Stroke Unit Duty Report

Tuesday September 23rd, 2014

ER: dr. Saptari
Consultant : dr. Isnawan
Stroke Unit : dr. Widya
Ward: dr. Pandu

Patient Identity

Name
: Mr. Y
Age : 26 years old
Address
: Gombel Permai, Semarang
Occupation : Private
Class
: I/ BPJS
Room
: Stroke Unit
MRS
: September 23rd, 2014
RM no.
: C498022

RECENT HISTORY

Main Problem : Altered consciousness

Location
: intracranial
Onset : 1 hour before admission
Quality
: No respons with pain stimulus.
Kuantitas
: ADL helped by family.

Cronology:
1 hour before admission, after patient arrived home from drove
his wife to work, he suddenly vomit many times, and patient had
seizure, generally, for about 1-2 minutes. After that, patient
seemed sleepy and difficult to woke. Then his family took him to
Banyumanik hospital, but his consciousness keep decreased.
Patient reffered to Kariadi Hospital about 30 minutes later.
Headache (-), extremity paralyse (-), numbness (-).

Aggravating factor : (-)

Relieving factor
: (-)
Other Symptomp
: (-)

 PAST HISTORY
- Haemorrhagic stroke (+) in cerebellum Juni 2014,
sequellae (-)
- Head trauma (-).
- Hipertension (-)
- DM (-)
FAMILY HISTORY
- Stroke (-)
SOCIAL-ECONOMY HISTORY
Class 1 BPJS kelas 1, kesan sosial
ekonomi cukup

Physical Examination
GCS E1M1VET
Vital Sign :
BP: 175/100 mmHg
HR : 124x /menit
RR : 12x / menit (bagging)
T : 36,3 C
SpO2: 100 %

NEUROLOGICAL STATUS
Head

: Mesocephal, Simetris

Eye

: Pupil round, isokhor, 3,5mm/3,5 mm, light reflex -/-

Neck

: nuchal rigidity (-)

Nn Cranialis : light reflex -/corneal reflex -/doll eye -/vagal reflex (-)
Gag reflex (-)

Motorik

Superior

Inferior

Movement

-/-

-/-

Strength of Motoric

Lateralisation (-)

Tonus

N/N

N/N

Trophy

E/E

E/E

Physiologic Reflex

-/-

-/-

Pathologic Reflex

-/-

-/-

Clonus

-/-

Sensibility
: cant be accessed
Vegetative state : DC (+), urine jernih

PEMERIKSAAN
PENUNJANG

Laboratory Examination 22/09/2014

Hb

15,1

PT

11,6

Ht

42,1

PPTK

10,4

Erithrocyte

TT

40,2

Leucocyte

27.500

Trombocyte

320.900

APTTK

34

Blood glucose
level

169

SGOT

35

SGPT

36

Ureum

53

Creatinine

3,09

Alkali
Phospatase

82

Mg

0,87

Gamma GT

19

Ca

2,17

Total Bilirubin

0,65

Na

141,6

3,4

Direct Bilirubin

0,12

Cl

106,7

Protein Total

8,1

Albumin

4,5

HBsAg

(-)

pH

7,15

pCO2

59

pO2

285

HCO3-

20,4

BE

-9,1

AaDO2

69

FIO2

60

PF Ratio

475

Head MSCT non Contrast

Intracerebral
Hemorrhage in pons,
vermis cerebellum and
hemisfer cerebellum
left and right
Intraventricular
Haemorrhage
Increased Intracranial
pressure TIK

RO thorax

Shape and location of

the heart normal
Infiltrat in the right
paracardial

DIAGNOSIS
I. Clinical Diagnostic : Altered
consciousness
Topis Diagnostic
: pons,
cerebellum
Etiology Diagnostic : SH (ICH, IVH)
II. Brain stem death
II. Grade II Hypertension

Program

Therap
y

IVFD RL 20 tpm
Inj. Ceftriaxone 2gr/24hrs (IV)
Inj. Ranitidin 50mg/12hrs (IV)
Inj. Asam Tranexamat 1 gr/6hrs (IV)

 Vital sign, GCS ,

MONITORIN Neurologic
G
Deficite

EDUCATIO
N

DIAGNOSIS,
THERAPY,
PROGNOSIS

THANK YOU