Case Presentation

Mr. S with Ischaemic Stroke

Presented by : Meilani Rose
03012166
Supervisor :
Dr. Ronny Y
 Identity
• Name : Tn S
• Date of birth : 01 / 11 / 1944
• Age : 73 years old
• Gender : male
• Marital status : married
• Address : Jemur
andayani XX / 46 Surabaya
• Admission date : 10 / 12 / 2017
 Anamnesis

• Chief Complaint : can’t

move the left side limb

• Additional complaint : difficulty

talking , headache
History of current disease

16/12/17
Patient feel that
get a headache
15/12/17 like heavy at
Already better, back head and
doctor planed shoulders 
the patient to numbness at
going home and left leg  cant
10/12/17 continue with move the left
hospitalized homecare , upper and lower
because of when wait the limbs and
febrile, anemia, reasuld of FNAB difficulty talking
limfadenopati
colli dextra
• History of Past disease : pastient
never get same symptom like this,
HT (+) controlled , hyperlipidemia ,
achalasia , patient never get stroke
attack before.
• History of Family Disease : -
• Daily medicine : amlodipin 1x10
mg
Physical examination
• At Selayar Saturday 16/12/17
General condition :
GCS : E4 V6 M5 , compos mentis
BP : 130/80 mmHg
Heart Rate : 88x / min
Respiratory rate : 20x /min
Temperature : 36,7 º C

General examination : abnormal finding

Enlarged of right colli lymphnode
Neurologic examination
Meningeal sign :
stiff neck : (-) Cranial nerve lesion :
brudzinsky I : (-/-) VII dextra central
brudzinsky II : (-/-) XII dextra central
laseque : (-/-)
kernique : (-/-) Pupil Isocor Ø 3mm/ 3mm
DLR +/+ ILR +/+
Physiological reflex : Pathological Reflex :
Bisep : ++/++ Hoffman : -/-
Trisep : ++/++ Tromner : -/-
Patella : ++/++ Chaddock : -/-
Achilles : ++/++ Babinski : -/+
Muscle strength :
5555I3333
5555I2222
Additional examination
• Laboratorium
14/12/17  Fasting Blood Sugar
level : 155 mg/dL
• CT Scan
Brain CT without contrast
CT scan result
 Summary
• Mr S, 73 years old, was hospitalized on Sunday
10/12/17 because of febrile, anemia and right
limfadenopathy colli. The day when patient can
go home and continued with home care ,
patient become can’t move his left side limbs
and difficulty talking. A few moments before,
patient feel heavy at back head and shoulders
and numbness. He has hypertension before
and controlled with amlodipin, beside that he
has history of hyperlipidemia. He never get the
same symptom before.
• From physical examination we get that
patient compos mentis GCS = 15, BP =
130/80 mmHg, HR 88x/min, RR 20x/min,
T 36,7 ºC. We get the enlarged of right
colli lymphnode.
• Neurological examination found : paresis
N VII and XII right central and left
hemiparesis
• Brain CT Scan result there is no
intracranial hemorrhage
 Working Diagnostic
AX1
• Clinic : hemiparesis sinistra,
paresis N VII and XII dextra central
• Etiologic : Ischemic Stroke
• Topic : Right Cortex cerebri
• Pathologic : Infarction
AX2
- Lymfadenopathy colli dextra , achalasia,
hypertension , dyslipidemia
 Therapy
• IVFD RL /12 h
• Citicolin injection 2x500mg IV
• Ranitidin Injection 2x1 IV
• Aspilet tablet 1x80mg
• Levofloxacyn caps 1x500mg
• Salbutamol 2x2mg
• Codein 3x10mg
• Metformin 1x500mg
Follow up (17/12/2017)
• S : left side paralysis
• O : E4 V6 M5
BP : 110/60 , HR : 82x/min , RR 36,7ºC
Neurologic status :
Pupil isocoria , DLR +/+, NDRL +/+
paresis NVII , NXII central dextra
Motoric strength : 5555I2222
5555I2222 RF = B : ++/++ RP = B : -/+
T : ++/++ C : -/-
P : ++/++ H : -/-
A : ++/++ T : -/-
• AX1 : C = hemiparesis sinistra , paresis NVII XII central dextra
E = IschemicStroke
T = right cortex cerebri
P = Infarction
• AX2 : Right lymphadenopathy colli, achalasia
• P : add Mefenamic acid 1x500 mg
 Follow Up 18/12/17
• S : uncomfortable at stomach, nausea, defecate yet
• O : E4 V6 M5
BP : 110/80 , HR : 82x/min , RR 36,3ºC
Neurologic status :
Pupil isocoria , DLR +/+, NDRL +/+
paresis NVII , NXII central dextra
Motoric strength : 5555I1111
5555I1111 RF = B : ++/++ RP = B : -/+
T : ++/++ C : -/-
P : ++/++ H : -/-
A : ++/++ T : -/-
• AX1 : C = hemiparesis sinistra , paresis NVII XII central dextra
E = IschemicStroke
T = right cortex cerebri
P = Infarction
• AX2 : Right lymphadenopathy colli, achalasia , dyspepsia
• P : IVFD RL  NACL 0,9% / 12 h, Extra 3 tablet aspilet 80 mg
Add Laxadyn Syr 3x1C
 Follow Up 19/12/17
• S : nausea , discomfort on the stomach
• O : E4 V6 M5
BP : 120/00 , HR : 86x/min ireguler , RR 36,7ºC
Neurologic status :
Pupil isocoria , DLR +/+, NDRL +/+
paresis NVII , NXII central dextra
Motoric strength : 5555I1111
5555I1111 RF = B : ++/++ RP = B : -/+
T : ++/++ C : -/-
P : ++/++ H : -/-
A : ++/++ T : -/-
• AX1 : C = hemiparesis sinistra , paresis NVII XII central dextra
E = Stroke Ischemic
T = Kortex cerebri dextra
P = Infarction
• AX2 : Right lymphadenopathy colli, achalasia , dyspepsia
• P : add bisolvon syr 3xC1
co : Rehab and cardio
Follow Up 20/12/2017
• S : nausea , discomfort on the stomach
• O : E4 V6 M5
BP : 120/00 , HR : 82x/min ireguler , RR 36,7ºC
Neurologic status :
Pupil isocoria , DLR +/+, NDRL +/+
paresis NVII , NXII central dextra
Motoric strength : 5555I1111
5555I1111 RF = B : ++/++ RP = B : -/+
T : ++/++ C : -/-
P : ++/++ H : -/-
A : ++/++ T : -/-
• AX1 : C = hemiparesis sinistra , paresis NVII XII central dextra
E = Ischemic Stroke
T = right cortex cerebri
P = Infarction
• AX2 : Right lymfadenopathy colli, achalasia , dyspepsia
• P : continued
 STROKE
• The damaging or killing of brain
cells starved of oxygen as a result
of the blood supply to part of the
brain being cut off. Types of stroke
include ischaemic stroke caused
by blood clots to the brain, or
haemorraghic stroke cause by
bleeding into the brain
ISCHEMIC STROKE
Ischemic stroke (see the image
below) is characterized by the
sudden loss of blood circulation to an
area of the brain, resulting in a
corresponding loss of neurologic
function. Acute ischemic stroke is
caused by thrombotic or embolic
occlusion of a cerebral artery and is
more common than hemorrhagic
stroke.
 ETIOLOGI
Ischemic strokes result from events that limit or
stop blood flow, such as extracranial or
intracranial thrombotic embolism, thrombosis in
situ, or relative hypoperfusion. As blood flow
decreases, neurons cease functioning. Although
a range of thresholds has been described,
irreversible neuronal ischemia and injury is
generally thought to begin at blood flow rates of
less than 18 mL/100 g of tissue/min, with cell
death occurring rapidly at rates below 10 mL/100
g of tissue/min
 RISK FACTOR
Unmodified
• Age
• Race
• Sex
• Ethnicity
• History of migraine headaches [20]
• Fibromuscular dysplasia
• Heredity: Family history of stroke or
transient ischemic attacks (TIAs)
Modified : • Transient ischemic attacks
• Hypertension (the most
important)
• Diabetes mellitus
• Cardiac disease: Atrial
fibrillation, valvular
disease, heart failure,
mitral stenosis, structural
anomalies allowing right-
to-left shunting (eg, patent
foramen ovale), and atrial
and ventricular
enlargement
• Hypercholesterolemia
(TIA)
• Carotid stenosis
• Lifestyle issues: Excessive
alcohol intake, tobacco
use, illicit drug use,
physical inactivity [23]
• Obesity
• Oral contraceptive
use/postmenopausal
hormone use
• Sickle cell disease
 Sign and Symptom
• Abrupt onset of • Dysarthria
hemiparesis, • Facial droop
monoparesis, or • Ataxia
(rarely) quadriparesis
• Vertigo (rarely in
• Hemisensory deficits isolation)
• Monocular or • Nystagmus
binocular visual loss
• Aphasia
• Visual field deficits
• Sudden decrease in
• Diplopia level of
consciousness
 Medication
• Anticoagulation
• Reperfusion
• Antiplatelet
• Neuroprotective
THANK YOU