palembang

Faculty of Medicine University of Sriwijaya


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IDENTIFICATION

Mr.Y/17 tahun/male/not yet

married/Islam/suburban/Desember 19st

2006


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ANAMNESIS

History of fever (-), history of long

cough (-), history bump in backbone (-)

This illness was the first time for him.


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Physical Examination

Generalis Status

General Condition: average sickness

Sens : compos mentis (GCS=E4M6V5)

Nutrition : lack of nutrition

Temp. : 36,8C

Pulse : 80 x/minute

Respiratory rate : 20 x/minute

Blood Pressure : 120/80 mmHg


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Generalis Status

Heart : HR: 80 x/menit,

murmur(-), gallop(-)Lung : vesikuler(+) normal,

ronkhi (-), wheezing(-)

Liver : not palpableSpleen : not palpable

Ekstremity : refer to neurological status


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Neurological Status

Nn. Craniales : no abnormality


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Motorik

Fungtion

Arm Leg

Right Left Right Left

Movement enough enough less less

Power 5 5 0 0

Tonus Normal Normal

Klonus - -

Physiological R. Normal Normal

Patological R. - - (-) (-)


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Sensorik function : hipestesia (+) 1 finger above

umbilicus start from tiptoe

Vegetatif function : retensio urineLuhur function : no abnormality

Abnormal Movement : no

Gait & Stability : no abnormalityGRM : tidak ada


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Additional Examination

Ro Thoracolumbal:

Compression frakture V. Th 12 and

V.L 1


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Etiological Differential Diagnosis

1. Myelitis Symptoms on the patientwere:

Symptoms:History of fever

Neck Stiffness and pain on the back

Asymetrical motoric abnormality

There is no fever

There was no neck stiffness

and pain on the back

Paraplegi inferior flaksid(simetric)

So the possibility of myelitis can be rejected

Working Diagnosis of Etiology: contussio medullae


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DIAGNOSIS BANDING ETIOLOGI

So the possibility of hematomyelia can be rejected

2. Hematomyelia Symptoms on the patientwere:

Symptoms:

History of trauma

Weakness was acute and getting

better by the time

History of trauma (+) 2

days before admitted to

RSMH, fall in buttockposition.

Weakness was acute but

permanent


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So the possibility of spinal subdural hematome

can be rejected

3. Spinal subdural

hematome

Symptoms on the patient were:

Symptoms:History of trauma

Weakness was chronic

progressif and not

permanent

History of trauma (+) 2 days

before admitted to RSMH, fall inbuttock position.

Weakness was acute andpermanent


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So the possibility of contussio medullae cant yet

be rejected

4. Contussio medullae Symptoms on the patientwere:

Symptoms:

History of trauma

Weakness was acute and

permanent

History of trauma (+) 2

days before admitted to

RSMH, fall in buttockposition.

Weakness was acute

and permanent


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DIAGNOSIS

Clinical Diagnosis :

Paraplegi Inferior Flaksid + hipestesia 1 finger above

umbilicus start from tiptoe + Retensio Urine

Topical Diagnosis :

Transversal totally lesion at Th.9

Etiological Diagnosis :

Contussio medullae


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MANAGEMENT

IVFD RL gtt xx/m

Catheter + urine bag

Vit B1, B6, B12 2 x 1 tablet

Diet NB Pro CT-Myelografi

Consult to spinal orthopedic surgery

Consult to rehabilitation medic


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PROGNOSIS

Quo ad vitam : bonam

Quo ad functionam : dubia ad malam


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