Lapsus Paraparesis

7/24/2019 Lapsus Paraparesis

1/23

LAPORAN KASUS

PARAPARESIS INFERIORFLACCID

Optie Ardha Berliana (H2A010039)


2/23

CATATAN MEDIK


3/23

DAFTA MA!A"AH

Tan##al A$ti% Tan##al &a'i%

3110201

1* &arapare'i' in%eri+r

,a--id

2* Hiperten'i #rade 1

3110201

.


4/23

ANAMNE!I!

&!


5/23


6/23


7/23

PEMERIKSAAN FISIKKEADAAN UMUM

K tapa$ 'a$it erat

Ke'adaran C+p+' enti'

4C! E5M6 7 8 1

TANDA VITAL

TD 15090 H#

Nadi 0 $alienit (re#:ler;i'i dan te#an#an -:$:p)

20 $alienit

!:h: 3


8/23

!TAT! NEO"O4I!FN4!I "H


9/23

!TAT! NEO"O4I!


10/23

NEN! CANIA"I!

Ne!(u' K!aniali' Kanan Ki!i

N) I *Ol+a,t"!iu'-

Da.a Pengidu

N+r+'ia

N+r+'ia

N)II *Opti,u'-

a)Da.a pengliatan

$)Lapang pandang

,)Fundu' "&uli

ai$

ai$

t*d*l

ai$

ai$

t*d*l

N)III *O,ul"%"t"!iu'-a)Pt"'i'

$)Ge!a& %ata &eata'

,)Ge!a& %ata &e$a/a

d)Ge!a& %ata %edia

e)U&u!an pupil

+)0entu& pupilg)Re1e& ,aa.a lang'ung

)Re1e& ,aa.a &"n'e'uil

i)Re1e& a&%"da'i

2)St!a$i'%u' di(e!gen

&)Dipl"pia

(.)

()

()

()

2;

B:lat; re#:ler()

()

()

(.)

(.)

(.)

()

()

()

2;

B:lat; re#:ler()

()

()

(.)

(.)


11/23

N*I7 (Tr+-hleari')

a*4era$ ata lateral

a?ah*!trai':' $+n>er#en

-*Dipl+pia

()

(.)(.)

()

(.)(.)

N*7 (Tri#ein:')

a*Men##i#it

*Me:$a :l:t

-*!en'iilita'

d*e,e$ $+rnea

e*e,e$ er'in

%* e,e$ a''eter

#*e,e$ i#+ati$:'

h*Tri':'

()

()

()

()

t*d*l

t*d*l

t*d*l

(.)

()

()

()

()

t*d*l

t*d*l

t*d*l

(.)


12/23


13/23


14/23


15/23


16/23

ANGGOTA GERAK

ATAS Kanan Ki!iRe1e& 3'i"l"gi& 4

0i'ep

T!i'ep

Radiu'

Re1e& Pat"l"gi 4

H"5%an

T!"%e!

n+ral

n+ral

n+ral

(.)

(.)

n+ral

n+ral

n+ral

(.)

(.)


17/23


18/23

Kete!angan Kana

n

Ki!i

Re1e&

Pat"l"gi'0a$in'&i

Cadd",&

Oppenei%

G"!d"nS,ae5e!

Mendel

0e,te!e/

R"''"li%"G"nda

Kl"nu'

patella

Kl"nu' &a&i

.

.

.

.

.

.

.

.

.

.

-

.

.

.

.

.

.

.

.

.

.

-

Kete!angan Kana

n

Ki!i

Rang'ang

MeningealKa&u Kudu&

Ke!nig 'ign

0!ud6in'&i I

0!ud6in'&i II

Rang'ang

Radi&ule!

Te' La'egueTe' Pat!i&

Te' K"nt!a Pat!i&

Tanda ne!i

Te' na56ige!

.

.

.

.


19/23

RESUME

N@*A :'ia 0 tah:n datan# den#an $el:han parapare'i'in%eri+r* 1 hari !M!* !elain it: pa'ien :#a era'a$an per:tee'ar; at:$; dan 'e'a$ napa'* !eel:n@a pa'ienera'a adan leah; :al; ':lit BAK dan BAB*; n@eripin##an#; pare'te'i dan hip+e'te'i pada ari tan#an dan $a$i;'in$+p (.); dan 'ei:re di'an#$al* Ke:dian +leh $el:ar#apa'ien dia?a $e !D T:#:re+* &a'ien en#a$:i ri?a@at

hiperten'i tah:n dan ter$+ntr+l* &a'ien aran# er+lahra#a* Dari peeri$'aan G'i$ didapat$an $eadaan :: tapa$ 'a$it

'edan#; $e'adaran -+p+' enti'; >ital 'i#n Te$anan darah15090 H#; Nadi 0=enit* !tat:' #ii IMT 2erei#ht); p:pil i'+$+r 2;2;* !tat:' Ne:r+l+#i'

Ke'adaran 4C! 1 (E5M67); #era$an (NNl . ); $e$:atan .... . 5.5.5.5.; t+n:' n+r+t+n:'n+r+t+n:'; tr+Ge:tr+Ge:tr+G; n+ral pada 'en'iitita'; di'$riina'i; p+'i'i;dan >ira'i* Ner>:' -raniali' dala ata' n+ral* !tat:' p'i$i'dala ata' n+ral* !en'iilita' dala ata' n+ral dan%:n#'i >e#etati% dala ata' n+ral*


20/23

Diagn"'i' Klini&

&arapare'i' In%eri+rFla--id

I'-hial#ia ilateral

Diagn"'i' T"pi&

!:'pe$ di'$:'

inter>erterali' " III.I7Diagn"'i' Eti"l"gi&

!:'pe$ HN& (HerniaNucleus Pulposus)

Hiperten'i #rade I

Ren,ana Diagn"'i'

':lanpeeri$'aan&eeri$'aanla+rat+ri: Darahr:tin; 4D III; &r+Gl

"ipid; a'a :rat

EK4

J %+t+ th+ra=

J %+t+ l:al A&lateral

MI


21/23

Ren,ana Te!api

Fa!%a&"l"gi

Fara$+terapi

O2 $an:l 5 lenit In%:' " 20 tp

Ine$'i e-+alain 1 = 00#

Ine$'i ranitidin 2 = 0 #

(&O) Al+dipin ta 1 = 10 #

(&O) Na Di-l+%ena- 2 = 0 #

(&O) Diepa 2 = 2 #

N+n Fara$+terapi

I'tirahat di tepat tid:rN"n +a!%a&"l"gi

Bed re't

K+n':l d+$ter !p*KF

M"nit"!ing

Keadaan ::

Tanda >ital

DeG'it ne:r+l+#i'Edu&a'i

Menela'$an $epada pa'iendan $el:ar#a en#enai$+ndi'i pen@a$it @an#

diderita pa'ien Menela'$an $epada pa'ien

:':lan peeri$'aanpen:nan# @an# dila$:$an:nt:$ en-ari pen@eapen@a$it pa'ien

Men@aran$an $epada$el:ar#a :nt:$ eeri$and:$:n#an $epada pa'iendan e$era'aa dalapenatala$'anaan pa'ien*


22/23

PROGNOSISAd >ita d:ia ad +na

Ad %:n#'i+na d:ia ad ala

Ad 'anati+na d:ia ad ala


23/23

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Lapsus Paraparesis