Lapsus Parkinson

8/20/2019 Lapsus Parkinson

1/12

LAPORAN KASUS

PARKINSON

Oleh :

EUDENSIA.A.W.GURU ( 06700099 )

Pembimbing

Dr. UTOO SUNARO S!. S

S"# I$"U PENA%IT SARA#

RSUD Dr. "O& SA$E& PRO'O$INGGO

#A%U$TAS %EDO%TERAN UNIERSITAS WIAA %USU"A

SURA'AA


2/12

Identitas Penderita

• N*m* !*+ien : '!,. Ahm*- "*-*ni

• eni+ ,el*min : $*,il*,i

• Um/r : 6 1hn

• Al*m*1 : Gen-ingPr2b2lingg2

• S/,/ : "*-/r*

• Ag*m* : I+l*m

• S1*1/+ m*ri1*l : S/-*h "eni,*h

• R/*ng*n : P2li S*r*3

• Pe,er4**n : Pen+i/n*n

• "RS :

• T*ngg*l !emeri,+**n : 50

•

SUBYEKTIF (S) DATA DASAR

(A/12*n*mne+*)

Keluhan utama : T*ng*n geme1*r 1er/+ mener/+

Ria!at "en!a#it se#aran$ :

P*+ien -*1*ng ,e !2li,ilini, +*r*3 RSUD "2h S*leh Pr2b2lingg2 -eng*n ,el/h*n ,e-/*

1*ng*n geme1*r -*n ,2n1r2l ,*rn* 2b*1 h*bi+.

P*+ien meng*1*,*n ,e-/* 1*ng*nn8* geme1*r 1er/+ -*n 1i*-* hen1i ,h/+/+ +**1 ber*,1ii1*+.

!*+ien mer*+* berge1*r 1*n!* +*-*r -*n 1*, 1er,en-*li.

P*+ien 4/g* men4*-i l*mb*1 4i,* ber4*l*n -*n lebih +/li1 1i-/r +**1 m*l*m h*ri. &*l ini +/-*h

-ir*+*,*n +e4*, ; bln 8*ng l*l/. 'A' -*n 'A% -*l*m ,e*-**n n2rm*l.

Ria!at "en!a#it dahulu

o &T (


3/12

Ria!at int%#si#asi ' Ti-*, *-* *lergi 2b*1

Ria!at s%sial e#%n%mi'

OBYEKTIF (O)

Status Interna Sin$#at '

Ten+i : 90=0 mmhg

N*-i : ;6 =meni1

RR : > =mn1

S/h/ : 6?;@

GiBi : C/,/!

%e!*l* : *=i=C=- ===

$eher : Pembe+*r*n 18r2i- %G' =

P*r/!*r/ : Rh2n,i = WheeBing =

*n1/ng : S/*r* SS 1/ngg*l reg/ler

Ab-2men : T/rg2r (N2rm*l)? 'i+ingU+/+ (N2rm*l)

&e!*r $ien : Ti-*, *-* !embe+*r*n

e,+1remi1*+ : E-em*().

Status Psi#iatri Sin$#at ' TDL

Status Neur%l%$i#

A* Kesan Umum '

%e+*-*r*n

,/*li1*1i3 : C2m!2+ men1i+

,/*n1i1*1i3 : G S : >56

PembiC*r**n

-i+*r1ri : ()

m2n212n : ()

+C*nning : ()

*3*+i*

m212ri, : ()

+en+2ri, : ()


4/12

Amne+1i, : ()

%e!*l*

'en1/, = be+*r : b/l*1

A+ime1ri+ : ()

Si,*! !*,+* : ()

T2r1iC2lli+ : ()

"/,*

"*+, : ()

"82!*1hi, : ()

#/llm22n : ()

$*in F l*in : ()

B* Pemeri#saan Khusus '

A. R*ng+*ng*n Sel*!/1 O1*, :

%*,/ %/-/, : ()

$*+e/e Te+1 : ()

%ernig Te+1 : ()

'r/-Bin+,i T*n-* $eher : ()

'r/-Bin+,i T/ng,*i %2n1r* l*1er*l : ()

'r/-Bin+,i T*n-* Pi!i : TD$

'r/-Bin+,i T*n-* +im!i+i+ !/bi+ : TD$

'. S*r*3 O1*,

Ner+us I KANAN KIRI

An2+mi* TD$

&i!2+mi* TD$

P*r2+mi* TD$

&*l/+in*+i TD$

Ner+us II KANAN KIRI

i+/+ D'N

24*8* !englih*1*n 1i-*, -il*,/,*n 1i-*, -il*,/,*n

"elih*1 H*rn* 1i-*, -il*,/,*n 1i-*, -il*,/,*n


5/12

#/n-/+,2!i 1i-*, -il*,/,*n 1i-*, -il*,/,*n

Ner+us III , I- , -I KANAN KIRI

%e-/-/,*n b2l* m*1* : -i1eng*h -i1eng*h

Perger*,*n b2l* m*1* :

,e n*+*l (


6/12

W*,1/ ger*,

"enger/1 -*hi NOR"A$

"en/1/! m*1* NOR"A$

'er+i/l NOR"A$

"em!erlih*1,*n gigi TD$

Ner+us -III KANAN KIRI

e+1ib/l*r

er1ig2 1-, -il*,/,*n 1-, -il*,/,*n

Ni+1*gm/+ ,e 1-, -il*,/,*n 1-, -il*,/,*n

Tinni1/+ */re/m 1-, -il*,/,*n 1-, -il*,/,*n

2Chle*r

Weber 1-, -il*,/,*n 1-, -il*,/,*n

Rinne 1-, -il*,/,*n 1-, -il*,/,*n

SChH*b*Ch 1-, -il*,/,*n 1-, -il*,/,*n

T/li ,2n-/,1i3 1-, -il*,/,*n 1-, -il*,/,*n

T/li !er+e!1i3 1-, -il*,/,*n 1-, -il*,/,*n

Ner+us I. , .

'*gi*n "212ri,

S/*r* bi*+* = !*r*/ = 1*, ber+/*r* : +/*r* bi*+*

"enel*n : bi+*

%e-/-/,*n *rC/+ !h*r8n : n2rm*l

%e-/-/,*n //l* : n2rm*l

Perger*,*n *rC/+ !h*r8n = //l* : n2rm*l

erne1 F ri-e*/ !hen2men2n : 1i-*, -il*,/,*n

De1i, 4*n1/ng : n2rm*l

'i+ing /+/+ : n2rm*l

'*gi*n +en+2ri,

Re3le,+ m/n1*h (!h*r8n) : 1i-*, -il*,/,*n

Re3le,+ !*ll*1/m m2lle : 1i-*, -il*,/,*n


7/12

NER-US .I KANAN KIRI

"eng*ng,*1 b*h/ N2rm*l N2rm*l

"em*ling,*n ,e!*l* N2rm*l N2rm*l

NER-US .II

%e-/-/,*n li-*h

H*,1/ i+1ir*h*1 ,e Teng*h Teng*h

H*,1/ ger*, ,e n2rm*l

A1r23i () ()

#*+i,/l*+i = 1rem2r () ()

%e,/*1*n li-*h mene,*n (


8/12

". biCe!+ (3lei leng*n b*H*h) : 5 5

". TriCe!+ (e,+1en+i leng*n b*H*h) : 5 5

#lei +en-i !ergel*ng*n 1*ng*n : 5 5

E,+1en+i !ergel*ng*n 1*ng*n : 5 5

"emb/,* 4*ri F 4*ri 1*ng*n : 5 5

"en/1/! 4*ri F 4*ri 1*ng*n : 5 5

T2n/+ 2121

12n/+ 2121 leng*n hi!212ni

h8!212ni () ()

S!*+1i, () ()

rigi- (


9/12

1%t%ri#

Ke#uatan %t%t

( N.' : 5 n2rm*l (00) ? > -!1 mel*H*n 1*h*n*n minim*l (75 )? -!1 mel*H*n

gr*i1*+i (50)? -!1 mengger*,*n +en-i (5)? m+h *-* ,2n1r*,+i 2121 (0)? 0

1i-*, *-* ger*, +*m* +e,*li (0).

T/ng,*i %ANAN %IRI

#lei *r1iC C2*e (1/ng,*i *1*+) : 5 5

E1en+i *r1iC C2*e (1/ng,*i *1*+) : 5 5

#lei +en-i l/1/1 (1/ng,*i b*H*h) : 5 5

E1en+i +en-i l/1/1 (1/ng,*i b*H*h) : 5 5

#lei !l*n1*r ,*,i : 5 5

E,1en+i -2r+*l ,*,i : 5 5

Ger*,*n 4*ri4*ri : 5 5

T%nus %t%t tun$#ai NOR"A$ %IRI

h8!212ni () ()

S!*+1i, () ()

rigi- () ()

reb2/n- Phen2men2n () ()

Re2le#s 2isi%l%$is

%PR N2rm*l N2rm*l

'PR N2rm*l N2rm*l

Re2le#s "at%l%$is

'*bin+,8 () ()

h*--2, () ()

O!enheim () ()

G2r-2n () ()

G2n-* () ()

SCh*e33er () ()

R2++2lim2 () ()

"en-el'eCh1ereH () ()

S1r*n+,8 () ()

SENSIBILITAS

E,+1er2+e!1i, : n2rm*l


10/12

Pr2!i2+e!1i, : n2rm*l

En1er2+e!1i, : 1i-*, -il*,/,*n

R*+* ,2mbin*+i : 1i-*, -il*,/,*n

3* Badan

• In+!e,+i : N2rm*l

• P*l!*+i

O121 !er/1 : -bn

O121 !ingg*ng : -bn

%e-/-/,*n -i*3r*gm*: ger*, : N2rm*l

i+1ir*h*1 : N2rm*l

• Per,/+i : N2rm*l

• A/+,/l1*+i : N2rm*l

• "212ri, : Ti-*, -il*,/,*nD. K%lumna -erte&ralis : Ti-*, -il*,/,*n

E* 4era#an5$era#an in+%lunter

• Trem2r

o W*,1/ i+1ir*h*1 : (


11/12

Anamnesa

P*+ien meng*1*,*n 1*ng*n geme1*r ,h/+/+n8* +**1 ber*,1ii1*+ 8*ng -ir*+*,*n

+emen4*, ; bln 8*ng l*l/

"*l*m men4*-i +/li1 1i-/r

*l*n men4*-i lebih l*mb*1

Pemeri#saan 2isi# '

o %U : '*i,

o Ten+i : 90=0 mmhg

o N*-i : ;6 =meni1

o RR : > =mn1

o S/h/ : 6?;@

Dia$n%sa Bandin$ ' Trem%r EssensiaL

ASSES1ENT (A)

DIAGNOSA :

Di*gn2+i+ %lini+ : &i!er1en+i +1*ge III

In+2mni*

*l*n +em*,in l*mb*1 (br*-i,ine+i*)

Trem2r

Rigi-i1*+

Di*gn2+i+ T2!i, : S/b+1*n+i* Nigr*

Di*gn2+i+ E1i2l2gi : P*r,in+2n

PLANNIN4

TERAPI

Ter*!i Um/m

Ter*!i 3i+i,? l*1ih*n = 2l*hr*g*? -ie1 -*n n/1ri+i

Ter*!i %h/+/+


12/12

$e2-2!*

Am*n1*-ine 0000 mg=h*ri

'r2m2,ri!1in

"AO Inhibi12r +elegine

Documents

Lapsus Parkinson