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Stroke Unit Duty Report
Tuesday September 23rd, 2014
ER: dr. SaptariConsutant : dr. !sna"an
Stroke Unit : dr. #idya
#ard: dr. $andu
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Patient Identity
• %ame : &r. '
• ()e : 2* years od
•
(ddress : +ombe $ermai, Semaran)• --upation : $riate
• Cass : !/ $S
•Room : Stroke Unit
• &RS : September 23rd, 2014
• R& no. : C4022
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•
Main Problem : Altered consciousness• Location : intracranial
• Onset : ± 1 hour before admission
• Quality : No respons with pain stimulus.
• uantitas : A!L helped by family.
RECENT HISTORY
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"ronolo#y:
± 1 hour before admission$ 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.
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A##ra%atin# factor : /(0
2elie%in# factor : /(0
Other 3ymptomp : /(0
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• 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
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$7ysi-a E8amination
• +CS E1&19ET
• 9ita Si)n :
$: 1;/100 mm
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%EUR?+!C(? ST(TUS,ead : Mesocephal$ 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
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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
$at7oo)i- ReAe8 5/5 5/5
Conus 5/5
• Sensibiity : -anBt be a--essed
• 9e)etatie state : DC 6, urine erni7
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PEMERIKSAANPENN!AN"
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?aboratory E8amination 22/0/2014PT ##$%
$$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
$rotein Tota ,1
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pH ($#'
pC2 ;
p2 2;
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R t7ora8
• S7ape and o-ation o@t7e 7eart norma
• !nGtrat in t7e ri)7tpara-ardia
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I) C*ini+a* ,iano.ti+ : (tered
-ons-iousness Topi. ,iano.ti+ : pons,
-erebeum Etio*oy ,iano.ti+ : S< !C
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Prora0
• !9FD R? 20 tpm• !n. Ce@tria8one 2)r/247rs !96•
!n. Ranitidin ;0m)/127rs !96• !n. (sam Trane8amat 1 )r/*7rs !96T1erapy
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• 9ita si)n, +CS ,%euroo)i-DeG-ite
&%!TR!%+
• D!(+%S!S, T
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THANK YO
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