laporan kasus cva bleeding
TRANSCRIPT
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RESPONSIFINNA ERNICA
07.70.0040
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SUBJECTIVE
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Tn. S, 43 tahun, menikah pekerjaan supir. Pasien datang tgl 25 November 2011 dengan keluhan utama lemah pada tangan dan kaki kiri setelah sholat. Kemudian, Pasien merasa bicara pelo dan lidah mencong ke kiri.
Keluhan Lain :Mbliyur (+), muntah (-), panas (-), SMRS BAB (N), BAK warna hijau.
ANAMNESA
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RPD:-HT (+) sejak 2 tahun yang lalu, Tekanan darah tertinggi 250 mmHg-Diabetes Melitus (-)-Batu ginjal (?)
R.Sosial:Sering minum jamu pegal linu
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OBJECTIVE
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T : 200/120 mmHg Temp : 36.3 C RR : 22 x/menit HR : 72X/menit K/L : DBN Thorax : DBN Abdomen : DBN
STATUS INTERNE
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STATUS NEUROLOGI
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Kesadaran Kualitatif: Somnolen GCS : 3-5-6
Kesan Umum
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Rangsang Selaput Otak : (-) N.I : Tidak Dilakukan N.II : Kesan Normal N.III, IV, VI : Normal N.V : Kesan Normal N.VII : Kesan Parese kiri
Pemeriksaan Neurologi
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N.VII : Kesan Normal N.IX, X : Kesan Normal N.XI : Normal N.XII :
◦ Kedudukan lidah waktu istirahat miring ke kiri◦ Kedudukan lidah waktu dijulurkan miring ke kanan
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Motorik : 5 / 1 Tonus : Normal/Hipotoni BPR : -/- TPR : -/- Hoffman : -/- Tromner : -/-
Extremitas Atas
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Sensibilitas:◦ Eksteroseptik : Normal/tidak merasa◦ Propioseptik : Normal/tidak merasa◦ Enteroseptik : (-)◦ Rasa Kombinasi : Normal/tidak merasa
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Motorik : 5 / 3 Tonus : Normal/Hipotoni KPR : -/- APR : -/- Babinsky : +/- Chaddok : -/- Openheim : -/-
Extremitas Bawah
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Gordon :+/- Gonda : -/- Schaeffer : -/+ Rossolimo : -/- Mendel Bechterew : -/- Stransky : +/-
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Sensibilitas:◦ Eksteroseptik : Normal/tidak merasa◦ Propioseptik : Normal/tidak merasa◦ Enteroseptik : (-)◦ Rasa Kombinasi : Normal/tidak merasa
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Reflek Dinding Abdomen : +/- Reflek Primitif : (-) Fungsi Luhur :
◦ Fingeragnosia : +(N)/-
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WBC / Hb/ HCT/ PLT6900 / 15.3/ 45.9 /157000
UA 8.5 (N 3.5 – 7.2)TG 776 (n 40 – 200)
PEMERIKSAAN LABORATORIUM
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Diagnosa Klinis : Hemiparese Kiri Diagnosa Topikal : Cortikal Diagnosa Etiologi : Hipertensi + CVA
Bleeding Diagnosa Banding : CVA Infark, Oedema
Otak
ASSESMEN
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Penurunan Kesadaran (+) Nyeri Kepala (-) Reflek Babinski (+)
Dua Gejala + STROKE HEMORRHAGIC
ALGORITMA GAJAH MADA
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2.5 Kesadaran + 2 Muntah +2 Sakit Kepala + 0.1 Diastolik -12-3 Tanda atheroma=
(2.5 x 1) + (2 X 0) + ( 2 X 0) + (0.1 X 120) –12 – (3 X 0) =2.5 + 0+12-12-0 = 2.5STROKE HEMORRAGIC
SIRIRAJ HOSPITAL
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Waktu serangan (saat aktivitas 6.5) Sakit kepala (tidak ada 0) Muntah (tidak ada 0) Kesadaran ( langsung 10) Waktu serangan (TD TINGGI 5)
TOTAL = 21.5 STROKE HEMORRAGIC
SKORING DJUNAEDI WIDJAJA
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Planning Diagnosa :- CT Scan- MRI
PLANNING
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Planning Terapi: Terapi Umum:
Pasang O2 bila sesak 24-48 jam pertama puasa setelah itu
diet bubur halus Pasang Dower Kateter Posisi Head Lift 45∘
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Terapi Khusus:Infus RL 20 tpmInj. Brainact 3 x 500 mgInj. Kalnex 3 x 2 amplInj. Vitamin KSohobion 5000 1-0-0Nifedipine 5 mg tiap jam sampai tensi
180Konsul jantungKonsul rehabilitasi medik
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Vital Sign Kesadaran, Bicara N.VII N.XII Rasa Sensibilitas Motorik Tanda – Tanda Peningkatan TIK
MONITORING
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Tanggal 28 November 2011◦ S: Pusing◦ O:
GCS : 4-5-6 Somnolen T : 190/110 Temp : 37.5 Nadi : 150 x/menit Status Neuro : SDA
FOLLOW UP
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Tanggal 10 Desember 2011◦ S: Tidak ada◦ O:
GCS: 4-5-6 Compos Mentis T : 140/90 Temp : 37 Nadi : 90 x/menit RR : 24 x/menit Status Neuro :
Motorik extremitas atas : 5/3 Motorik extremitas bawah : 5/4
FOLLOW UP
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A : Post CVA Bleeding P :
◦ Sohobion 5000 1-0-0◦ Piracetam 800 mg 3 x 1◦ Kontrol Poli Saraf◦ Kontol Poli Rehab◦ Kontrol Poli Jantung untuk hipertensi
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Kontrol Tekanan Darah Pantang makanan tinggi kolesterol Pantang makanan tinggi asam urat
Bayam
Emping
Nangka
Jeroan
Oncom ( kacang – kacangan )
Lodeh ( mengandung santan)
EDUKASI
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Dubia ad bonam
PROGNOSIS
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TERIMA KASIH