Joincase ALVIN

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    NEUROPSYCHIATRY JOIN

    CASE

    Consultants:Abdulloh Machin, dr. Sp.S

    Didi Aryanto, dr. Sp.KJ (K)

    Presented by: Alvin Rahmawati, dr.

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    CASE REPORT2

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    IDENTITY

    Name : Mr. A

    Age : 42 y.o

    Sex : Male

    Address : Semampir Gang Kelurahan107, Surabaya

    Religion : Moslem

    Occupation : - Marital status : Divorced

    Hospitalized : March 17, 2013

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    ANAMNESIS

    Chief complaint: seizure

    History of present illness:

    Patient had seizure 1x, 4 hours before admission

    when sleeping the night (at 02.30 am),

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    ANAMNESIS

    At ER, patient had seizure, 1x, type of seizure

    was similar. After wake up, he was mumble.

    Half body weakness (-), numbness/tingling (-),

    slurred speech (-),visual disturbances (-), hearingdisturbance (-), micturition and defecation

    difsturbances (-) forgetfulness (-), not

    understoodable communication (-), wandering (-),

    other behaviour changes (-).

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    ANAMNESIS

    Patient had been seizure when he was 16 yo. He

    always had mumble after seizure.

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    ANAMNESIS

    History of past illness:

    Neoplasma(-), Infection(-), Stroke(-),

    Hypertension(-), DM (-), Febrile convulsion(-)

    Psychiatric outpatient clinic haloperidol tab

    2x0.5 mg

    Neurology outpatient clinic carbamazepin2x200mg, vit B6 1x1, as folat 1x1

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    GENERAL EXAMINATION

    Vital Signs :

    BP 120/ 80mmHg; PR 80x/m,regularly ; RR20x/mnt ; T 36,5C

    Head & Neck : A-/I-/C-/D- ; JVP not increased ;Bruits carotid -, solid mass in the cervicallymphonodi (-)

    Chest :

    - Cardiac : S1, S2 single ES-/G-/M-

    - Lung : Ves / Ves, Rh-/-, Whz-/-

    Abd : H/L not palpable, peristaltic (+)N

    Extremities : Warm, edema -/-

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    NEUROLOGICAL

    EXAMINATION

    GCS : 456 Meningeal sign : Nuchal rigidity -, Br I-IV : -/- Cranial Nerves :

    II,III : pupil round 3mm/3mm, lightreflex +/+visus ODS: >2/60, visual field: wnl

    VII : wnl

    XII : wnlother cranial nerves wnl Motor system : 55555/ 55555, tonus: rigidity

    wnl55555/ 55555

    Sensory system : wnl

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    NEUROLOGICAL

    EXAMINATION Physiological Reflexes :

    BPR +2 /+2TPR +2 /+2KPR +2 /+2

    APR +2 /+2

    The Superficial (Cutanneous) ReflexesBHR +/+

    +/+

    Pathologic ReflexesBabinski sign -/- Chaddock sign -/-Hoffmann & Tromner sign -/-

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    NEUROLOGICAL

    EXAMINATION

    Primitive reflex : Palmomental -/-, snout (-),

    glabella (-), sucking (-), graps (-)

    CV / ANS : wnl

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    LABORATORIUM

    Leu : 13.800

    Hb : 13.2

    Tromb : 376.000

    RBG : 119 mg/dL

    SGOT/SGPT : 31/20

    BUN/SK : 5/0.9

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    Ro THORAX-PA

    Cor/pulmo wnl

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    Results: Abnormal EEG III (anterior

    temporal sharp wave in the right and left,

    and general CSA)

    Abnormal EEG indicates potentialepileptogenicity in bilateral anterior

    temporal region with mild diffuse

    encephalopathy

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    HEAD MSCT WITH

    CONTRAST

    Within normal limit

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    NEUROBEHAVIOUR

    EXAMINATION

    1. Atensi : 4 digit (abnormal)

    2. Vigilance (konsentrasi) : ommision error : 0

    comission error: 0

    (normal) 3. Token test : 36 (normal) mild

    4. MMSE : 27 (normal)

    5. CDT : 4 (normal)

    6. Constructional praxis : 12 (normal)

    7. Mirror test : normal

    8. Trail making test : >180 detik(abnormal)

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    NEUROBEHAVIOUR

    EXAMINATION

    9. Visual memory : 12/12 (normal)

    10. Verbal memory : 7.5/10 (abnormal)

    11. Categorical naming : 10 (abnormal)

    12. Delay recognition task : I.5 II.6 III.8 (total

    19) normal

    There are abnormal results in attention, trail

    making B, verbal memory, and categoricalnaming which could be caused by underlying

    disease. Long term use haloperidol could

    affect cognitive function

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    DIAGNOSIS

    Clinical : - status generalized tonic clonic seizure

    -behaviour changes

    Topical :

    Etiological: psychotic epilepsy

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    MANAGEMENT

    1. PHARMACOTHERAPY:

    - Psychiatry: haloperidol 2x0.5 mg tab

    - Neurology: carbamazepin 2x200mg, folic

    acid 1x1, piridoxin 1x1

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    MANAGEMENT

    2. Supportive Psychotherapy

    3. Family psychoeducation

    4. Re-test neurobehaviour examination in next

    3 months.

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    THANK YOU22