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WHO : a clinical
syndrome consisting of
rapidly developing clinical
signs of focal (or global in
case of coma) disturbance
of cerebral function lasting
more than 24 hours or
leading to death with no
apparent cause other than
a vascular origin.
Epidemiolo
gy
USA
Cause of
death in the
3rd ranks after
heart disease
and cancer.
Riskesdas
20078,3/1000
population
2013
12,1/1000
population
Classification of
Stroke
Classification of
Stroke
Pathogenesis
Rupture of blood vessels of the brain
ICH
SAH
ICH
Primary
Secondary
Primary ICH
Chronic Hypertension
Caused by chronic
hypertension which causes
cerebral vasculopathy
leading to rupture of blood
vessels in the brain
ICH
secondary hemorrhage
Congenital vascular
anomalies,
coagulopathy, brain
tumors, nonhypertensive
vasculopathy (cerebral
amyloid), vasculitis,
moya-moya, post
ischemic stroke,
anticoagulant
medication (fibrinolytic
or sympathomimetic)
SAH
SAH
Symptoms
Suddenly
severe headache
and vomiting.
Can be accompanied by a
stiff neck.
Residif during the first 2472 hours severe
cerebral vasospasm
+ brain infarction
Subarachnoid hemorrhage
Excessive
Alcohol
Consumptio
n
Risk
Factors &
Etiology
Clinical Manifestations
Headache
Focal Neurologic
Deficits
Weakness or paresis to
one side of extremities
Disturbances of
sensibility in one or
more extremity
(hemihipestesi)
A sudden change in
mental status
(somnolence, delirium,
lethargy, stupor or
coma)
F.A.S
.T
Clinical Manifestations
Monocular and
binocular blindness
Blurred vision or visual
field defects
Dysarthria or
comprehension
disorders
Vertigo or ataxia
Aphasia
Seizure
F.A.S
.T
Pemerikasaan
Penunjang
Laboratory
Routine blood test
Blood chemistry test
Random blood sugar: in acute stroke can occur
reactive hyperglycemia, blood sugar can reach
250 mg in the serum and then gradually then
gradually decrease
Urea, creatinine, uric acid, liver function
(SGOT / SGPT / CPK) and lipid profile (total
cholesterol, triglycerides, LDL, HDL)
Pemerikasaan
Penunjang
Examination of hemostasis
Prothrombin time
APTT
Fibrinogen levels
D-dimer
INR
Plasma viscosity
Protein S
Protein C
ACA
Hemosistein
Pemeriksaan Penunjang
CT Scan
Non contrast computed
tomography (CT) is a
standard imaging modality
for the initial evaluation of
patients with acute stroke
symptoms. The main
advantage of the
diagnostic CT in
hyperacute phase (0-6
hours) that can show
bleeding
(A x B x C) / 2
A = length of
lesions
B = width of lesion
C = high of
lesions (the
number of
pieces
contained CT
picture of
bleeding)
MRI
Cerebral
angiography
neurovaskular termasuk
USG doppler, yang dapat
menunjukkan plak
ateroma dan stenosis
pembuluh darah besar
terutama di karotis dan
juga arteri vertebrobasiler
General Management
Fast imaging examinations with CT or MRI
CT angiography and CT with contrast
Patients deficiency of coagulation factor replacement
therapy or severe thrombocytopenia or platelet
coagulation factors
In ICH Patients and INR related to oral anticoagulant
drug warfarin, therapy to replace with vitamin Kdependent factor + Correcting INR + intravenous
vitamin K
General Management
Correction of coagulation disorders Vitamin K 10 mg
intravenously, FFP 2-6 units of correcting a deficiency of
blood clotting factors
Preventing venous thromboembolism with intermittent
pneumatic compression
Heparin effect can be overcome by administration of
protamine sulfate 10-50 mg IV within 1-3 minutes
Systole BP (SBP)> 200 mmHg or mean arterial pressure
(MAP) > 150 mmHg, derived using continuous intravenous
antihypertensive drugs with blood pressure monitoring
every 5 minutes.
General Management
If the SBP > 180 mmHg or MAP > 130 mmHg
accompanied by symptoms and signs of increased
intracranial pressure (ICP) ICP have to monitored.
BP withintravenous antihypertensive drugs
continuously or intermittent and monitoring of
cerebral perfusion pressure 60 mmHg.
If the SBP > 180 mmHg or MAP > 130 mmHg
absence of symptoms and signs of increased ICT,
BP carefully using continuous intravenous
antihypertensive medication or intermittent
monitoring of blood pressure every 15 minutes until
the MAP 110 mmHg or BP 160/90 mmHg , SBP up to
140 mmHg are still allowed
General Management
In ICH patients with SBP 150-220 mmHg, decreased
SBP rapidly to 140 mmHg quite safe. After
craniotomy the target of MAP is 110 mmHg
Pain management is important in reducing BP in
patients with intracerebral hemorrhage stroke
Management of seizure with anti-epileptic drugs.
Continuous ECG monitoring.
Surgery
Meanwhile patients with higher GCS and smaller
lesions tend to have good results with
conservative measures or non-surgical
management.
Ventricular drainage as the treatment of
hydrocephalus can be considered in patients with
a decreased level of consciousness.
Best surgery is in
patients with
initial GCS < 14
and hematoma
volume
> 40
ml
pRognoSis
:
point
Intracerebral
30 cm3
: 1 point
hemorrhage volume
Intracerebral
< 30 cm3
: 0 point
hemorrhage volume
Intraventicular
Yes 1 point, No 0
:
hemorrhage
point
Hemphill et.al study, all patients with intracerebral hemorrhage score
= 0 can survive and all patients with a score of 5 died.
5. Social-economy :
Patients works as a cashier at the tofu factory, her husband
works as a construction worker with 2 sons dependent,
medical expenses covered by National Insurance (BPJS).
Present States
General state
: Looked moderately ill
Vital sign
: BP
: 150/80 mmHg
HR
: 94 times / minute, regular
RR
: 20 times / minute
T : 36,7 C
VAS : 3
2. Internal state
Head
: symmetrical, mesochepal
Eyes
: Anemia of conjunctiva -/-, icteric of scleral -/Neck
: Nuchal rigidity (-), lymph node enlargement
(-), struma (-)
Chest
Cor
: Normal heart sound, murmur (-),gallop (-)
Lungs
Abdomen
spleen
Extremity
: normal breathing, Rhonchi -/-, Wheezing -/:normal peristaltic sound, unpalpable liver and
: Edema (-/-), turgor normally, cyanosis -/-
Nutrition Status
Height
: 158 cm
Weight
: 70 Kg
BMI
: BB = 70 Kg
TB2 (1.58m)2
3. Psychological Status
Way of thinking
Mood
:
Behavior
:
Memory
:
Cognitive
:
: realistic
normothymic
normoactive
adequate
adequate
4. Neurologic status
Level of Consiousness : GCS: E4M6V5=15
Eyes
: pupil round isocor, 2,5 mm/2,5 mm, light
reflex +/+
Leher
: nuchal rigidity (-)
Cranial nerves : The mouth shift to the right and the tongue
shift to the left
Motoric
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex
++/++
++
Pathologic reflex
-/-/Clonus
-/Sensibility
: Numbness in the left extremity
Vegetative : Within normal
5-
++/
Abnormal movement
Tremor
:
Athetose
:
Myoclonic
:
Chorea
:
(-)
(-)
(-)
(-)
Laboratory
Result
Unit
Normal Value
14.3
40.8
4.8
29.8
84.9
35.1
8.4
277.1
13.1
7.7
g/dL
%
10^6/uL
pg
fL
g/dL
10^3/uL
10^3/uL
%
fL
12.00 15.00
35 47
4.4 5.9
27.00 32.00
76 96
29.00 36.00
3.6 11
150 400
11.60 14.80
4.00 11.00
HEMATOLOGI
Hemoglobin
Hematocryte
Erythrocyte
MCH
MCV
MCHC
Leucosite
Thrombocyte
RDW
MPV
Clinical Chemistry
Random Glucose
Level
Ureum
Creatinin
117
mg/dL
80 160
17
0.80
mg/dL
mg/dL
15 39
0.60 1.30
144
3.2
106
mmol/L
mmol/L
mmol/L
136 - 145
3.5 5.1
98 107
ELECTROLYTE
Sodium
Potassium
Chlorida
Impression: hypocalemia
Osmolarity: 2(144 + 3.2) + 117/18 +
17/6 = 303.7
Fluid defisit: (303.7 295)/295 x 0.6 x
56 = 0.9 liter
Motoric
: hemiparese sinsitra (UMN Type)
Sensibility : hemihipestesi sinistra
Vegetative : Within normal
ECG
: Normo Sinus Rhythm, LAD, LVH
Thorax Foto : cor and lungs within normal
CT Scan
: Intracerebral hemorrhage on lentiformis nucleus
and right external capsule ( 5.78 cc volume)
which causes a narrowing of the right lateral
ventricle and corticalis sulcus and fissures sylvii at
lession area. No sign of increased ICP
VI. DIAGNOSIS :
Clinical Diagnosis
V. Initial Plan
Haemorrhage Stroke
IpDx
: Lab: GD I/II, HbA1c, profil lipid, urid acid,
PPT, PTTK
- Consult cardiologist (history of heart
disease)
- Consult to clinical nutrition
- Consult to opthalmologist (funduscopy)
- Consult to physic rehabilitation
IpTx
: Infus RL 20 gpm
O2 3 liter/min
Inj. Citicolin 500 mg intravena
Inj Tranexamic Acid 1 gr/6 hr intravena
Inf. Manitol 125 mg/6 hr intravena
Inj Ranitidin 50 mg intravena
Paracetamol 500 mg/8 hr p.o
IpMx
: General state of conciousness,
Hypertension
IpDx
: Consult to opthalmologist (funduscopy)
IpTx
: Amlodipin 10 mg/24 hr p.o
IpMx
: General state of conciousness, neurological
deficit, VS
IpEx
: Explaining about the disease, examination
plan
Hipokalemia
IpDx
:IpTx
: KCL tab / 8 hr p.o
IpMx
: General state of conciousness, neurological
deficit, VS
IpEx
: Explaining about the disease, management
plan
Day I (10-02-2015)
Sensibility
Vegetative
: E4M6V5 = 15
: BP:150/80 mmHg , HR:84x/minute, RR:20x/minute, T : 36,80C VAS=3
: Parese N.VII and XII sinistra (UMN Type)
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/: Numbness in the left extremity
: Defecate and urinate normally
Haemorrhage Stroke
Hipertension
Hypocalemia
Amlodipin 10
mg/24 hr p.o
KCL tab/8 hr
Day II (11-02-2015)
Sensibility
Vegetative
: E4M6V5 = 15 VAS = 2
: BP:140/80 mmHg , HR:88x/minute, RR:22x/minute, T : 36,40C
: Parese N.VII and XII sinistra (UMN Type)
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/: Numbness in the left extremity
: Defecate and urinate normally
Haemorrhage Stroke
Hipertension
Amlodipin 10
mg/24 hr p.o
Hypocalemia,
Hypertriglyserid
Ischemic heart
disease
-KCL tab/8 hr
-Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Lab Result
2015)
(11-02-
Laboratory
HEMATOLOGY
HbA1c
PPT
PTTK
CLINICAL
CHEMISTRY
Fasting Glucose
Level
Reduction I
2 Hours Post
Prandial
Reduction II
Total
Cholesterol
Triglycerides
HDL Cholesterol
LDL direct
Ureum
Creatinin
Impression:
Urid Acid
Hipertriglyserides
Result
Unit
5.4
10.3
30,7
Normal Value
%
detik
detik
6.0 8.0
10 -15
23.4-36.8
97
mg/dL
104
mg/dL
152
mg/dL
80 109: Good;
110 125: Average;
> 126: Bad.
< 200
180
29
84
30
0.81
4.4
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
< 150
40 60
0 100
15 39
0.60 1.30
2.6 6.0
Sensibility
Vegetative
: E4M6V5 = 15 VAS = 2
: BP:140/70 mmHg , HR:85x/minute, RR:24x/minute, T : 36,70C
: Parese N.VII and XII sinistra (UMN Type)
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/: Numbness in the left extremity
: Defecate and urinate normally
Haemorrhage Stroke
Hypertension
Amlodipin 10
mg/24 hr p.o
Hypocalemia
Hypertriglyserid
Ischemic heart
disease
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Day IV (13-02-2015)
Sensibility
Vegetative
: E4M6V5 = 15 VAS = 3
: BP:140/100 mmHg , HR:90x/minute, RR:20x/minute, T : 36,30C
: Parese N.VII and XII sinistra (UMN Type)
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/: Numbness in the left extremity
: Defecate and urinate normally
Haemorrhage Stroke
Head elevation 30 Inf. RL 20 tpm,
Inj. Citicoline 500 mg/8 hr, Inj.Asam
Traneksamat 1 gr/6 hr, Inj. Ranitidin
50 mg/12 hr, Paracetamol 500
mg/8 hr p.o
Hipertension
Amlodipin 10
mg/24 hr p.o
Hypocalemia
Hypertriglyserid
Ischemic Heart
Disease
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Day V (14-02-2015)
Sensibility
Vegetative
: E4M6V5 = 15 VAS = 3
: BP:150/100 mmHg , HR:90x/minute, RR:20x/minute, T : 36,30C
: Parese N.VII and XII sinistra (UMN Type)
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/: Numbness in the left extremity
: Defecate and urinate normally
Haemorrhage Stroke
Head elevation 30 Inf. RL 20 tpm,
Inj. Citicoline 500 mg/8 hr, Inj.Asam
Traneksamat 1 gr/6 hr, Inj. Ranitidin
50 mg/12 hr, Paracetamol 500
mg/8 hr p.o
Hipertension
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
Hypocalemia
Hypertriglyserid
Ischemic Heart
Disease
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
Simvastatin 10
mg/24 hr
Sensibility
Vegetative
: E4M6V5 = 15 VAS = 3
: BP:140/90 mmHg , HR:80x/minute, RR:20x/minute, T : 36,70C
: Parese N.VII and XII sinistra (UMN Type)
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/: Numbness in the left extremity
: Defecate and urinate normally
Haemorrhage Stroke
Head elevation 30 Inf. RL 20 tpm
Aff, Citicoline 500 mg/12 hr po,
Asam Traneksamat 500 mg/8 hr po,
Ranitidin 150 mg/12 hr po,
Paracetamol 500 mg/8 hr p.o
Hipertension
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
Hypocalemia
Hypertriglyserid
Ischemic Heart
Disease
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Day IX (18-02-2015)
Sensibility
Vegetative
: E4M6V5 = 15 VAS = 1
: BP:150/70 mmHg , HR:82x/minute, RR:20x/minute, T : 36,70C
: Parese N.VII and XII sinistra (UMN Type)
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/: Numbness in the left extremity
: Defecate and urinate normally
Haemorrhage Stroke
Head elevation 30, Citicoline 500
mg/12 hr po, Asam Traneksamat 500
mg/8 hr po, Ranitidin 150 mg/12 hr
po, Paracetamol 500 mg/8 hr p.o
Program TCD (on Friday, 20/02/2015)
Hipertension
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
Hypocalemia
Hypertriglyserid
Ischemic Heart
Disease
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Day X (19-02-2015)
Sensibility
Vegetative
: E4M6V5 = 15 VAS = 3
: BP:140/80 mmHg , HR:86x/minute, RR:20x/minute, T : 36,70C
: Parese N.VII and XII sinistra (UMN Type)
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/: Numbness in the left extremity
: Defecate and urinate normally
Haemorrhage Stroke
Head elevation 30, Citicoline 500
mg/12 hr po, Asam Traneksamat 500
mg/8 hr po, Ranitidin 150 mg/12 hr
po, Paracetamol 500 mg/8 hr p.o
Program TCD (on Friday, 20/02/2015)
Hipertension
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
Hypocalemia
Hypertriglyserid
Ischemic Heart
Disease
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Program Echo
(on Monday
23/02/2015)
Day XI (20-02-2015)
Sensibility
Vegetative
: E4M6V5 = 15 VAS = 1
: BP:120/70 mmHg , HR:84x/minute, RR:22x/minute, T : 36,30C
: Parese N.VII and XII sinistra (UMN Type)
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/: Numbness in the left extremity
: Defecate and urinate normally
Haemorrhage Stroke
Head elevation 30, Citicoline 500
mg/12 hr po, Asam Traneksamat 500
mg/8 hr po, Ranitidin 150 mg/12 hr
po, Paracetamol 500 mg/8 hr p.o
Program TCD today
Hipertension
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
Hypocalemia
Hypertriglyserid
Ischemic Heart
Disease
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Program Echo
(on Monday
23/02/2015)
Sensibility
Vegetative
: E4M6V5 = 15 VAS = 1
: BP:120/80 mmHg , HR:90x/minute, RR:24x/minute, T : 36,70C
: Parese N.VII and XII sinistra (UMN Type)
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/: Numbness in the left extremity
: Defecate and urinate normally
Haemorrhage Stroke
Hipertension
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
Hypocalemia
Hypertriglyserid
Ischemic Heart
Disease
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Program Echo
(on Monday
23/02/2015)
Result of TCD:
An increase in resistance to blood flow in the internal carotid
artery right / left.
The speed and resistance to blood flow in the right middle
cerebral artery, posterior cerebral artery right and left, right and
left vertebral artery and basilar artery is still within normal limits.
Left middle cerebral artery can not be accepted by the wave
doppler (hyperostosis?)
Impression: suspicious of atherosclerosis in the carotid artery
right & left
Sensibility
Vegetative
: E4M6V5 = 15 VAS = 1
: BP:100/70 mmHg , HR:80x/minute, RR:20x/minute, T : 36,30C
: Parese N.VII and XII sinistra (UMN Type)
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/: Numbness in the left extremity
: Defecate and urinate normally
Haemorrhage Stroke
Hipertension
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
Hypocalemia
Hypertriglyserid
Ischemic Heart
Disease
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Program Echo
today
Day XV (24-02-2015)
GCS
: E4M6V5 = 15 VAS = 1
VS
: BP:100/70 mmHg , HR:80x/minute, RR:20x/minute, T : 36,30C
Nn Cranialis :
Parese N.VII and XII sinistra (UMN Type)
Motoric
:
Superior
Inferior
Movement
+/
+/
Strength
5-5-5/4-4-4
5-5-5/4-4-4
Tonus
N/N
N/N
Trophy
E/E
E/E
Physiologic reflex +/+
+/+
Pathologic reflex -/-/Clonus
-/Sensibility
: Numbness in the left extremity
Vegetative : Defecate and urinate normally
Haemorrhage Stroke
Discharge
Head elevation 30, Citicoline 500
mg/12 hr po, Asam Traneksamat 500
mg/8 hr po, Ranitidin 150 mg/12 hr
po, Paracetamol 500 mg/8 hr p.o
Hipertension
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
Hypocalemia
Hypertriglyserid
Ischemic Heart
Disease
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Result of Echocardiography:
LVH(+) consentric,
Fungsional sistolic LV global is good, LVEF : >70%
diastolic Disfuncsion LV gr 1, E/A: 0,68
10 2 2015 (Day-0)
S:
A woman 46 y.o coming to the RSDK ER with hemiparese sinsitra spastic, 1 day
onset accompanied with parese N.VII and XII of the left central, chepalgia and
hemihipestesi sinistra
O:
Status praesen
: BP: 150/80 mmHg, HR: 94 times / minute,
RR: 20 times / minute, T: 36,7 C, VAS: 3
Status internus
: Within normal
Status neurologi
Motoric : Weakness of left extremity
Sensbility : Numbness in the left extremity
CT Scan : Intracerebral hemorrhage on lentiformis nucleus and right
external capsule. No sign of increased ICP.
Lab
: Potassium 3.2
ECG
: Normo Sinus Rhythm, LVH, LAD
Thorax Foto
: cor dan lung within normal
A
: Haemorrhage Stroke (ICH),Hypertension st I, Hypocalemia
P
: lab GD I/II, HbA1c, Profil lipid, urid acid, PPT, PTTK
Consult
: Cardiologist, Clinical nutrition, opthalmologist, physic rehabilitation
Tx:
Infus RL 20 tpm, O2 3 liters/mnt, Inj. Citicolin 500 mg/8 hr i.v, Inj
12-2-2015 ( Day - 3)
S : Headache, Weakness of the left
extremity, Cant defecate for 5 days
O :
PE : GCS: E4M6V5 = 15
BP : 140/70 mmHg, N : 85x/mnt, RR :
24x/mnt, t : 36,7oC VAS:2
A : Haemorrhage Stroke (ICH),
Hypertension st I, Hypocalemia,
Hypertriglycerid
P : tx : Dulcolax supp I, Fenofibrate
300 mg/24 hr
Tranexamic Acid 1 gr/6 hr i.v, Inj Ranitidin 50 mg i.v, Paracetamol 500 mg/8 hr p.o
10-2-2015 (Day 1) :
S : Headache, Weakness of the left extremity
O : GCS: E4M6V5 = 15
BP : 150/80 mmHg, N : 84x/mnt, RR : 20x/mnt, t : 36,8oC
Status internus : tetap
Status neurologis: tetap
Result of consult to opthalmology (+)
Result of consult to clinical nutrition dept (+)
A : Haemorrhage Stroke (ICH),Hypertension st I, Hypocalemia
P : Waiting for lab result
Tx : Infus RL 20 tpm, O2 3 liter/menit, Inj. Citicolin 500 mg/8 jam i.v,
Inj Asam traneksamat 1 gr/6 jam i.v, Inf. Manitol 125 mg/6 jam i.v, Inj
Ranitidin 50 mg i.v, Paracetamol 500 mg/8 jam p.o, amlodipin 10
mg/24 jam p.o, KCL tab/8 jam p.o
11-2-2015 (Day-2) :
S : Headache, Weakness of the left extremity
O : GCS: E4M6V5 = 15
BP : 140/80 mmHg, HR :88x/mnt, RR : 22x/mnt,
t : 36,4oC, VAS:2
Result of Consult to Cardiology Dept (+)
Result of Consult to Physic Rehabilitation (+)
A: Haemorrhage Stroke (ICH), Hypertension st I,
Hypocalemia, Hypertriglycerid, Ischemic heart disease
P: Echo if possible
Tx: Fenofibrate 300 mg/24 hr,Simvastatin 10 mg/24 hr
p.o (night)
14-2-2015 (Day-5) :
S : Headache, Weakness of the left extremity
O : GCS: E4M6V5 = 15
BP:150/100 mmHg, HR:90x/mnt, RR:20x/mnt,
t : 36,3oC, VAS:3
A : tetap
P: Tx: valsartan 80 mg/24 hr p.o
16-2-2015 ( Day- 7)
S : Headache, Weakness of the left
O :
PF : GCS: E4M6V5 = 15
BP : 140/90 mmHg, HR : 80x/mnt,
RR : 20x/mnt, t : 36,7oC VAS:3
A : Haemorrhage Stroke (ICH),
Hypertension st I, Hypocalemia,
Hypertriglycerid, Ischemic heart disease
P : tx : Head elevation 30 Inf. RL 20
tpm Aff, Inj. Citicoline 500 mg/12 hr po,
Inj.Asam Traneksamat 500 mg/8 hr po,
Inj. Ranitidin 150 mg/12 hr po,
Paracetamol 500 mg/8 hr p.o
20-2-2015 (Day-11) :
S : Weakness of the left extremity
O : GCS: E4M6V5 = 15
TD : 120/70 mmHg, N : 86x/mnt, RR :
22x/mnt, t : 36,3oC
A: Haemorrhage Stroke (ICH), Hypertension
st I, Hypocalemia, Hypertriglycerid, Ischemic
heart disease
P: Program for TCD today
Tx: : Head elevation 30, Citicoline 500
mg/12 hr po, Asam Traneksamat 500 mg/8 hr
po, Ranitidin 150 mg/12 hr po, Paracetamol
500 mg/8 hr p.o
23-2-2015 (Day-14) :
S
: Weakness of the left
extremity
O : GCS: E4M6V5 = 15
BP:120/70 mmHg,HR : 86x/mnt,
RR : 22x/mnt, t : 36,6oC
Hasil TCD (+)
A: Haemorrhage Stroke (ICH),
Hypertension st I, Hypocalemia,
Hypertriglycerid,
Ischemic
heart
disease
P: Waiting schedule for echo
Tx: : Head elevation 30,
Citicoline 500 mg/12 hr po, Asam
Traneksamat 500 mg/8 hr po, Ranitidin
150 mg/12 hr po, Paracetamol 500
mg/8 hr p.o
24-2-2015 (Day-15) :
S : Weakness of the left extremity
O : GCS: E4M6V5 = 15
BP : 140/90 mmHg, HR : 90x/mnt, RR : 20x/mnt, t :
36,3oC
Result of Echo (+)
A:Haemorrhage Stroke (ICH), Hypertension st I,
Hypocalemia, Hypertriglycerid, Ischemic heart disease
P: Discharge after echocardiography
VI.
List of Problems
No
Active Problem
1.
2.
3.
4.
5.
6.
7.
8.
Hemparesis sinistra
(UMN) 6
Chepalgia 6
Paresis of N.VII sinistra
(UMN) 6
Paresis N.XII sinistra
(UMN) 6
Hemihipestesi sinistra 6
Haemorrhage Stroke
Stage I Hypertension
Hypocalemia
Tgl
09-022015
09-022015
09-022015
09-022015
09-022015
09-022015
No
.
Pasive
Problem
Tgl
Thanx You...