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LAPORAN KASUS
PARAPARESIS INFERIORFLACCID
Optie Ardha Berliana (H2A010039)
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CATATAN MEDIK
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DAFTA MA!A"AH
Tan##al A$ti% Tan##al &a'i%
3110201
1* &arapare'i' in%eri+r
,a--id
2* Hiperten'i #rade 1
3110201
.
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ANAMNE!I!
&!
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PEMERIKSAAN FISIKKEADAAN UMUM
K tapa$ '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
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!TAT! NEO"O4I!FN4!I "H
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!TAT! NEO"O4I!
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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$i'%u' di(e!gen
&)Dipl"pia
(.)
()
()
()
2;
B:lat; re#:ler()
()
()
(.)
(.)
(.)
()
()
()
2;
B:lat; re#:ler()
()
()
(.)
(.)
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N*I7 (Tr+-hleari')
a*4era$ 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$:'
h*Tri':'
()
()
()
()
t*d*l
t*d*l
t*d*l
(.)
()
()
()
()
t*d*l
t*d*l
t*d*l
(.)
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ANGGOTA GERAK
ATAS Kanan Ki!iRe1e& 3'i"l"gi& 4
0i'ep
T!i'ep
Radiu'
Re1e& Pat"l"gi 4
H"5%an
T!"%e!
n+ral
n+ral
n+ral
(.)
(.)
n+ral
n+ral
n+ral
(.)
(.)
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Kete!angan Kana
n
Ki!i
Re1e&
Pat"l"gi'0a$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!
.
.
.
.
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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*
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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
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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*
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PROGNOSISAd >ita d:ia ad +na
Ad %:n#'i+na d:ia ad ala
Ad 'anati+na d:ia ad ala
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