29. anamnesis dan diagnosis topis (dr. hendro sp.s)

7/21/2019 29. Anamnesis Dan Diagnosis Topis (Dr. Hendro Sp.s)

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History and Topical

Diagnosis in Neurology

Dr Jofzal Jannis Sp.S(K)Dr. Darma Imran SpS

Department o Neurology

aculty o !edicine "ni#ersity oIndonesia

Neuropsyc$iatry !odule %&'&%&''



earning o*+ecti#es

• T$e importance o $istoryta,ing in neurology

• Topical diagnosis in ner#oussystem

• -linical met$od

• -linical -ase



Introduction

• e enter medicine or many di/erentreasons *ut t0o most re1uently reasons 20e lo#e $umanity and science.

• 3atients and amily 0ant a doctor 0it$ 2 – 4 doctor 0$o is caring and 0$o 0ill understand

t$e patients5 pro*lems and 0$o 0ill listen6 ad#iseand support *ot$ t$e patients and t$eir amilies.

• 7ur +o* is not simply a*out ma,ing adiagnosis6 it is a*out $elping and caring orpatients 0it$ t$eir medical pro*lems.



History

• History ta,ing is usually your frstcontact 0it$ t$e patient

•It is esta*lis$es t$e oundation oryour uture relations$ip 0it$ t$epatient and t$eir amily.

• It is a time 0$en you *egin to *uild 2 – trust6 confdence and aut$ority.



History ta,ing re1uires 2

'. time6

%. s,ill6

8. concentration

9. e:perience

;. tact and diplomacy

<. patience.

your only lac, is only on point 9



-oma

• -oma $istory (rom relati#es or attendants) – 7nset o coma (a*rupt6 gradual)

– =ecent complaints ($eadac$e6 ocal 0ea,ness6#ertigo etc)

– =ecent in+ury

– 3re#ious medical illnesses (e.g.6 dia*etes6renal ailure6 $eart disease)

–3re#ious psyc$iatric $istory – 4ccess to drugs (sedati#es6 psyc$otropicdrugs)



T$e onset o coma

• Sudden onset 2 – In a pre#iously $ealt$y6 young patient 2 drugpoisoning6 su*arac$noid $emorr$age6 or $eadtrauma

– In t$e elderly 2 cere*ral $emorr$age or inarction.

• >radual onset 2 – 4 $istory o premonitory signs6 including ocal

0ea,ness suc$ as dragging o t$e leg or complaints

o unilateral sensory symptoms or diplopia6suggests a cere*ral or *rainstem mass lesion.

– !ost patients 0it$ meta*olic disorders



-ase '

• 4 ;& year old man 0it$ a sudden losto counsciouness 0$ile in t$emeeting at $is o?ce

• 3$ysical e:amination 2• @lood pressure %&&A''& mmHg

• >-S B'!9C'<

• 3in point pupil

–$ere is t$e possi*le lesion@rain lesion 2 pons



-$anges in pupils in patients 0it$ lesions atdi/erent le#els o t$e *rain t$at cause coma



-ase %

• 4 9& year oldman 0it$ let

lo0er lim* andupper lim*0ea,ness 2

–$ere is t$epossi*lelesion

S$eet @'



-ase 8

• 4 8& year oldman6 compos

mentis *ut $adan allour lim*0ea,ness 2

–$ere ist$e lesion E

S$eet @'



-ase 9

• 4 F8yearold 0oman $ad a 9days $istory o e#er6nausea6 and #omiting.

• s$e a0o,e on t$e t$ird day and ound it di?cult to 0al, tot$e *at$room6 *y t$e aternoon s$e $ad di?culty ins0allo0ing

• 3$ysical e:amination 2 – Cital sign normal6 B8!<C;. – 3upils 0ere e1ual and constricted rom 8 to % mm 0it$ lig$t6

– Diplopia 0$en try to loo, to t$e let side – letsided acial num*ness – let lo0er motor neuron acial 0ea,ness. – t$e tongue de#iated to t$e rig$t – t$e let lim*s 0ere clumsy comparing to $er rig$t side



-ase 9 2 1uestion

'. Did t$e patients $ad a neurologicalpro*lem E

– mention $er defcits

%. $ere is t$e lesion (anatomicaldiagnosis)



-ase 9 2 ans0er

• et a*ducens palsy (N. CI)

• et acial palsy (N. CII)

• et trigeminal (sensory) ner#e defcit(N.C)

• et $ypoglossal palsy (N GII)

• ..

• Where is the lesion ?



-ase 9 2 ans0er

oo, atyour -'

s$eet

3eter

Duus.%&&;a e<;



-ase 9 2 1uestion

• Is it possi*le to $a#e *rain stemlesion and at t$e same time retainrelati#ely good consciousness E



-ase 9 2 ans0er

oo, at your 4' and 4% s$eet

3lum %&&F

page%8&



-ase ;• History

– 4 % yearold man 0as riding a motor cycles6 0$en suddenly$e cras$ to anot$er motor cycle approac$ing rom t$e side. – uc,ily 4ter t$e accident $e is alert6 0it$ out a signifcant

in+ury. – urt$er in1uiry rom t$e doctor 6 re#ealed t$at in t$e past <

se#eral times $e *umped into somet$ing in $is side 0$ile0al,ing.

– He also complaint t$at $e can not get an erection since 8mont$ ago.

• 3$ysical e:amination 2 – Cital sign normal – Cisual acuity normal

– -onrontation #isual feld testing 2 perip$eral #isual feld lost on *ot$side

$at is $is pro*lem E Bye pro*lemor Neurological pro*lem E 7r *ot$ E



-ase ; 2 ans0er

3eter

Duus.%&&;a e '8'



-ase ; 2 ans0er

• $at are t$e possi*le pat$ologyunderlying t$is case E



Clinical method

• T$roug$ case ' ; 0e already

e:ercise clinical met$od tounderstand patients pro*lem



Clinical method

T$is is an orderly series o steps6as ollo0s2

'. Symptoms and signs%. 4natomic diagnosis8. 3at$ologic and etiologic diagnosis

9. 3rognosis and treatment



Symptoms and signs

• T$e undamental steps in diagnosisal0ays in#ol#e t$e accurateelicitation of symptoms and signs

and t$eir correct interpretation interms o disordered unction o t$ener#ous system.

• !ost oten 0$en t$e diagnosis is 0rong6 it 0ill*e ound later t$at t$e symptoms 0ereincorrectly interpreted in t$e frst place.



Symptoms and signs

• History and p$ysical e:amination. – symptoms and p$ysical signs considered

rele#ant to t$e pro*lem at $and are

interpreted in terms o p$ysiology andanatomy 2

• identifes t$e disorder(s) o unction

• pat$op$ysiology pat$ogenesis

• t$e anatomic structure(s) t$at areimplicated.



-onclusion

• Neurology is not a di?cult su*+ect6en+oy ta,ing care o your patients

sign and symptoms and gi#e asolution to t$eir pro*lem.



T$an, you

• Dr Jofzal Jannis Sp.S(K)

• Dr. Darma Imran SpS

• Dep o Neurology aculty o!edicine "ni#ersity o Indonesia

• correspondencedarmaimranLya$oo.com



HemiparesisPhys reflexes↑Patho reflexes ↑Cranial nerve palsy

Cortical brain fc dist

Quadry/paraparesisPhys reflexes↑

Path reflexes↑

Sensory level Autonom disturb

adi!s

"euromuscular #unction

$uscle

$onoparesisPhys reflexes %

"o path reflexesSensory & dermatome se'ment

Paralysis asendensSymmetry(P )/)

*luctuate+ recurrent Activity influencesPalpebra+ dyspha'i)disphonia

Proxymal , distal-o.er si'nuc! 'ait

"o sensory disturbances

-0S

$iastenia -ravis

29. anamnesis dan diagnosis topis (dr. hendro sp.s)

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