Spitalul Clinic Judetean de Urgenta Mure~Clinica de Neurologie I

FO 24763/2011CNP 1710814054717

BILET DE EXTERNARE/SCRISOARE MEDICALA

(iN ATENTIA MEOICULUI DE FAMILIE $1 A MEOICULUI DIN AMBULATORUL DE SPECIALITATE)

Pacientul Qurgiu Vasile in varsta de 39 de ani, domiciliat in Oradea, judetul Bihor, a fost internat in clinicanoastra in perioada 04.05.2011 -11.05.2011, cu diagnosticul:

PARAPAREZA SPASTICA FAMILIALA IN OBSERVATIE. PAREZA DE NERV SCIATIC POPLITEU EXTERNSTANG. PAREZA DE NERV SCIATIC POPLITEU EXTERN DREPT POSTTRAUMATICA. ATROFIE CEREBRALA.

Pacient, tanar, cu multiple politraumatisme in tinerete (sportiv), insa fara fracturi, cu antecedente heredo­colaterale semnificative, mama diagnosticata cu scleroza laterala amiotrofica la varsta de 70'de ani, cu fratele si soramamei cu deficit motor la nivelul membrelor inferioare, acuza debutul bolii actuale in urma cu un an, in mod insidios,prin disestezii la nivelul membrelor inferioare, urmate de deficit motor la acest nivel. Aceste acuze s-au accentuatprogresiv pana la internarea in clinica noastra.

Examenul clinic general: normostenic, facies expresiv, tegumente si mucoase normal colorate si hidratate, nuse palpeaza ganglioni mariti patologic, zgomote cardiace ritmice, fara sufluri cardiace sau carotidiene, AV SO/min, TA120170 mmHg, torace simetric, participa bilateral la miscarile respiratorii, fara raluri pulmonare, abdomen farasensibilitate la palpare superficiala sau profunda, loje renale libere, Giordano negativ bilateral.

Examenul neurologic la intemare: fara semne de irita~e meningiana, fara semne din partea nervilor cranieni, mersspastic, para paretic, stepat, mers imposibil pe calcaie bilateral, parapareza spastica grad 4, forta segmentara scazuta lanivelul labei piciorului bilateral, fara tulburari de coordonare, ROT vii, clonoide global, reflexe cutanate abdominaledeclansabile, reflexele fundului de gat dedansabile, semn Babinski prezent bilateral, semn Rossner prezent bilateral, faratulburari de sensibilitate superficiala sau profunda, fara tulburari sficteriene, fara tulburari afazice, constient, orientat, GCS 15pet.

Examinarile paracliniceProbe/e serice: hemoglobina 13,3 mg%, hematocrit 40,4 %, leucocite 4930/mmc, trigliceride S6,4 mg/dl,

colesterol196,7 mg/dl, VSH 22 mm/h, transaminaze SGPT 2S UII, GOT 45 UII, uree 31,5 mg/dl, glicemie la internare9S mg%.

Examen sumar de urina: fara modificari.

E/ectrocardiograma: RS SO/min, P-PQ normal, complexe QRS de morfologie si durata normala, faramodificari de faza terminala.

RTG pu/monara: SCO drept taiat. Fara leziuni acute pleuropulmonare, cord corespunzator varstei.PEV:unda P 100 se formeaza la OS la 119 ms, OS la 124 ms.ENG (Dr. Motataianu A.):anexat. Concluzii: traseu neurogen cu fenomene de reinervare prezente. Neuropatie

axonala nerv peronier drept.Examen FO (Dr. Arde/ean A.): papile bine delimitate, cu excavatie, CPO, artere cu reflex largit, vene usor

dilatate discreta capilaroza maculara (Oislipidemie?). TO 15-22. Recomanda reevaluare./RM c%ana c%ana cervico-dorsa/a (Dr. Opris Z.): fara evidentiarea de leziuni de semnal medular in

segmentul C-O. Amprente discale intraligamentare pe discurile 07-010.Pe perioada internarii, pacientul a beneficiat de tratament cu: antispastic central, neurotrofic, cu evolutie usor

favorabila, cu diminuarea spasticitatii la nivelul membrelor inferioare. Se externeaza cu urmatoarele recomandari:

Recomandari:

1. Pacientul revine peste 3 luni, pentru reevaluare neurologica si reevaluare ENG.2. Recomandam efectuarea in ambulator al urmatoarelor analize: ANCA, AAN, anticorpi anti Borrelia IgG si IgM,

vitamina B12.

3. Se contrainterzice consumul de bauturi alcoolice precum si fumatul.4. Este interzis vaccino si seroterapia.5. Regim alimentar normocaloric, cu hidratare corespunzatoare6. Evitarea expunerii la intemperii (frig, umezeala), tratarea infectiilor intercurente.7. Se recomanda exercitii fizice regulate.8. Tratament medicamentos cronic neintrerupt cu: Lioresal10 mg 1-1-1 tb/zi.9. Control periodic neurologic, prin policlinica teritoriala. _10. Oispensarizare prin cabinetul medicului de familie, respectarea indicatiilor din biletul de externare.

$eful cliniciiConf. Univ. Dr. Rodica Bala~aMedic primar neurolog

Medic rezidentDr. Tomos Lilla

medic rezident neurolog

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Patient: giurgiu vasile, 39 yearsData: Thursday, May OS, 2011Doctor: [Doctor name]Interference EMG

Spont. activity1: right, Mentalis, Facialis, Nucl.nJacialisSpont. activity1: left, Deltoideus, Axillaris, C5 C6Phenomena

Spont. activity1: left, Abductor pollicis brevis, Medianus, c6-tlSpont. activity1: right, Vastus latera lis, Femoralis, L2-L4Spont. activity1: left, Tibialis anterior, Peroneus, L4 L5 slInterf.1: left, Deltoideus, Axillaris, C5 C6Interpretation

Turn-amplitude analysis

Turn-arrplitude analysis

Checkup report

t-- .----_._----.---1--.- --

-----!---.-.....------ .--

- -

•-. ••1----

iiir--

--;-~. ".

--- '------,

,2,400

2,200

2,000

:s. 1,800

.g 1,600..f1 1,400

g. 1,200

~ 1,000

~ 800f- 600

400

200

oo 200 400 600 800 1,000 1,200

Turns frequency, 1/s

Interf.1: left, Abductor pollicis brevis, Medianus, c6-tlInterpretation

Turn-arrplitude analysis

-----+--- ----I

- f~~'.•-.~~i!~~-1·-- -.-

•••••-_ ..~--....-r-- -.--H", ,

2,400

2,200

2,000

:s. 1,800

.g 1,600..f1 1,400

g. 1,200

~ 1,000

~ 800f- 600

400

200

o() 200 400 600 800 1,000 1,200

Turns frequency, 1/s

Interf.1: right, V:!stus latera lis, Femoralis, L2-L4Interpretation

giurgiu vasile 5/5/2011

Turn-af11)litude analysis

II

2,500 -I~> I.::J..

C1i 2,000-c:J

~ 1,500 - ---!.~t:: I a.('0 I .• IIJ) •

E 1,000- --~+!.= I. e;.500 I· ~n

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oo 200 400 600 800 1,000 1,200

Turns frequency, 1/s

Interf.1: left, Tit ialis anterior, Peroneus, L4 L5 slInterpretationTurn-amplitude analysis

Turn-af11)litude analysis

2,400 -,2,200 -.--~. -2,000 ­

5 1,800

.g 1,600 1­~ 1,400 -~---t

~ 1,200 -il~_--!~

~ 1,000 ..•••• J~ 800-

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O -. I~~() 200 400 600 800 1,000 1,200

Turns frequency, 1/s

MUP

1: left, Deltoideus, Axillaris, C5 C6

Our,

norm,ms

108

MUP dura1ion

;Iinf1ax-j MeandUL, cur., I dUL,ms l1S ms

~T~.~_J 12.36MUP ampJitude

~in ~ Ma~qMeanl Amp!.

amp!., arr,p!., amp!., I norm,I-!V ~V l1V I !-IV126.5 20B2.9 86331475_L _

OUL Sta-

dev., ge%

-88.6 II

Ampl > 1 mVdev., amp!.,% %

+81.7 25,0

MUPcount

Poly­phase,

%37.5

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turn,%

50.0

-T Sta-MUPl

I Du'. Du,

norm, dev.,gecount

ms % ,93.0 -84.9II6

MUP

1: left, Abductor pollicis brevis, Medianus, c6-tl

MUP duralion

Min~r'1ax r-dUL, dUL, I.J!!?~L

10.05 1E.75 I__ ...L- 1

MUP ampLtude

giurgiu vasil: 5/5/2011 2

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Amp!.,Dur.,Area,AreaDist.,Tpoint ms

mVmsmVxmincrem.,mms

%----- -- rist 2.60 6.256.4523.6

--

-bow 6.556.656.9024.7-+5.0230 ,3.<--

-rist 3.758.846.3028.9

Ibow

7.508.676.5529.4+1.62103.75

Jle of the foot3.156.906.1517.1

--

-.- -10.30 4.857.4014.1-17.33907.15

Ie of the foot4.101.765.054.7

Ij of fibula

10.301.846.004.5-4.73106.20t

liteal fossa

11.651.895.054.2-7.1801.35--of the foot 4.653.525.059.7

j of fibula

10.603.885.4010.5+8.130015.95 --

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---liteal fossa 5.4510.7+1.7801.55I------.

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Amp!., Time,Lat., Dur.,Area,Dist.,__(lead)J~oints

ms.J!VmsnVxsmmms'ist

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rist

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I FminF amp!., I Mlat.,Fmin-MFmeanjM! lat., ms

uVmslat. msamD!..%-:-:-T- - 450.12.6025.804.4~iti 28.40:n1icis

27.35627.43.7523.604.6c6-tl gus,

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Checkup reportPatient: giurgiu vasile, 39 yearsData: Thursday, May OS, 2011Doctor: [Doctor name]Motor OJ

!feSt1 - --rI Lead

i4---right, Abductor di9itifl-- j m~imJ, Ulnaris~~JL __

I -rei1 left, Abductor polliCis---tv;.

_~~V~_Me~an~~-tl~11 Iright, Abductor I s

hallucis, Tibia'is, 14L5Sl

2

y--+/i9ht,Extensor ----t50

1 digitorum brevis,]'eroneus, 14~~SJ_ ~.

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I. I P

-9 -- -r left, -EXtensor- - -II'S-dig 'xurr. br"'l'is,

I ~_~l'eroneusI..14 L5Sl, __

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~.sensoryCV _,--

NerveJTest

6 I·right~-n.Ulna~s . ~

3 •left, ~Medianus i w~.lri9ht~.Surails, Sl-S2 J1

rF-~~V~()~rameters -

I Lead

-5--lrigt,t, ~bductor d__ ~lnlmJ, Uh1J~~,S;2 left. Abductor pol

r: j>,,', ;',-,","';0,"">,8 Irig':t: Peron~lJs 10

__ Per(1n~u.s,.L: SJ__10 left, Peroneus Ion

,Peroneus, L5SlT" -- - --

12 I righ~,AbductorI halllJcis,Tibialis, IL. S!Motor CV

1: right, Abductor digiti minimi, Ulnaris, C8 T1

M-wave amplitude at distal point stimulation 6.25 mV. Residual latency 1.57 ms. Velocity on wrist - elbow 58.2 m/s.Motor CV

1: left, Abduct~r p.:>ilicisbrevis, Medianus, c6-tl

M-wave arnplitude at distal point stimulation 8.84 mV. Residual latency 2.14 ms. Velocity on wrist - elbow 56.0 mjs.Motor CV

1: right, Abductor l1allucis, Tibialis, 14L5 Sl

M-wave amDlitucie at distal point stimulation 6.90 mV, Residual latency 1.87 ms. Velocity on sole of the foot - 2 54.5m/s.Motor CV

1: right, Extensor dlgitorum brevis, Peroneus, 14L5 Sl

giurgiu vas1p 5/5/2011 1

M-wave amplitude at distal point stimulation 1.76 mV. Residual latency 2.80 ms. Velocity on sale of the foot - head offibula 50.0 m/s. Velocity on head of fibula - popliteal fossa 59.3 m/s.Motor CV

1: left, Extensor digitorum brevis, Peroneus, 14L5 51

M-wave amplitude at distal point stimulation 3.52 mV. Residual latency 3.46 ms. Velocity on sale of the foot - head offibula 50.4 m/s. Velocity on head of fibula - popliteal fossa 51.6 m/s.Sensory CV1: right, n. Ulnaris

Nerve AP "3mplitude on wrist 32.1 /lV. Velocity on segment wrist 60.0 m/s.Sensory CV1: left, n.Medianus

Nerve AP ."3mplitll~~ on wrist 20.5 /lV. Velocity on segment wrist 63.2 m/s.Sensory ':.V1: righ':, ,...~.uraHs.51-52

Nerve A':) ·?'11,:,':~':C·~01 1 37.1 !J.V.Velocity on segment 1 66.7 m/s.F-wave1: right, J\~)ductor aigiti minimi, Ulnaris, C8 T1

Minimum F-wave latency 28.40 ms, maximum 36.95 ms, mean 30.53 ms, difference 8.55 ms. F-wave amplitude isnormal, rTl2an amplitude 450.1!lV. F/M-wave ratio: maximum 8.1 %, mean 4.4 %. Repeated F-waves 0.0 %. Blocks0.0 %, giant waves 0.0 %. Peripheral latency 15.00 ms.F-wave1: left, Abductor pollicis brevis, Medianus, c6-tl

Minimum r~-wave latency 27.35 ms, maximum 30.35 ms, mean 28.40 ms, difference 3.00 ms. F-wave amplitude isnormal, mean amplitude 627.4 !lV. F/M-wave ratio: maximum 18.1 %, mean 4.6 %. Repeated F-waves 23.5 %. Blocks0.0 %, gia:lt waves 17.6 %. PeriDherallatency 15.05 ms.F-wave1: right, P2roneus longus, Peroneus, L5 51

Minimum F-wave latency 39.80 ms, maximum 56.90 ms, mean 46.38 ms, difference 17.10 ms. F-wave amplitude isnormal, mean am~lItude 169.1!lV. F/M-wave ratio: maximum 8.6 %, mean 6.2 %. Repeated F-waves 0.0 %. Blocks0.0 %, gic:nt waves 0.0 %. Peripheral latency 21.53 ms.F-wave1: left, Peroneus longus, Peroneus, L5 51

Minimum r.··wave :".tency 45.05 ms, maximum 48.05 ms, mean 46.87 ms, difference 3.00 ms. F-wave amplitude isnormal, mean an",plitude 470.2 !lV. F/M-wave ratio: maximum 10.9 %, mean 9.1 %. Repeated F-waves 36.4 %. Blocks36.4 %, giant waves 0.0 %. Peripheral latency 24.30 ms.F-wave1: right, Abductor hallucis, Tibialis, 14L5 51

Minimum F-wavE: '2.':ency 77.65 ms, maximum 89.95 ms, mean 84.37 ms, difference 12.30 ms. F-wave amplitude isnormal, mean am')jitude 610.4 !lV. F/M-wave ratio: maximum 8.1 %, mean 6.2 %. Repeated F-waves 0.0 %. Blocks0.0 %, gi?nt waves 0.0 %. Peripheral latency 39.93 ms.

CONCLUSION:

giurgiu vasil,> 5/5/201:

Doctor: [Doctor name]

2

Min I Max Mean I Amp!. Ampl > 1 mV Poly- I Poly-amp!., amp!., amp!., I norm, dev., amp!., phase, turn,

I!'{_. _IJV _jJ'{~jJV % % % %876.2_ r 3165.5 218~~5 +359 83.3 83.3 16.7

MUP

1: right, Vastus latera lis, Femoralis, L2-L4

MUP duration

Min !Max ~jeandur., dur., dur..,

ms ms ms- - -10.07 29.60 15.92- --

MUP am litude

Min Max Mea~Amp!.1 Ampl > 1 mV I Poly-amp!., amp!., amp!., norm, dev., amp!., I phase,

IJ-'L- _jJV V jJV % % I %236.0 3826.7 2112.7 475 +345 68.8 !75.0

Sta­

ge

Our. TOUr.

norm, dev.,ms %

115 -86.2 III

MUP

count

16

Poly­turn,

%12.5

MUP

1: left, Tibialis anterior, Peroneus, L4 LS sl

Ampl > 1 mV Poly­dev., amp!., phase,

% % %+328 72.7 54.5

MUP duration

IMTnl r·1ax I Mean lOur. Our. I Sta-

I dur.J,dur., . dur., I norm, dev., ge~~s o11S ms ms %~-=- 23.i7_ J1~~:)8-1114 -87.7 IIIMUP amQlitude

Min! Max - Mean i Amp!.

amp!., I amp!., amp!., I norm,jJV jJV ..V t-IJY743.2 13662.6 2031.41475

MUP

count

11

Poly­turn,

%45.5

CONCLUSION:

Doctor: [Doctor name]

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Dr. An~ . Ot!tAIIiMUmedi. list neurolog. 61