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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