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


Head

• Normocephalic

Eyes

• Anemic conjunctiva -/- , Icteric sclera -/-

Mouth

• Lip: cyanosis (-) dryness (-)

Neck

• Lymph gland & Thyroid gland is not palpable


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 (-)


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


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


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


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


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 + -


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


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


Subjective


• Speech disturbance (dysarthria) (-)

Objective


mmHg• Cor : S1S2



Babinski : -/+

• Motoric: 5555 1111


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


Subjective


• Pain when defecation•

Objective


mmHg• Cor : S1S2



Babinski : -/+

• Motoric: 5555 0000


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


Subjective


• Pain when defecation and urinate

• Red urine•

Objective


mmHg• Cor : S1S2



Babinski : -/-

• Motoric: 5555 0000


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


Subjective


• Pain when urinating• Less red urine color•

Objective


mmHg• Cor : S1S2



Babinski : -/-

• Motoric: 5555 0000


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

Case Report SNH.pptx

Documents

Transcript of Case Report SNH.pptx