Professional Documents
Culture Documents
Name
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
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
6
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
Hb
: 11,3 g/dL
Additional Examination
Kolesterol HDL
: 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
Kalium
: 4,1
10
Specific examination
Vertebral column X- Ray:Compressive
fracture/burst T.11 and Spondylolistesis T
11-12
11
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 :
12
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
13
Vitamin B1, B6, B12 3x1 tab
PROGNOSIS
Quo ad vitam
: bonam
Quo ad functionam : dubia ad malam
14
Complication
Urinary tract infection
DVT
Pulmonary embolism
Death
15
16
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
17
18
19
20
21
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)
22
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
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
Case analysis-con't-5
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