Stroke Unit Duty Report Widya SEPTEMBER 23RD, 2014

8/18/2019 Stroke Unit Duty Report Widya SEPTEMBER 23RD, 2014

1/18

Stroke Unit Duty Report

Tuesday September 23rd, 2014

ER: dr. SaptariConsutant : dr. !sna"an

Stroke Unit : dr. #idya

#ard: dr. $andu


2/18

Patient Identity

• %ame : &r. '

• ()e : 2* years od

•

(ddress : +ombe $ermai, Semaran)• --upation : $riate

• Cass : !/ $S

•Room : Stroke Unit

• &RS : September 23rd, 2014

• R& no. : C4022


3/18

•

Main Problem : Altered consciousness• Location : intracranial

• Onset : ± 1 hour before admission

• Quality : No respons with pain stimulus.

• uantitas : A!L helped by family.

RECENT HISTORY


4/18

"ronolo#y:

± 1 hour before admission$ after patient arri%ed home from dro%ehis wife to wor&$ he suddenly %omit many times$ and patient had

sei'ure$ #enerally$ for about 1() minutes. After that$ patient

seemed sleepy and difficult to wo&e. *hen his family too& him to

+anyumani& hospital$ but his consciousness &eep decreased.Patient reffered to ariadi ,ospital about - minutes later.

,eadache /(0$ etremity paralyse /(0$ numbness /(0.


5/18

A##ra%atin# factor : /(0

2elie%in# factor : /(0

Other 3ymptomp : /(0


6/18

• PAST HISTORY

- ,aemorrha#ic stro&e /40 in cerebellum 5uni )16$

se7uellae /(0- ,ead trauma /(0.

- ,ipertension /(0

- !M /(0

• FAMILY HISTORY

- Stroke 56

• SOCIAL-ECONOMY HISTORY

Cass 1 $S keas 1, kesan sosiaekonomi -ukup


7/18

$7ysi-a E8amination

• +CS E1&19ET

• 9ita Si)n :

$: 1;/100 mm


8/18

%EUR?+!C(? ST(TUS,ead : Mesocephal$ 3imetris

8ye : Pupil round$ iso&hor$ 9 -$mm;-$ mm$ li#ht refle (;(

Nec& : nuchal ri#idity /(0

Nn "ranialis : li#ht refle (;(

corneal refle (;(

doll eye (;(

%a#al refle /(0


9/18

Motorik Superior Inferior

&oement 5/5 5/5

Stren)t7 o@ &otori- ?ateraisation 56

Tonus %/% %/%

Trop7y E/E E/E

$7ysioo)i- ReAe8 5/5 5/5

$at7oo)i- ReAe8 5/5 5/5

Conus 5/5

• Sensibiity : -anBt be a--essed

• 9e)etatie state : DC 6, urine erni7


10/18

PEMERIKSAANPENN!AN"


11/18

?aboratory E8amination 22/0/2014PT ##$%

$$T 10,4 TT 40,2

($TT 34

S+T 3;

S+$T 3*

(kai$7ospatase

2

+amma +T 1

Tota iirubin 0,*;

Dire-t iirubin 0,12

$rotein Tota ,1


12/18

pH ($#'

pC2 ;

p2 2;


13/18


14/18

R t7ora8

• S7ape and o-ation o@t7e 7eart norma

• !nGtrat in t7e ri)7tpara-ardia


15/18

I) C*ini+a* ,iano.ti+ : (tered

-ons-iousness Topi. ,iano.ti+ : pons,

-erebeum Etio*oy ,iano.ti+ : S< !C


16/18

Prora0

• !9FD R? 20 tpm• !n. Ce@tria8one 2)r/247rs !96•

!n. Ranitidin ;0m)/127rs !96• !n. (sam Trane8amat 1 )r/*7rs !96T1erapy


17/18

• 9ita si)n, +CS ,%euroo)i-DeG-ite

&%!TR!%+

• D!(+%S!S, T


18/18

THANK YO

Stroke Unit Duty Report Widya SEPTEMBER 23RD, 2014

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