Duty Report

Tuesday September
30rd, 2014
ER: dr. Dewi
Consult : dr. Asty
Stroke Unit : dr. Fati
Ward: dr. Pandu
Tandem : dr. Ega

Patient Identity
Name
Age

: Mr. Y
: 54 years old

Address

: Peranten, Semarang

Occupation

: private

Class

: I / BPJS down grade class III

Room

: Rajawali 3B

MRS

: Oct 10th 2014

RM no.

: C470348

RECENT HISTORY
Main Problem : Submission from Ken Saras Hospital
with asphyxiate
Location
:
Onset
: 6 hour before
Quality
: Asphyxiate with tracheostomi
Quantity
: ADL helped by family.

Cronology:
Patient referrals from Ken Saras hospital with complaints of
Asphixiate and attached Tracheostomy, while in Ken Saras
patient treated at ICU during 18 days, and 10 days attached a
tracheostomy, weak of limb (+), Vomit (-),altered of
consciousness (+). According a Family, patient had experienced a
seizure before admission at ken Saras Hospital, and had a loss of
consciousness, but no vomit and a headache previous.
The patient had a history of previous stroke, stroke obtained first
4 years ago, and was diagnosed as SNH, then re-exposed to
attack 2 years later, when it was recovered with sequelae weak
limbs to the right. juni 2014 patients re-admitted and diagnosed
with SH,

Aggravating factor
Relieving factor
Other Symptom

: (-)
: (-)
: (-)

 PAST HISTORY
- Non Haemorrhagic stroke (+) in 2010,2012 sequellae (+) weak limb
Right side

- Stroke haemorragic (+) June 2014

- Head trauma (-).
- Hipertension (+) since 2009, but not previously control
- DM (-)
FAMILY HISTORY
- Stroke, DM, HT (-)
SOCIAL-ECONOMY HISTORY
Class 1 BPJS down grade to Class III BPJS

Physical Examination
GCS E3M5VTracheostomy
Vital Sign :
BP:

140/100 mmHg

HR:

90x

/minute

RR: 24x / minute with Tracheostomy

T : 37,4 C

NEUROLOGICAL STATUS
Head

: Mesocephal, Simetris

Eye

: Pupil round, isokhor, 2,5mm / Post operation

Light reflex +/- (decreased)

Neck

: nuchal rigidity (-)

Nn Craniales

: difficult to accessed, seemed lateralitation to the left

Siriraj score :
2x0 + 1x2 +0x2+110x10%- 1x3-12 = 3
Haemorrhage Stroke

Motoric
Movement
Strength

Superior

Inferior

+/decrease

+/decrease

Seems Lateralisation to
sinistra

Tonus
Trophy

E/E

E/E

Physiologic Reflex

++/++

++/++

Pathologic Reflex

-/-

-/+

Clonus
Sensibility
Vegetative state

(B)

-/: difficult to accessed

: DC (+), no blood (-)

Laboratory Examination
22/09/2014
Examination

RESULT

Normal Point

Hb

11.7

13 - 16 g/dl

Ht

33.2

40 52 %

Erythrocyte

4.06

4.3 - 6.0 mil /ul

Leukocyte

11.700

4800 - 10800/ul

Thrombocyte

432.000

150000 - 400000/ul

MCV

81.8

80 96 fL

MCH

28.8

27 - 32 pg

MCHC

35.2

32 36 g/dL

Routine Hematology

JENIS PEMERIKSAAN

HASIL

NILAI RUJUKAN

Ureum

12

20 - 50 mg/dl

Creatinine

0.75

0.5 1.5 mg/dl

Random Blood Sugar

108

< 140 mg/dl

Natrium

141.5

135 147 mmol/L

Kalium

4.2

3.5 5.0 mmol/L

Chloride

107.6

95 105 mmol/L

Kimia klinik:

MSCT
SCAN
Juni 2014

ICH Parietal Sinistra ( 14 cc)

Multiple infarct nucl. Lentiformis
dextra, Kapsula externa Dextra,
and Korona Radiata Dextra

RO thorax
Cardiomegali (LV)
Suspect
Bronchopneumonia

DIAGNOSIS
I. Clinical Diagnostic
:
Hemiparese dextra Spastic
Altered Consciousness
Seizure History
Topis Diagnostic
: Parietal Sinistra
Etiology Diagnostic : SH
II. Clinical Diagnostic :
Hemiparese sinistra spastic
Parese N. VII Sinistra Sentral
Topic diagnostic : nucleus lentiformis, kapsula
eksterna, corona radiata
Etiology Diagnostic : SNH
III. Bronchopneumonia

Stroke Hemmoragic

BRONCHOPNEUMONIA