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Definition of stroke

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.

According to AHA/ASA 2013


Definition of ischemic stroke: An episode of neurological
dysfunction caused by focal cerebral, spinal, or retinal infarction.

Definition of stroke caused by intracerebral hemorrhage:


Rapidly developing clinical signs of neurological dysfunction
attributable to a focal collection of blood within the brain parenchyma or
ventricular system that is not caused by trauma.
Definition of stroke caused by subarachnoid hemorrhage: Rapidly
developing signs of neurological dysfunction and/or headache because of
bleeding into the subarachnoid space (the space between the arachnoid
membrane and the pia mater of the brain or spinal cord), which is not
caused by trauma

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

Blood Vessels Anatomy of The Brain


The main supply of blood
to the brain by two
internal carotid arteries
and two vertebral
arteries. These four artery
located inside
subarachnoid space and
the branches
anastomoses on the
inferior surface of the
brain to form the circle of
Willis

Classification of

Stroke

Based on the anatomical pathology and its causes


Ischemic Stroke
Transient ischemic attack
Cerebral Thrombosis
Cerebral Embolism
Haemorrhage Stroke
Intracerebral haemorrhage
Subarachnoid haemorrhage

Classification of

Stroke

Based on the stage / time considerations


TIA
Stroke-in-evolution
Completed stroke
Based on the vascular system
Carotid system
Vertebrobasilar system

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

Subarachnoid hemorrhage (SAH) is the extravasation of


blood into the subarachnoid space between the arachnoid
membrane and the piamater
SAH of spontaneous intracranial hemorrhage
Etiology ruptured aneurysm, vascular malformations

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

Additional examination depend on indications

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

In ICH bleeding volume was estimated by calculating


validated method that can give you a prognosis at the time of
initial clinical evaluation. The formulas used are as below

(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)

Prevalent findings on CT scan in


patients ICH based on the onset of
events
Onset 7-10 first day

Onset 11 days 2 month

Onset > 2 month

Clearly defined, homogeneous


lesions, hiperdens, oval or
irregularly shaped frequently
accompanied by edema in the
surrounding areas with
hipodens picture with narrow
limits.
In the lesions area become the
low-density with ring
enhancement in the vicinity
(hemosiderin deposition).
homolateral ventricular
enlargement (in small
hematoma in hipodens area can
be a isodens area)
Isodens area with a decrease in
the intensity enhancement

Examination of magnetic resonance imaging


(MRI) including diffusion-weighted imaging
(DWI) has an excellent ability to display the
appearance, size, location and extent of
ischemia

MRI

Cerebral
angiography

Angiography is strengthened by processing


of digital images accurately showed
stenosis and occlusion of blood vessels and
the extracranial and intracranial aneurysms,
vascular malformations and other vascular
disorders such as arteritis and vasospasm

T ranscranial Doppler (TCD)

ntuk meneliti kelainan

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

Depending on the severity


of stroke as well as the
location and extent of
bleeding
GCS associated with
poor prognosis and
mortality.
bleeding volume is also
associated with poor
prognosis.
bleeding volume poor
functional outcome and
mortality

pRognoSis

Score intracerebral hemorrhage is often used to predict


outcome in hemorrhagic stroke. The score is calculated
as below
GCS score
34
: 2 points
GCS score
5 12
: 1 point
GCS score
13 15
: 0 point
80
Yes 1 point, No 0
Age
:
years
point
Yes 1 point, No 0
Infratentorial origin

:
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.

III. Subjective Data


Autoanamnesis on Februari 09th, 2015
1. Chief complaint
: weakness of left extremity
2. Recent history :
- Location
: left extremity
- Onset
: 1 day before hospital admission (suddenly)
- Quality
: left extremity can only hold light to middle
resistance
- Quantity
: ADL helped by family
- Cronology :
+ 1 day before hospital admission while wake up in the
morning and going to prayers, patient suddenly fell down
because weakness and got heavy of the left extremity. Left
extremity can only hold light to middle resistance. Patient
can work as usual. Numbness in the left extremity (+)

3. Past Medical History:


o History of Hypertension (+) since 14 y ago, routine
consumption captopril.
o DM (+) routine consumption metformin 500 mg and
glimepirid,
o Heart disease (+) since 1 y ago with pain in the left
chest and has done a treadmill stress test with the
results is positive of stress tests of ischemia, patient
regularly take amlodipine 10 mg and 2.5 mg bisoprolol
o History of stroke before was denial
o History of trauma was denial

4. Family Medical History:


o History of stroke before was denial
o History of HT was denial
o History of DM was denial
o History of Heart disease was denial

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).

IV. Objective Data


1.

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

= 29,1 Kg/m2 (overweight)

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

Coordination, Gait & Balance Test


Gait
: Not perfomed
Romberg Test
: Not perfomed
Dysdiadochokinesis
: (-)
Ataxia
: (-)

5-

++/

Abnormal movement
Tremor
:
Athetose
:
Myoclonic
:
Chorea
:

(-)
(-)
(-)
(-)

ECG result (21/3/2013):

Impression : Normo sinus rythme, LAD,LVH

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

: Hemiparese sinistra (UMN Type)


Parese N.VII and XII sinistra (UMN Type)
Hemihipestesi sinistra
Chepalgia
Topical Diagnosis : lentiform nucleus and right external capsula
Etiological Diagnosis : Haemorrhage Stroke (ICH)
Hypertension stage I
Hypocalemia

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

VIII. DAILY PROGRESS REPORT

Day I (10-02-2015)

Headache, Weakness of the left extremity


GCS
VS
Nn Cranialis
Motoric

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

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

Amlodipin 10
mg/24 hr p.o

KCL tab/8 hr

MX : KU, GCS, vital sign, neurologic defisit


Ex : Tetap

Result of consult to opthalmology:


ODS: Grade III hipertension retinopathy, grade II
arteriolosclerosis, non proliperative DM retinopathy, non CSME
mild.
Suggestion Managing of risk factor of DM and HT
Result of consult to clinical nutrition dept:
Nutrition status: obesity
metabolic Status : hypermetabolic
gastrointestinal status : functional
Energy demand: 1600 kcal/day
Protein demand : 60 gr/day
carbohydrate demand : 195 gr/day
Fatty demand: 31 gr/day
Dietary Plan:
Diit given from 80% of the target and increased gradually with
low salt, DM 1300 kcal

Day II (11-02-2015)

Headache, Weakness of the left extremity


GCS
VS
Nn Cranialis
Motoric

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

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

Amlodipin 10
mg/24 hr p.o

MX : KU, GCS, vital sign, neurologic defisit

Hypocalemia,
Hypertriglyserid

Ischemic heart
disease

-KCL tab/8 hr
-Fenofibrate 300
mg/24 hr

-Simvastatin
10 mg/24 hr

Result of Consult to Physic Rehabilitation Dept:


Breathing exercise, Gentle AAROM exercise, Mobilitation,
backrest
sitting in bed
Result of Consult to Cardiology Dept
A: Ischemic heart disease
P: If no contra indication
Valsartan 160 mg/24 hr (if the BP target has not been
reached)
Amlodipin keep on
Simvastatin 10 mg/24 hr (@night)
Echo if possible

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.

80 140: Good; 145


170: Average; > 180:
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

Day III (12-02-2015)

Headache, Weakness of the left extremity, Cant defecate for 5 days


GCS
VS
Nn Cranialis
Motoric

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

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, dulcolax supp I extra

Hypertension
Amlodipin 10
mg/24 hr p.o

MX : KU, GCS, vital sign, neurologic defisit


Ex : Tetap

Hypocalemia
Hypertriglyserid

Ischemic heart
disease

KCL tab/8 hr
Fenofibrate 300
mg/24 hr

-Simvastatin
10 mg/24 hr

Day IV (13-02-2015)

Headache, Weakness of the left extremity, defecate (+)


GCS
VS
Nn Cranialis
Motoric

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

MX : KU, GCS, vital sign, neurologic defisit


Ex : Tetap

Hypocalemia
Hypertriglyserid

Ischemic Heart
Disease

KCL tab/8 hr
Fenofibrate 300
mg/24 hr

-Simvastatin
10 mg/24 hr

Day V (14-02-2015)

Headache, Weakness of the left extremity


GCS
VS
Nn Cranialis
Motoric

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

MX : KU, GCS, vital sign, neurologic defisit


Ex : Tetap

Hypocalemia
Hypertriglyserid

Ischemic Heart
Disease

KCL tab/8 hr
Fenofibrate 300
mg/24 hr

Simvastatin 10
mg/24 hr

Day VII (16-02-2015)

Headache, Weakness of the left extremity


GCS
VS
Nn Cranialis
Motoric

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

MX : KU, GCS, vital sign, neurologic defisit


Ex : Tetap

Hypocalemia
Hypertriglyserid

Ischemic Heart
Disease

KCL tab/8 hr
Fenofibrate 300
mg/24 hr

-Simvastatin
10 mg/24 hr

Day IX (18-02-2015)

Weakness of the left extremity


GCS
VS
Nn Cranialis
Motoric

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

MX : KU, GCS, vital sign, neurologic defisit


Ex : Tetap

Hypocalemia
Hypertriglyserid

Ischemic Heart
Disease

KCL tab/8 hr
Fenofibrate 300
mg/24 hr

-Simvastatin
10 mg/24 hr

Day X (19-02-2015)

Headache, Weakness of the left extremity


GCS
VS
Nn Cranialis
Motoric

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

MX : KU, GCS, vital sign, neurologic defisit


Ex : Tetap

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)

Weakness of the left extremity


GCS
VS
Nn Cranialis
Motoric

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

MX : KU, GCS, vital sign, neurologic defisit


Ex : Tetap

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 XIII (22-02-2015)

Weakness of the left extremity


GCS
VS
Nn Cranialis
Motoric

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

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

MX : KU, GCS, vital sign, neurologic defisit


Ex : Tetap

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

Day XIV (23-02-2015)

Weakness of the left extremity


GCS
VS
Nn Cranialis
Motoric

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

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

MX : KU, GCS, vital sign, neurologic defisit


Ex : Tetap

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)

Weakness of the left extremity

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

MX : KU, GCS, vital sign, neurologic defisit


Ex : Tetap

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

Tanggal 18-2-2015 (Day-9) :


S : nyeri kepala, lemah anggota gerak kiri
O : GCS: E4M6V5 = 15
TD : 150/70 mmHg, N : 82x/mnt, RR :
20x/mnt, t : 36,7oC
A : Haemorrhage Stroke (ICH), Hypertension st
I, Hypocalemia, Hypertriglycerid, Ischemic
heart disease
P : Program TCD Friday (20/02/2015)
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

19-2-2015 ( Day- 10)


S : Weakness of the left extremity
O :
PF : GCS: E4M6V5 = 15
TD : 140/80 mmHg, N : 86x/mnt,
RR : 20x/mnt, t : 36,5oC VAS:2
A : Haemorrhage Stroke (ICH),
Hypertension st I, Hypocalemia,
Hypertriglycerid, Ischemic heart disease

P : Registering Echo schedule


24/02/2015
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

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

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

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...

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