Case Report

Febriena Amalia
030.11.097

Mentor :
Dr. Ronny Yoes Sp.S

KEPANITERAAN KLINIK ILMU SARAF

RS AL DR MINTOHARDJO
PERIODE 16 Mei 17 Juni 2016
FAKULTAS KEDOKTERAN UNIVERSITAS
TRISAKTI
JAKARTA

Identity
Name : Mr. RB
Gender : Male
Age : 50 years old
Address : Cileduk
Date of hospital admission: May 26 th, 2016
Marital Status : Married
Education : Senior High School
Room : Numfor Island (May 29th 2016)

Main complaint
Unconscious 2 hours before admitted
to the hospital

History of present illness

This patient was being unconscious since 2 hours before
admitted to the hospital. He was found in his offices toilet by the
security guard who felt suspicious when the patient didnt came
out from the toilet for about an hour. After that, the security
guard forced open the toilet door and the patient was found
unconscious and remain in unconscious state until he brought to
the hospital an hour later. At the Emergency Departement, he
got his head scanned and found a Haemorragic Stroke with
Intra Ventricular Bleeding.
The doctor directly performed a surgery to plant a VP Shunt.
The surgery done succesfully and the patient moved to the
Intensive Care Unit (ICU) . He got the treatment at the ICU for
about 3 days and his consciousness was slowly increased. He
was moved to Numfor Island when his condition has stabilized.

Since a month ago he often complained of

having a mild headache described as a
tight feeling on the back of his head.
But he refused to go to the doctor. He
usually tried to take a rest or took a
headache drugs like bodrex and felt the
headache lessen. No nausea, vomit,
convulsion, fever, or extremity weakness
admitted. Theres no history of head
injury

Past medical history

This was his first time. Hypertension (+) 2
years ago, uncontrolled. diabetes (-), lung and
heart problems (-), tumor/cancer (-)

Family history
Cancer (-), hypertension (+) father,
diabetes (-), lung and heart problems (-)
tumor (-)
Social-economy and personal history
Good. Smoking (-) coffee (-)

Objectives

General condition
: somnolence
Level of consciousness : E3, M6, V5
(GCS = 14)
Vital sign

Blood pressure : 140/80

Heart rate
: 90x/min
Respiration rate : 21x/min
Temperature : 37,6C

General examination : normal

Localized Status

Head
1 post operation wounds on right side
of the posterior temporal region.
Stitches condition are good, dry, blood
(-), pus (-), drainage (-)

Neurological examination

Meningeal sign

Nuchal rigidity : Brudzinsky I

:Brudzinsky II
:Laseque
:Kernig
:-

Cranial Nerves

NI
:N II
: hard to evaluate
N III, IV, VI : hard to evaluate, direct/indirect
light reflexes +/+ , pupils isocoria 2mm/2mm
NV
: hard to evaluate
N VII
: within normal limits
N VIII
:N IX, X
:N XI
: hard to evaluate
N XII
: hard to evaluate

Sensibilities: hard to evaluate

Motoric
: slight lateralization to the right
Reflexes
Physiological : bisep +2/+2
: Trisep +2/+2
: Patella +2/+2
: Achilles +2/+2
Pathological
: Babinsky -/: Chaddock -/: Hofman-tromner -/-

Laboratory Findings
29/5/2016
Diff count
WBC
: 17.100/L
Basophils
:0
RBC
: 5. 04 mil/dL
Eosinophils : 1
Hb
: 14,7 g/dL
Neutrophils
Ht
: 44 %
rod
:2
Platelets : 259.000 /L
segment : 69
Lymphocytes : 25
Monocyte
:3

Electrolytes
Natrium : 138
Kalium : 3.00
Cloride: 103
30/5/2015
Renal function
Ureum : 39
creatinine : 1.0 mg/dL

Radiology Findings

CT scan ( non- contrast) 26/5/2016

Head Ct Scan without

contrast
Brain window axial
- Hyperdensitic Lesion in
the left paraventricle and
intra ventricle
- Ventricular system
stretched
Results :
Left cerebral dan
intraventricular
hemorrhage
Internal cerebral

Diagnose

Dx 1
: Unconsiousness, post VP

Clinical
shunt
Ethiological : Hemorrhagic Stroke
Topical : Intra Ventricular
Pathological : Hemorrhage
Dx 2
Hypertension
Dx 3
hypokalemia

Treatment

Head 30
elevation
NGT
Urine catheter

IVFD NaCl 0,9% + KCL 250meq 12

dpm
Manitol
4 x 150cc
Transamin 3x1
Ceftriaxone 3x1gr
Gentamicin 1x320gr
Vit K3x1
OMZ2 x 40mg
Dexamethasone 3 x 1 amp
Neulin 2 x 500mg
Sanmol
3x1
Amlodipin 1x10mg
Captopril 3x25mg

Resume

Patient named Mr.RA being unconscious since 2

hours before admitted to the Hospital and complained
having a mild headache since a month ago. General
condition somnolence, GCS 14, Vital sign BP 140/80,
HR 90x/min, RR 21x/min, temp 37,6C. There is an
operation wound on the right side of temporal
posterior region, in good condition. There are no
Meningeal signs, cranial nerves mostly hard to
evaluate except N III pupils isocoria 2mm/2mm,
direct-indirect light reflexes -/- and N VII which has
normal result. Physiological reflexes +2/+2 upper and
lower extremities. Pathological reflexes -/-. Lab
findings leukocytosis and hypokalemia. CT scan
without
contrast
shows
Left
cerebral
dan
intraventricular hemorrhage and Internal cerebral

Prognosis
Ad vitam
: dubia ad malam
Ad functionam : dubia ad malam
Ad sanationam : dubia ad malam
Poor prognosis

Thank you