cr sr hani
TRANSCRIPT
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PRESENTASI KASUS
STROKE NON HEMORAGIK DENGAN DISLIPIDEMIA DAN
HIPERTENSI GRADE II
Hani ZahiyyahSuarsyaf
Pembimbing !r" H" Sim#n Tambunan"$ S%" S
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I" IDENTITAS PENDERITANama Ny" SRUmur &' (h
)enis Ke*amin Perem%uan
S(a(us Meni+ahA*ama( Purb#*ingg#Pe+er,aan Ibu Rumah Tangga
N# RM -./0/'Masu+ RS 01 Mare( -102
LAPORAN KASUS
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II. DATA SUBYEKTIF
1. RIWAYAT PENYAKIT SEKARANG (Alloanamnesis oleh ana!asien"
Ke*uhan U(ama Lemah angg#(a gera+ bagian +ananL#+asi In(ra3erebra*Onse( 4 - hari sebe*um masu+ RSA5
Kua*i(as angg#(a gera+ +anan masih !a%a(me*a6an (ahanan ringan
Kuan(i(as A+(i7i(as sehari8hari se%enuhnya !iban(u#*eh +e*uarga
Ge,a*a %enyer(a Su*i( bi3ara$ mu*u( mer#( +e +iri
9a+(#r yang mem%erbera( : 8 ;9a+(#r yang mem%eringan : 8 ;
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Kr#n#*#gis
Pa!a hari Kamis 01 Mare( -102 %u+u* 1
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%. RIWAYAT PENYAKIT KELUARGA
Ti!a+ a!a angg#(a +e*uarga yang sa+i( se%er(i ini$Ri6aya( %enya+i( !arah (inggi %a!a +e*uarga a!aKen3ing manis !an s(r#+e %a!a +e*uarga (i!a+ a!a"
&. RIWAYAT SOSIAL EKONO'I
Pasien mengguna+an =P)S +e*as >Kesan S#se+ ?u+u%
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III. DATA OBEKTIF
1.STATUS PRAESENS
Kea!aan umum Tam%a+ sa+i( se!angKesa!aran ?#m%#s men(is Te+anan Darah 021@011 mmHg
Na!i .< @meni(RR -- @meni(Suhu >2$.1?
Tinggi =a!an 0&& 3m
=era( =a!an && +g=MI O7er6eigh(
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#. STATUS INTERNUS
Ke%a*a Sime(ris$ n#rm#3e%ha*
Ma(a K#n,ung(i7a anemis :8;$ s+*era i+(eri+ :8;Leher Sime(ris$ !e7iasi (ra+ea :8;
Th#ra )an(ung Suara ,an(ung I$II n#rma*$ bising :8;
Paru S#n#r$ 7esi+u*er n#rma*$ r#n+hi 8@8
Ab!#men Tim%ani$ %eris(a*(i3 :B; n#rma*$ he%ar !an *ien(i!a+ (eraba
%. STATUS PSIKIKUS
?ara ber%i+ir su*i( !ini*ai
Perasaan ha(i su*i( !ini*ai
Ting+ah *a+u su*i( !ini*ai
Inga(an su*i( !ini*ai
Ke3er!asan su*i( !ini*ai
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Sensibi*i(as su*i( !ini*ai
ege(a(if !bnGera+an Abn#rma* Trem#r : 8 ;
A(he(#se : 8 ;
Mi#+*#ni : 8 ;
Kh#rea : 8 ;
K##r!inasi$ Gai( !an Keseimbangan
?ara ber,a*an (i!a+ !a%a( !i*a+u+an
Tes( R#mberg (i!a+ !a%a( !i*a+u+anDis!ia!#+#+inesis (i!a+ !a%a( !i*a+u+an
A(a+sia (i!a+ !a%a( !i*a+u+an
Reb#un! Phen#men (i!a+ !a%a( !i*a+u+an
Disme(ri (i!a+ !a%a( !i*a+u+an
I). PE'ERIKSAAN TA'BA$AN
Sirira, S3#re 1B1B1B018180- C 8- S(r#+e
N#nHem#ragi+
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I" RESUME
Pasien 6ani(a usia &' (ahun !a(ang !engan +e*emahan
angg#(a gera+ +anan$ #nse( 4 - hari SMRS" Pasien su*i(berbi3ara !an mu*u( mer#( +e +iri" Pasien memi*i+i ri6aya(
hi%er(ensi (i!a+ (er+#n(r#*"
Pa!a Pemeri+saan !i!a%a(+an Kesa!aran G?S C E'M2afasia m#(#ri+
Tan!a 7i(a* TD C 021@011 mmHg Na!i C .< @meni(
RR C -- @meni(
Suhu C >2$.1?
Ma(a Pu%i* bu*a($ is#+#r -"&mm@-"&mm$ ree+ 3ahaya
B@B
Nn ?rania*is Paresis N II !e(ra sen(ra*$%aresis N FII !e(ra sen(ra*
Leher Ka+u Ku!u+ :8;M#(#ri+ Kesan hemi%aresis !e(ra s%as(i+
Sensibi*i(as su*i( !ini*ai
ege(a(if !bn
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I" DIAGNOSIS
0" Diagn#sis K*inis 8 Hemi%aresis !e(ra s%as(i+ 8 Paresis n" II !an FII !e(ra sen(ra* Diagn#sis T#%is In(ra3erebra* Diagn#sis E(i#*#gis S(r#+e N#n Hem#ragi+
-" Hi%er(ensi gra!e II (i!a+ (er+#n(r#*
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II" REN?ANA PENGELOLAAN AAL
1. S*+oe Non $emo+a,i
D 8 Lab#ra(#rium !arah *eng+a%
8 ?T s3an
8 GDS
T 8 E*e7asi +e%a*a >1#
8 Infus RL -1 (%m 8 ?i(i3h#*in in,"-&11 mg :i7;
8 Si*#s(as#* -011mg :%#;
8 Rani(i!in -0 :i7;
M G?S$ Tan!a 7i(a*$ Desi( Neur#*#gis
E Men,e*as+an +e%a!a +e*uarga mengenai %enya+i($ren3ana %emeri+saan$ !an %eng#ba(an
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#. $i!e+*ensi G+a-e II
TD 021@011 mmHg$ MAP 0-1 mmHgD Hi%er(ensi gra!e II T 8 Am*#!i%in 001mg :%#;M 8 M#ni(#ring (e+anan !arah 2 ,am se+a*i
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?T S3an :00@>@-102; Tam%a+ *esi hi%#!ens+e3i* !i 3a%su*ae(erna !e(ra$gang*ia basa*is !an3#r#na ra!ia(abi*a(era*
Kesan Mu*(i%*e *a3unarinfar+ !i 3a%su*ae(erna !e(ra$gang*ia basa*is$ !an
3#r#na ra!ia(a
HARI PERAWATAN
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HARI PERAWATAN
(2 ) 11/3/2016
S Kesadaran membaik, Lemah anggota gerak kanan, mulut merot ke kiri, bicara pelo
O
KU/KS Tampak sakit sedang/ ompos mentis
TD 1!0/100 mm"g
N !# $ /mnt
RR 20 $ /mnt
S 36,%&
Status
Neuro-
logis
' *#+6-.1-+ata upil bulat, isokor, 2,-mm/2,-mm, cahaa /4nKranialis . arase 455, 55 de$tra sentral
ensibilitas dbnegetati7 dbn
P
T$ *le8asi kepala 300 9 5n7us L 20 tpm
9 iticholin in:2$-00 mg (i8)
9 ilostasol 2$100mg (po) 9 anitidin 2$1 (i8) 9 ;mlodipin 1$10mg(po)
rogram ro7il lipid, ureum, kreatinin, T scan
A
5
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Hasi* Lab#ra(#rium :0-@1>@-102;
Hematologi Hasil Kimia Klinik HasilHb(gr%) .! GDS "#HT(%) $$.% Ureum (mg!") 45 ↑#ritrosit($tmmk) 4."4 Kreatinin (mg!") 4.$" ↑MH(p&) "&. Asam Urat (mg!") $.5!M'(f")
'!.$Kolesterol Total
(mg!") $#4 ↑MH(g!l) $5.4 Trigliseri!a
(mg!")"
"ekosit(rbmmk) '.!4 HD" (mg!") 4!Trombosit(rbmmk) "%! "D" (mg!") "$#.&
↑D(%) "."
M*'(f") /"'
HARI PERAWATAN
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8/18/2019 CR SR hani
17/21
HARI PERAWATAN
(3) 12/3/2016
S Lemah anggota gerak kanan, bicara pelo, mulut merot ke kiri, demam
O
KU/KS Tampak sakit sedang/ ompos mentis
TD 220/120 mm"g
N !0 $ /mnt
RR 20 $ /mnt
S 3!,3&
Status
Neuro-
logis
' E'M2& C 0&+ata upil bulat, isokor, 2,-mm/2,-mm, cahaa /4nKranialis . arase 455, 55 de$tra sentral
ensibilitas dbnegetati7 dbn
P
T$ *le8asi kepala 300 9 5n7us L 20 tpm
9 iticholin in:2$-00 mg (i8) 9 ilostasol 2$100 (po)
9 anitidin 2$1 (i8) 9 icnat 3$1 (po) 9 ;sam 7olat 1$1mg (po) 9 aracetamol 3$-00mg (po)
rogram =isioterapi
9
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HARI PERAWATAN
(#) 13/3/2016
S Lemah anggota gerak kanan, bicara pelo, mulut merot ke kiri
O
KU/KS Tampak sakit sedang/ ompos mentis
TD 1@0/110 mm"g
N @6 $ /mnt
RR 20 $ /mnt
S 3%,3&
Status
Neuro-
logis
' E'M2& C 0&+ata upil bulat, isokor, 2,-mm/2,-mm, cahaa /4nKranialis . arase 455, 55 de$tra sentral
ensibilitas dbnegetati7 dbn
P
T$ *le8asi kepala 3 9 5n7us L 20 tpm
9 iticholin in:2$-00 mg (i8) 9 ilostasol 2$100 (po)
9 anitidin 2$1 (i8) 9 ;mlodipin 1$10mg (po) 9 im8astatin 1$1 (po) 9 >icnat 3$1 (po)
9 ;sam 7olat 1$1mg (po)
rogram =isioterapi 9
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8/18/2019 CR SR hani
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HARI PERAWATAN
(-) 1#/3/2016
S Lemah anggota gerak kanan, bicara pelo, mulut merot ke kiri
O
KU/KS Tampak sakit sedang/ ompos mentis
TD 220/120 mm"g
N !! $ /mntRR 20 $ /mnt
S 36,1&
Status
Neuro-
logis
' E'M2& C 0&+ata upil bulat, isokor, 2,-mm/2,-mm, cahaa /
4nKranialis . arase 455, 55 de$tra sentral
ensibilitas dbnegetati7 dbn
P
T$ *le8asi kepala 300 9 5n7us L 20 tpm
9 iticholin in:2$-00 mg (i8) 9 ilostasol 2$100 (po)
9 anitidin 2$1 (i8) 9 icnat 3$1 (po) 9 ;sam 7olat 1$1mg (po)
rogram =isioterapi
9
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8/18/2019 CR SR hani
20/21
HARI PERAWATAN
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8/18/2019 CR SR hani
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HARI PERAWATAN
(%) 16/3/2016
S Lemah anggota gerak kanan, bicara pelo, mulut merot ke kiri
O
KU/KS Tampak sakit sedang/ ompos mentis
TD 220/120 mm"g
N !! $ /mnt
RR 20 $ /mnt
S 36,1&
Status
Neuro-
logis
' E'M2& C 0&+ata upil bulat, isokor, 2,-mm/2,-mm, cahaa /
4nKranialis . arase 455, 55 de$tra sentral
ensibilitas dbnegetati7 dbn
P
T$ *le8asi kepala 300 9 5n7us L 20 tpm
9 iticholin in:2$-00 mg (i8) 9 ;spilet 1$1 (po)
9 anitidin 2$1 (i8) 9 aptopril 3$12,-mg(po) 9 Tia?id 3$2-mg(po)
9 im8astatin 1$10mg (po) 9 >icnat 3$1 (po) 9 ;sam 7olat 1$1mg (po)
ulang dengan kontrol
A
5