Case Report SNH.pptx
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Transcript of Case Report SNH.pptx
Case ReportISCHEMIC STROKE
Anggi Miranda Tanjung030.10.031
Clinical Clerkship in Neurology Department RSAL MintohardjoFaculty of Medicine Trisakti University
Supervisor: dr. Ronny Yoes, Sp.S
PATIENT’S IDENTITY• Mr. WName
• 55 y.oAge
• High schoolEducation
• Retired civil servantOccupation
• MoslemReligion
• JavaneseEthnic
• MarriedSocial status
• 28/6/2015Admission date
AUTOANAMNESIS
Chief Complaint: sudden weakness all over the body, especially left arm and leg since ± 3 hours before admission
History of Present Disease: Patient came to ER with sudden weakness all over the body, especially left arm and leg since ± 3 hours before admission. Dizziness (+), difficulty in speaking (+), nausea (-), vomitting (-), loss of conciousness (-), headache (-), seizure (-).
AUTOANAMNESIS
History of past
diseases
• Same illness before (+)
• Hypertension (+)• Heart disease (+)• Diabetes Mellitus (-)• Kidney disease (-)
Family history of diseases
• Same illness like the patient (-)
• Hypertension (+)• Diabetes Mellitus (-)• Heart disease (-)• Kidney disease (-)
AUTOANAMNESISHABITS
Alcohol consumption (-)
Smoking (-)
Unhealthy food (+)
Exercise (rarely)
PHYSICAL EXAMINATION
• Moderately illGeneral
condition
•Compos mentis•GCS = 15 (E4M6V5)
Conciousness • Blood pressure: 120/80
mmHg• Temperature: 36.2
celcius• Heart rate: 80x/min• Respiration rate:
18x/min
Vital signs
PHYSICAL EXAMINATION
Head
• Normocephalic
Eyes
• Anemic conjunctiva -/- , Icteric sclera -/-
Mouth
• Lip: cyanosis (-) dryness (-)
Neck
• Lymph gland & Thyroid gland is not palpable
PHYSICAL EXAMINATION
Cor
• S1-S2 irregular, gallop (-) , murmur (-)
Pulmo
• Vesicular (+/+) , rhonchi (-/-) , wheezing (-/-)
Abdomen
• Supel , organomegaly (-) , bowel Sound (+) normal
Extremity
• Warm (+/+) , Oedema (-/-)
NEUROLOGICAL EXAMINATION
Sensibility
• Soft: (+/+)• Pain: (+/+)
Motoric• Movement: (+/-)• Strength:5555
5555 0
0
• Trophy: normal• Tonus: (+/-)
Pathological Reflex• Hofman-Tromner : -/-• Babinski : -/+• Chaddok : -/-• Schaeffer : -/-• Oppenheim :
-/-• Gordon : -/-Physiological Reflex• Biseps : +/+• Triseps: +/+• Patella: +/+• Achilles: +/+
NEUROLOGICAL EXAMINATION
Meningeal Sign• Neck Stiffness : (-)• Brudzinski I : (-)• Brudzinski II : (-)• Kernig : (-)• Laseque : (-)
Speech• Motoric aphasia: (-)• Sensoric aphasia: (-)• Dysarthria : (+)
CRANIAL NERVES EXAMINATION
N. I (N. Olfacory)• Not checked
N. II (N. Optic)• Not checked
N. III (N. Oculomotor)
• Strabismus : -/-• Nystagmus : -/-• Exophtalmos : -/-• Pupil : 2,5 mm / 2,5mm;
isocoria• Direct light reflex : +/+• Indirect light reflex : +/+
CRANIAL NERVES EXAMINATIONN. IV (N. Trochlear)• Eye movement (downward – inside): normal• Diplopia (-)
N. V (N. Trigeminal)• Mouth opening: normal• Chewing: normal• Biting: normal• Cornea reflex: not checked• Face sensibility: normal
N. VI (N. Abducens)• Eye movement (lateral): normal• Diplopia (-)
CRANIAL NERVES EXAMINATION
N. VII (N. Facial)• Furrowing forehead: (+/+)• Closing eyes: (+/+)• Showing teeth: lips droop to the left side• Puffing cheeks: (+/-)• Taste sensibility: not checkedN. VIII (N. Vestibulocochlear)• Swabach: not checked• Rinne: not checked• Weber: not checked
N. IX (N. Glossopharyngeal)
• Taste sensibility: not checked• Pharynx sensibility: not checked
CRANIAL NERVES EXAMINATION
N.X (N. Vagus)• Pharyngeal arch: not checked• Speaking: normal• Swallowing: normal• Oculocardiac reflex: not checked
N.XI (N. Accessory)
• Uplifting shoulders: normal• Turning head aside: normal
N.XII (N. Hypoglossal)
• Tongue out: prone to the left side• Tongue movement: normal• Articulation: disturbed
LABORATORY EXAMINATION (29/06/15)
Routine Blood Test
Leukocyte 13,700 5000-10000/µL
Erythrocyte 4,75 4,6-6,2 juta/µL
Hemoglobin 14,7 14-16 g/dL
Hemotocrit 43 42-48 %
Thrombocyte 231,000 150,000-450,000/µL
Lipid Blood Test
Triglycerides 88 60-170 mg/dL
Total cholesterol
144 <200 mg/dL
HDL cholesterol
29 40-60 mg/dL
LDL cholesterol
97 <130 mg/dL
LABORATORY EXAMINATION (29/06/15)
Liver Function Test
SGOT 25 <35 U/I
SGPT 41 <55 U/I
Total Protein
Total Protein 6,6 6,4 – 8,3 g/dL
Albumin 3,5 3,5 – 5,2 g/dL
Globulin 3,1 2,6 – 3,4 g/dL
Kidney Function Test
Uric Acid 5,4 3,5 – 7,2 mg/dL
Glucose Test
118 mg/dL
INR 1,10 2,0 – 3,0
LABORATORY EXAMINATION (01/07/15)
Routine Blood Test
Leukocyte 10,500 5000-10000/µL
Erythrocyte 4,74 4,6-6,2 juta/µL
Hemoglobin 14,7 14-16 g/dL
Hemotocrit 43 42-48 %
Thrombocyte 204,000 150,000-450,000/µL
Electrolyte
Natrium 139 134 – 146 mmol/L
Kalium 3,01 3,4 – 4,5 mmol/L
Chloride 102 96 – 109 mmol/L
Glucose Test 94 mg/dL
LABORATORY EXAMINATION (02/07/15)
Urine Test
Color Yellowish Yellowish
Blood/Erythrocyte
+++/250 -
Glucose - -
Leucocyte - -
Bilirubin - -
Keton +-/5 -
Density 1.015 1.003 – 1.031
pH 7,0 4,5 – 8,5
Protein - -
Urobilinogen +/1,0 3,5 – 17
Nitrit + -
LABORATORY EXAMINATION (02/07/15)
Urine Microscopic Test
Erythrocyte Full 0-1/LPB
Leukocyte + (5-8) 0-5/LPB
Epithelium +1 +/LPK
Bacteria - - motil/LPK
Cylinder - -/LPB
Crystal AMORF -/LPB
LABORATORY EXAMINATION (06/07/15)
Liver Function Test
SGOT 51.00 <35 U/I
SGPT 48 <55 U/I
Kidney Function Test
Ureum 36 17-43 mg/dL
Creatinin 1.0 0.7 – 1.3 mg/dL
RADIOLOGY
Head MRI (01/07/15)
Interpretation: Acute infarct cerebri pars temporo parietalis dextra et causa aclasia in Artery cerebri media dextra branch
Kidney & Bladder USG (07/07/15)Interpretation:
Benign Prostate Hypertrophy
ASSESMENTClinical : Left hemiplegiaEtiology : Ischemic strokePathology : Infarct cerebriTopis : Right hemisphere
ASSESMENT 2Atrial FibrilationBenign Prostate HypertrophyExternal Hemorrhoid grade II
RESUME
• Male patient, 55 Y.O, came to ER with sudden weakness all over the body, especially left arm and leg since ± 3 hours before admission, dizziness (+), difficulty in speaking (+), same illness before (+), hypertension (+), heart disease (+). Patient has habits like consuming fatty food and exercising rarely.
Anamnesis
RESUME
Physical Examinatio
n
• Cor: S1S2 irregular, Neurological examination: movement: (+/-), strength: 5/0, tonus: (+/-), Pathological reflex: Babinksy (-/+), Speech: dysarthria, Cranial nerves examination: lips droop to the left side, puffing cheeks: (+/-), tongue out prone to the left side, articulation: disturbed
RESUME
Supporting Examinatio
n
HDL Cholesterol: 29, INR: 1.10, Urine test: blood/Erythrocyte full, leukocytes: + (5-8). Head MRI: Acute infarct cerebri pars temporo parietalis dextra et causa aclasia in Artery cerebri media dextra branch, Kidney & bladder USG: Benign Prostate Hypertrophy
TREATMENTNeulin injection 2x500 mgTransamin injection 3x1Vit K injection 3x1Amlodipine 1x10 mgBisoprolol 1x5 mgRamipril 1x5mgFolic acid 2x1Ardium 4x1Mefenamic acid 3x500 mgPhysiotherapySuggestion: TURP, Hemorrhoidectomy
PROGNOSIS
• Quaod vitam : dubia ad bonam
• Quaod functionam :dubia ad bonam
• Quaod sanationam :dubia ad bonam
FOLLOW UP DAY 1 (29/06/15)
Subjective
• Weakness on left side of the body
• Speech disturbance (dysarthria)
Objective
• Consciousness : GCS 15• BP : 150/90
mmHg• Cor : S1S2
irregular• Physiological reflex: +/+
• Pathological reflex:
Babinski : -/+
• Motoric: 5555 1111
5555 1111• Paresis left N.VII & N.XII
central type
Assesment 1
• Dx klinis : Left hemiparesis • Dx etiologis : SNH• Dx patologis : Infarct cerebri• Dx topis : Right hemisphere
Other assesments
• Atrial Fibrilation• Hypertension
Plan
• IVFD NS 12 hrs/kolf• Inj.Neulin 2x500 mg• Inj NB 1x5000mg • Aspilet 1x80mg• Amlodipine 1x10mg• Bisoprolol 1x5mg• Terapril 1x5 mg• Folic acid 2x1
FOLLOW UP DAY 3 (01/06/15)
Subjective
• Weakness on left side of the body
• Speech disturbance (dysarthria) (-)
Objective
• Consciousness : GCS 15• BP : 130/90
mmHg• Cor : S1S2
irregular• Physiological reflex: +/+
• Pathological reflex:
Babinski : -/+
• Motoric: 5555 1111
5555 1111• Paresis left N.VII & N.XII
central type
Assesment 1
• Dx klinis : Left hemiparesis • Dx etiologis : SNH• Dx patologis : Infarct cerebri• Dx topis : Right hemisphere
Other assesments
• Atrial Fibrilation• Hypertension
Plan
• IVFD RL 12 hrs/kolf• Inj.Neulin 2x500 mg• Inj NB 1x5000 mg• Aspilet 1x80mg• Amlodipine 1x10mg• Bisoprolol 1x5mg• Terapril 1x5 mg• Folic acid 2x1• Physiotherapy
FOLLOW UP DAY 6 (04/07/15)
Subjective
• Weakness on left side of the body
• Pain when defecation•
Objective
• Consciousness : GCS 15• BP : 120/80
mmHg• Cor : S1S2
irregular• Physiological reflex: +/+
• Pathological reflex:
Babinski : -/+
• Motoric: 5555 0000
5555 0000• Paresis left N.VII & N.XII
central type
Assesment 1
• Dx klinis : Left hemiplegia• Dx etiologis : SNH• Dx patologis : Infarct cerebri• Dx topis : Right hemisphere
Other Assesments
• Atrial Fibrilation• Hypertension• Hemorrhoid externa grade IV
Plan• IVFD RL 12 hrs/kolf• Inj.Neulin 2x500 mg• Inj NB 1x5000mg • Aspilet 1x80mg• Amlodipine 1x10mg• Bisoprolol 1x5mg• Terapril 1x5 mg• Folic acid 2x1• Ardium 4x1• Physiotherapy
FOLLOW UP DAY 8 (06/07/15)
Subjective
• Weakness on left side of the body
• Pain when defecation and urinate
• Red urine•
Objective
• Consciousness : GCS 15• BP : 130/80
mmHg• Cor : S1S2
irregular• Physiological reflex: +/+
• Pathological reflex:
Babinski : -/-
• Motoric: 5555 0000
5555 0000• Paresis left N.VII & N.XII
central type • Urine bag: hematuria
Assesment 1
• Dx klinis : Left hemiplegia • Dx etiologis : SNH• Dx patologis : Infarct cerebri• Dx topis : Right hemisphere
Other assesments
• Atrial Fibrilation• Hemorrhoid externa grade IV
Plan
• IVFD RL 12 hrs/kolf• Inj.Neulin 2x500 mg • Aspilet 1x80mg• Amlodipine 1x10mg• Bisoprolol 1x5mg• Terapril 1x5 mg• Folic acid 2x1• Ardium 4x1• Transamin 3x1• Vit K 3x1
FOLLOW UP DAY 12 (09/07/15)
Subjective
• Weakness on left side of the body
• Pain when urinating• Less red urine color•
Objective
• Consciousness : GCS 15• BP : 120/80
mmHg• Cor : S1S2
irregular• Physiological reflex: +/+
• Pathological reflex:
Babinski : -/-
• Motoric: 5555 0000
5555 0000• Paresis left N.VII & N.XII
central type • Urine bag: hematuria
Assesment 1
• Dx klinis : Left hemiplegia • Dx etiologis : SNH• Dx patologis : Infarct cerebri• Dx topis : Right hemisphere
Other assesments
• Atrial Fibrilation• Hypertesnion• BPH• Hemorrhoid externa grade IV
Plan
• IVFD RL12 hrs/kolf• Inj.Neulin 2x500 mg • Aspilet 1x80mg• Amlodipine 1x10mg• Bisoprolol 1x5mg• Terapril 1x5 mg• Folic acid 2x1• Ardium 4x1• Transamin 3x1• Vit K 3x1• Outpatient: physiotherapy