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CASE MYELOPATHY-
Mielopati [Dr. Usman G
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LAPORAN KASUS ”MIELOPATI”
Di susun oleh : septiana Citradewi
Pembimbing : Dr. Susanto. Sp.S
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
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STATUS PASIEN IDENTITAS
Nama
: Tn.M
Jenis kelamin
: Laki-laki
Umur
: 43 tahun
Alamat
: Cianjur
Status
: Menikah
Agama
: Islam
ANAMNESIS
Keluhan Utama Lumpuh pada kedua tungkai sejak 1 bulan yang lalu.
Riwayat Penyakit Sekarang
Pasien datang ke RSUD Cianjur dengan keluhan lumpuh kedua tungkai seja You're Reading a Preview 1 bulan yang lalu. Keluhan didahului lemah pada kedua tungkai sejak Unlock full accessoleh with arasa free trial.
bulan SMRS. Pasien harus menyeret kakinya untuk berjalan dan sendal yan Download With Free Trial dipakai sering terlepas dari kakinya. Keluhan lemah ini di rasakan makin lam
makin memberat sehingga timbul keluhan lumpuh. Keluhan kesemutan dan ba pada kedua tungkai di rasakan sejak 3 bulan SMRS.
Untuk menghilangkan keluhan lemah dan rasa baalnya ini pasien per berobat ke mantri, oleh mantri di berikan suntikan penghilang nyeri
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menjalar sampai tungkai sebelumnya. Pasien tidak dapat BAK selama 10 ha
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
Search document
Riwayat Keluarga
Riwayat keluarga yang memiliki penyakit jantung, hipertensi ataupun kencin manis tidak diketahui.
Riwayat Pengobatan
Pasien mengaku sudah berobat ke mantri untuk keluhan ini tetapi tidak ad perbaikan.
Riwayat Psikososial Pasien mengaku tidak pernah merokok ataupun mengkonsumsi alkohol .
PEMERIKSAAN FISIK •
Keadaan umum
: Tampak sakit sedang
•
Kesadaran
: Composmentis
•
Tanda Vital - Nadi
You're Reading a Preview : 82 x/menit, reguler, kuat Unlock full access with a free trial.
- Pernapasan - Suhu - TD
: 20 x/menit, reguler
: 37 0C Download With Free Trial : 130/ 80 mmHg
•
Mata : konjungtiva anemis (-/-), sklera ikterik (-/-)
•
Hidung : Deviasi septum (-), Sekret (-/-)
•
Telinga : Normotia, Sekret (-/-)
Mulut with Scribd Master your semester Terlihat mencong kesebelah & The New York Times •
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Palpasi :
–
•
Nyeri tekan (-/-) , tidak teraba massa
•
Vokal fremitus dextra-sinistra sama.
•
Iktus cordis teraba di ICS V linea midklavikularis kiri.
Perkusi :
–
Sonor seluruh lapang paru
•
Auskultasi :
–
Vesikuler + / +, ronkhi -/- , wheezing -/- , murmur (-), gallop (-)
•
Abdomen
Inspeksi
Palpasi
Mielopati [Dr. Usman G
Penggunaan otot-otot bantu pernapasan (-)
•
of 16
CASE MYELOPATHY-
: Datar
Nyeri tekan
Hepar
Splen
Ballotement
: Tidak ada
: Tidak teraba You're Reading a Preview : Tidak teraba Unlock full access with a free trial.
Perkusi
Auskultasi
:-/-
Download With Free Trial : Timpani
: Bising usus (+) N
Ekstremitas : –
Edema
-/-
hangat +/+ Master your semesterAkral with Scribd & The New York TimesSianosis -/ –
–
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CASE MYELOPATHY-
–
Kerniq
> 130
–
Burdzinski I
(-)
–
Burdzinski II (-)
–
Burdzinski III (-)
Mielopati [Dr. Usman G
Search document
Saraf otak
Nervus I (Olfaktorius)
Dextra
Sinistra
N
N
Dextra
Sinistra
Daya penglihatan
N
N
Lapangan pandang
N
N
Refleks cahaya
+
+
Daya pembau Nervus II (Optikus)
Nervus III (Okulomotorius) Dextra You're Reading a Preview Ptosis -
Sinistra -
Unlock full access with a free trial.
Gerak mata ke : Medial
Download With Free Trial +
+
Atas
+
+
Bawah
+
+
Ukuran pupil
3mm
3mm
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bulat bulat Read Free Foron 30this Days Sign up to vote title
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Dextra
Sinistra
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
Search document
Diplopia
-
Nervus V (Trigeminus)
-
Dextra
Sinistra
Menggigit
+
+
Membuka mulut
+
+
Atas
+
+
Tengah
+
+
Bawah
+
+
Refleks kornea
+
+
Refleks bersin
+
+
Sensibilitas muka :
N. VII ( Fasialis ) Mengangkat dahi Meringis Menutup mata Mengembungkan pipi
Dextra
Sinitra
+ You're Reading a Preview
+
Sudut nasolabialis (+)
sempurna Download With Free Trial +
sempurna +
Daya kecap 2/3 ant
Nervus VIII (akustikus) mendengar suara berbisik Master your semester with Scribd mendengar detik arloji & The New York Times Special offer for students: Only tes$4.99/month. Rinne
+
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N
Dextra
Sinistra
+ Read Free Foron 30this Days Sign up to vote title +
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Useful
+
+
+ +
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
Search document
Nervus X (Vagus)
Dextra
Sinistra
Arkus farings
Tidak deviasi
Tidak deviasi
+
+
Dextra
Sinistra
Memalingkan kepala
+
+
Sikap bahu
+
+
Mengangkat bahu
+
+
Menelan Nervus XI (Aksesorius)
Nervus XII (Hipoglosus)
Dextra
Sinistra
sikap lidah
Tidak ada deviasi
Artikulasi
Tidak terganggu
tremor lidah You're Reading a Preview
menjulurkan lidah
Unlock full access with a free trial.
atrofi otot lidah
Download With Free Trial
fasikulasi lidah
Motorik
5
5
5
5
Master your semester with Scribd Sensorik & The New York Times
Special offer for students: Only $4.99/month.
-
-
+
+
-
-
-
-
Read Free Foron 30this Days Sign up to vote title
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Useful
Anestesi
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
Search document
Fungsi Vegetatif Miksi Anuri
: Positif sejak 15 hari
Defekasi
: belum BAB sejak 7 hari yang lalu
Reflek Fisiologis Reflex Biceps
: +/+
Reflex Trisep
: +/+
Reflex Patella
: -/-
Reflex Achilles
: -/-
Refleks Patologik
Dextra
Sinistra
Babinski
-
-
Chaddocck
-
-
Oppenheim
-
-
Gordon Schaeffer Gonda Rossolimo Mendel-Bechterew
You're Reading a Preview -
Unlock full access with a free trial.
Download With Free Trial -
-
STATUS LOKALIS
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
Search document
PEMERIKSAAN RADIOLOGI
Hasil foto rontgen vetebro thorako-lumbal didapatkan : -
Allignment dari vertebra thorakal kurang kifosis
-
Terdapat spur di daerah Vertebro Th 9
RESUME PASIEN
You're Reading a Preview Unlock full access with a free trial.
Pasien datang ke RSUD Cianjur dengan keluhan lumpuh kedua tungk Download With Free Trial sejak 1 bulan yang lalu. Keluhan didahului oleh rasa lemah pada kedua tungk
sejak 2 bulan SMRS. Pasien harus menyeret kakinya untuk berjalan dan send
yang dipakai sering terlepas dari kakinya. Keluhan lemah ini di rasakan mak
lama makin memberat sehingga timbul keluhan lumpuh. Keluhan kesemutan da
baal pada kedua tungkai di rasakan sejak 3 bulan SMRS. Sebelum kaki lumpu
Master your pasien semester with Scribd tungk merasa pinggangnya nyeri, tidak ada menjalar sampai Read Free Foron 30this Days Signnyeri up to vote title & The New York Times Useful Not useful sebelumnya. Pasien tidak dapat BAK selama 10 hari, belum BAB sejak 1 minggu Special offer for students: Only $4.99/month.
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Pemeriksaan fisik didapatkan semua dalam batas normal. Status neurolog
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
Search document
Status Lokalis
Ulkus dekubitus
DIAGNOSIS •
Diagnosis Klinis Myelopati Thorakalis Setinggi Medula spinalis Thl lesi Thorakal 7 + Ulkus dekubitus
•
Diagnosis banding
You're Reading a Preview PENATALAKSANAAN •
Terapi Cairan
Unlock full access with a free trial.
Infus RL 30 tts/mnt Download With Free Trial •
•
Terapi Farmakologis –
DulcolaxSupp
–
Cefotaxim 2 x 1 gr
Terapi Rehabilitasi
Terapi Non-Farmakologi Master your semester with Scribd Pemasangan kateter & The New York Times •
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laporan mielopati.doc
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
Search document
TINJAUAN PUSTAKA DEFINISI
Myelopathy adalah istilah yang berarti bahwa ada sesuatu yang salah dengan sar
tulang belakang itu sendiri. Ini biasanya merupakan tahap berikutnya penyak
tulang belakang leher, dan sering pertama terdeteksi sebagai kesulitan berjala karena kelemahan umum atau masalah dengan keseimbangan dan koordinasi. Tingkatan Mielopati berdasarkan Nurick
System Nurick myelopathy grade dari 0-5, dengan 5 menjadi yang palin berat.perubahan karakteristik terjadi pada masing- masing
tingkatan sebag
berikut: –
Grade 0: signs and symptoms of root involvement but without evidence
spinal cord disease. –
–
Grade 1: signs of spinal cord disease but no difficulty in walking. You're Reading a Preview Grade 2: slight difficulty in walking but does not prevent full-tim Unlock full access with a free trial.
employment. –
Download With Free Trial in walking that requires assistance and preven Grade 3: severe difficulty
full-time employment and avocation. –
Grade 4: ability to walk only with assistance or with the aid of a frame.
–
Grade 5: chairbound or bedridden.
Master your semester with Scribd Myelopati Dengan Skala klasifikasi Frankel Read Free Foron 30this Days Sign up to vote title A: complete motor and sensory involvement & The New YorkGrade Times Useful . Not useful –
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Special offer for students: OnlyGrade $4.99/month. B: complete motor involvement, some sensory sparing including s acr –
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
Search document
KLASIFIKASI
Cedera medula spinalis dapat dibagi menjadi komplet dan tidak kompl berdasarkan ada/tidaknya fungsi yang dipertahankan di bawah lesi Tabel. Tabulasi perbandingan klinik lesi komplet dan inkomplet Karakteristik
Lesi Komplet
Lesi Inkomplet
Motorik
Hilang di bawah lesi
Sering (+)
Protopatik (nyeri, suhu)
Hilang di bawah lesi
Sering (+)
Propioseptik( joint position, vibrasi) Hilang di bawah lesi
Sering (+)
Sacral sparing
negatif positif
Ro. vertebra
Sering fraktur, luksasi, Sering normal
atau listesis You're Reading a Preview MRI (Ramon, 1997, data 55 pasien Hemoragi (54%),
Edema (62%),
cedera medula spinalis; 28 komplet, Kompresi (25%),
Kontusi (26%),
Unlock full access with a free trial.
27 inkomplet)
Download With Free (11%) Trial Kontusi
normal (15%)
Pemeriksaan Tabel 3. Rekomendasi AISA untuk pemeriksaan neurologi lokal
Master your semester with Scribd Otot (asal inervasi) & The New York Times M. deltoideus dan biceps brachii (C5) Special offer for students: Only $4.99/month.
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Abduksi bahu dan fleksi siku
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
Search document
M. illiopsoas (L2)
Fleksi panggul
M. quadricep femoris (L3)
Ekstensi lutut
M. tibialis anterior (L4)
Dorsofleksi kaki
M. extensor hallucis longus (L5)
Ekstensi ibu jari kaki
M. gastrocnemius-soleus (S1)
Plantarfleksi kaki
Sensoris Dermatom
You're Reading a Preview Unlock full access with a free trial.
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Tabel 2. Komparasi Karakteristik Cedera Medula Spinali Master your semester with ScribdKlinik Sindrom Read Free Foron 30this Days Sign up to vote title & The New York Times Useful Not useful Karakteristik Central Cord Anterior Cord Brown Sequard Posterior Cord Special offer for students: Only $4.99/month.
Klinik
Syndrome
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Syndrome
Syndrome
Syndrome
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CASE MYELOPATHY-
of 16
komplet
Mielopati [Dr. Usman G
Search document
desenden);
lesi; ggn traktus descenden
biasanya
desenden (+)
ringan
bilateral Protopatik bervariasi
Sering
hilang Sering
Gangguan
total(ggn
tractus total (ggn tractus bervariasi
tidak khas
hilang Gangguan
ascenden);bilateral ascenden)
biasanya
Kontralateral Propioseptik Jarang sekali
Biasanya utuh
terganggu
Hilang
ringan
total Terganggu
ipsilateral;
ggn
tractus ascenden Perbaikan
Sering
nyata Paling
dan cepat;
diantara khas Lainnya
kelemahan
buruk Fungsi
buruk, NA
namun independensi paling
tangan dan jari Baik You're Reading a Preview menetap
Unlock full access with a free trial.
Download With Free Trial PEMERIKSAAN PENUNJANG •
Pemeriksaan laboratorium darah
•
Pemeriksaan radiologis. –
Dianjurkan
melakukan
pemeriksaan
posisi
stand
(anteroposterior, lateral) untuk vertebra servikal, dan posisi ap
Master your semesterlateral withuntuk Scribd Read Free Foron 30this Days vertebra thorakal dan Signlumbal. up to vote title & The New York Times useful Useful Not Pada kasus-kasus yang tidak menunjukkan kelainan •
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radiolog
pemeriksaan lanjutan dengan ct scan dan mri sangat dianjurkan. Magnet
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
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dengan cedera medula spinalis komplet hanya memiliki peluang 5% untu kembali normal. •
Namun demikian penggunaannya sebagai terapi utama cedera medu
spinalis traumatika masih dikritisi banyak pihak dan belum digunaka sebagai standar terapi •
Kajian oleh Braken dalam Cochrane Library menunjukkan bahw
metilprednisolon dosis tinggi merupakan satu-satunya terapi farmakolog
yang terbukti efektif pada uji klinik tahap 3 sehingga dianjurkan untu digunakan sebagai terapi cedera medula spinalis traumatika. •
Tindakan rehabilitasi medik merupakan kunci utama dalam penangana
pasien cedera medula spinalis. Fisioterapi, terapi okupasi, dan bladd training pada pasien ini dikerjakan seawal mungkin. •
Tujuan utama fisioterapi adalah untuk mempertahankan ROM ( Range
Movement ) dan kemampuan mobilitas, dengan memperkuat fungsi oto otot yang ada. •
You're Reading a Preview Lesi medula spinalis komplet yang tidak menunjukkan perbaikan dalam 7 Unlock full access with a free trial.
jam pertama, cenderung menetap dan prognosisnya buruk. •
Download Free Trial Cedera medula spinalis tidakWith komplet cenderung memiliki prognosis yan
lebih baik. Apabila fungsi sensoris di bawah lesi masih ada, mak kemungkinan untuk kembali berjalan adalah lebih dari 50% •
Metilprednisolon merupakan terapi yang paling umum digunakan untu
cedera medula spinalis traumatika dan direkomendasikan oleh Nation
Institute with of Health di Amerika serikat. Master your semester Scribd Read Free Foron 30this Days Sign up to vote title Terapi okupasional terutama ditujukan memperkuat & The New York Times Useful untuk Not useful •
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fungsi ekstremitas atas, mempertahankan kemampua
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CASE MYELOPATHY-
Mielopati [Dr. Usman G
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PROGNOSIS •
Sebuah penelitian prospektif selama 27 tahun menunjukkan bahwa rat
rata harapan hidup pasien cedera medula spinalis lebih rendah dibandin
populasi normal. Penurunan rata-rata lama harapan hidup sesuai deng
beratnya cedera. Penyebab kematian utama adalah komplikasi disabilit neurologik yaitu : pneumonia, septikemia, dan gagal ginjal •
Penelitian Muslumanoglu dkk terhadap 55 pasien cedera medula spinal
traumatik (37 pasien dengan lesi inkomplet) selama 12 bulan menunjukka
bahwa pasien dengan cedera medula spinalis inkomplet akan mendapatka perbaikan motorik, sensorik, dan fungsional yang bermakna dalam bulan pertama.
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