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8/9/2019 Refleksi Kasus hemiparese
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REFLEKSI KASUS
Iin Astria
G 501 09 080
8/9/2019 Refleksi Kasus hemiparese
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Identitas
• Nama: Ny.S
• Umur: 60 taun
•
!enis Ke"amin: #erem$uan• A%ama: Is"am
• A"amat: La&uan
• '%" #emeri(saan: )5*09*)01+
• ,asu( RS: )5*09*)01+
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Anamnesis
• Ke"uan Utama:
masu( den%an (e"uan ti&a - ti&a (a(i (iri terasa&erat
•
In/rmasi tentan% (e"uan utama:(e"uan dirasa(an sea( (emarin saat sedan%&era"an. Sa(it (e$a"a*23mua"*23munta*23$enurunan (esadaran*23demam*23 sa(it (e$a"a
(r/ni( $r/%resi*23 terseda( saat minum42. '$ertama sete"a seran%an 107100 mm%3 'rata) 1607*mm%.
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#emeri(saan Fisi(
• Kesan: sa(it sedan%
• Kesadaran: /m$/s mentis
•
Gi;i: &ai(• ': )007110 mm%
• N: 9< =7menit
•
S: +63</ • R: )<=7menit
• Anemi *23 I(terus *23 Sian/sis *2
8/9/2019 Refleksi Kasus hemiparese
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• '/ra=
Ins$e(si: Res$irasi dadasimetris7&i"atera"
#a"$asi: ,assa *23 #er%era(an dada&i"atera"
#er(usi: #aru S/n/r23 >atas antun%
n/rma"3 &unyi $e(a(Aus(u"tasi: #aru ?esi(u"er2 dan !antun%S1 dan S)3 &unyi tam&aan *2
8/9/2019 Refleksi Kasus hemiparese
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• A&d/men
Ins$e(si: ,assa *23 da"am &atasn/rma"
Aus(u"tasi: #erista"ti( usus 42
#er(usi: >unyi tym$ani di < (uadran3#em&esaran e$ar *23 "ien *2
#a"$asi: Nyeri te(an *2
8/9/2019 Refleksi Kasus hemiparese
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Status Neur/"/%is
• GS: E< ?5 ,6
• Ner@us (rania"
• N.I /"a(t/rius2 : #en%idu :N/rm/smia
• * N.II /$ti(us2 : S
• * Ketaaman #en%"iatan676 676
• * La$an%an #en%"iatan n/rma" n/rma"
8/9/2019 Refleksi Kasus hemiparese
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• N.III3 I?3 ?I
• e"a (e"/$a( mata
– #t/sis : *2
– E=/ta"mus : *2
• #/sisi &/"a mata
• #u$i" : S
* U(uran7&entu( +mm7&u"at+mm7&u"at
• * Is/(/r7anis/(/r is/(/r is/(/r
• * ReBe(s Caaya "an%sun% n7n n7n
• 7ta( "an%sun%
• ReBe(s a(/m/dasi n/rma" n/rma"
• Gera(an &/"a mata :
#arese (eara * *
Nista%mus * *
8/9/2019 Refleksi Kasus hemiparese
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• N.? 'ri%eminus2 :
DSensi&i"itas : S
* N.?1 : n/rma" menurun
* N.?) : n/rma" menurun
* N.?+ : n/rma" menurun
• D,/t/ri( : Ins$e(si
• istiraat7men%%i%it2• DReBe(s da%u7masseter : n/rma"
• DReBe(s /rnea : n/rma"
8/9/2019 Refleksi Kasus hemiparese
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• * N.?II FaCia"is2:
D,/t/ri( :
m. Fr/nta"is m. r&i(. /(u"i m. /r&i(. ris
n7n n7menurunn7menurun
D#en%eCa$ )7+ "ida &a%ian de$an : n/rma"
• * N. ?III Aus(u"tasi2 :
• D#enden%aran : n/rma"7 menurun• D'est rinne7e&er : tida( di"a(u(an
• Dun%si @esti&u"aris : tida( di"a(u(an
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•
N. I7 G"/ss/$arin%eus7@a%us2 :D#/sisi ar(us $arin(s istiraat7AA2 :
simetris
DReBe(s te"an7munta : menurunD#en%eCa$ 17+ "ida &a%ian &e"a(an%
:n/rma"
DF/nasi :4
D'a(i(ardi7&ardi(ardi :*
8/9/2019 Refleksi Kasus hemiparese
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• N. I ACCeC/rius2 :
D,ema"in%(an (e$a"a den%an7tan$a taanan : n/rma"
DAn%(at &au : n/rma"
• N. II y$/%"/sus2
De@iasi "ida : *
DFasCiCu"asi : *
DAtr/ :4D'rem/r :*
DAta=ia
8/9/2019 Refleksi Kasus hemiparese
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e=tremitas su$eri/r e=tremitas ineri/r
• ,/t/ri(:
#er%era(an: n7nn7n
Ke(uatan: 57<57<
>entu( /t/t: eutr/7eutr/ eutr/7eutr/
'/nus /t/t: n7nn7n
• ReBe(s Fisi/"/%is
>iCe$s: n7n
'riCe$s: n7n
Radius: n7nU"na: n7n
#ate"a: n7n
ACi""es: n7n
• K"/nus
Lutut *7*Ka(i*7*
8/9/2019 Refleksi Kasus hemiparese
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E=tremitas su$eri/r E=tremitas ineri/r
• ReBe(s $at/"/%is
/man: *7**7*
'r/mner:*7**7*>a&ins(i: *7**7*
add/C(: *7**7*
G/rd/n: *7**7*
SCaeer: *7**7*$$eneim: *7**7*
• Sensi&i"itas
Nyeri n7menurunn7menurun
Rasa ra&a a"us n7menurunn7menurun
8/9/2019 Refleksi Kasus hemiparese
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* Gan%%uan (//rdinasi
'es ari idun%: n/rma"7 su"it di"a(u(an
'es $r/nasi*su$inasi: n/rma"
'es tumit: n/rma"
'es $e%an% ari: n/rma"
- Gan%%uan (eseim&an%an
tes r/m&er% *2
* Gait *2
8/9/2019 Refleksi Kasus hemiparese
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Resume
anita 60 taun emi$arese sinistra3 nausea*23 @/mitin%*23sea"%ia*23$in%san*2
e&ris*23 sea"%ia (r/ni( $r/%resi *2
reBe(s si/"/%i: n/rma"
reBe(s $at/"/%is: ne%ati
N. rania":
N.? : N?1 N?) N?+
n7menrun n7menurunn7menurun
N.?II m/t/ri(
/r&i(u"aris /ris : $arese sinistra
/r&i(u"aris /(u"i : $arese sinistra
N.I3: reBe(s mene"anmenurun2
,/t/ri(: (e(uatan 57< 57<
Sensi&i"itas: ra&a a"us n7menurunn7menurun
8/9/2019 Refleksi Kasus hemiparese
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#emeri(saan $enunan%
• ara:
' : +538
> : 1+GS: 1))
8/9/2019 Refleksi Kasus hemiparese
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ia%n/sa
• ia%n/sa ("inis : emi$arese ty$iCasinistra
• ia%n/sis t/$is : emiser sere&ride=tra
• ia%n/sis eti/"/%i : su$. NS
8/9/2019 Refleksi Kasus hemiparese
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'era$i
• Anti$a"te"et : As$irin
• Anti(/a%u"an : e$arin
•
Neur/$r/te(tan : Citi(/"in• Neur/tr/$i( : >13 >63>1)
8/9/2019 Refleksi Kasus hemiparese
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#r/%n/sa
• Hua ad @itam : &/nam
• Hua ad sanati/nem : &/nam
8/9/2019 Refleksi Kasus hemiparese
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Anuran
• Fisi/tera$i
• ,ena%a $/"a ma(an
8/9/2019 Refleksi Kasus hemiparese
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is(usi
anita 60 taun emi$arese sinistra3 nausea*23@/mitin%*23 sea"%ia*23$in%san*2
e&ris*23 sea"%ia (r/ni( $r/%resi *2
reBe(s si/"/%i: n/rma"
reBe(s $at/"/%is: ne%ati
N. rania": N.?II m/t/ri(
/r&i(u"aris /ris : $arese sinistra
/r&i(u"aris /(u"i : $arese sinistra
N.I3: reBe(s mene"anmenurun2
,/t/ri(: (e(uatan 57< 57<
Sensi&i"itas: ra&a a"us n7menurunn7menurun
8/9/2019 Refleksi Kasus hemiparese
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• Ka(i terasa &erat ti&a - ti&a saat &era"anmenunu((an suatu (e"ainan Cere&r/@as(u"arstr/(e2
• 'ida( ada demam menanda(an tida( ada ine(si
• 'ida( ada sa(it (e$a"a (r/ni( $r/%resimenanda(an &u(an dise&a&(an tum/r
• Riayat trauma + &"n yan% "a"u ta$i tida(
men%e"u(an nyeri (e$a"a sete"a (eadian itumenunu((an &u(an dia(i&at(an trauma
• Riayat ,*2 menanda(an &u(an $/"ineur/$ati
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• Saat (eadian tida( ada sa(it (e$a"a3tida( ada munta dan tida( ada$enurunan (esadaran menunu((an
sus$. NS
• ari $emeri(saan neur/"/%idida$at(an $arese e=tremitas
sinistra3 i$/anstesia e=tremitassinistra3 $arese ner@us Crania"sinistra menunu((an suatu
emi$arese ty$iCa" sinistra
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• 'era$i
mena%a 5>
mena%a A>anti an%resi tr/m&/sit: as$irin 80 m%7ari
neur/$r/teCtan : CitiC/"in )00m%71) am
neur/tr/$i( : >13>63>1)
si/tera$i
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• 'ida( di&eri(an antii$ertensi (arenasist/" te(anan daranya masi di&aa ))0 mm% dan masi ase
a(ut 1 min%%u2 (arena da$atmem&uat daera yan% masi n/rma"dise(itar deara inra( $enum&ra2
a(an i(ut mati a(i&at sir(u"asi dara(e /ta( &er(uran%
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