Non Hemoragic Stroke
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Transcript of Non Hemoragic Stroke
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REFLEKSI KASUSSTROKE HEMORAGIK
BAGIAN ILMU PENYAKIT SARAF
FKIK UNTAD – RSU ANUTAPURA
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IDENTITAS PASIEN
• Nama : Tn. Y
• Umur : 59 tahun
• Kelamin : Laki - laki
• Agama : Islam
• Alamat : Pantoloan
• Masuk RS : 4 Juni 2014
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ANAMNESIS
• Keluhan utama: lemah pada tubuh sebelah kanan
• Informasi mengenai keluhan utama:
Pasien masuk dengan keluhan lemah pada bagian tubuh sebelah kanan sejak 4 hari yang lalu, lemah pada tubuh sebelah kanan terjadi tiba-tiba saat pasien sedang tidak beraktivitas. Selain itu pasien juga kesulitan dalam berbicara. tetapi masih bisa memahami apa yang disampaikan kepadanya. Pasien menyangkal keluhan sakit kepala (-), kejang (-), pusing (-), nyeri dada (-), mual (-), muntah (-), demam sebelumnya (-). Riwayat jatuh atau mengalami trauma pada kepala sebelumnya disangkal.
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RIWAYAT PENYAKIT DAHULU
• Riwayat hipertensi (-)
• Riwayat hiperkolesterol (-)
• Riwayat diabetes mellitus (-)
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PEMERIKSAAN FISIK
• Keadaan umum : sakit berat
• Kesadaran : compos mentis
• Gizi : baik
• Tekanan darah : 150/100 mmHg
• Nadi : 96 x/menit, reguler, berisi
• Pernapasan : 20 x/menit, reguler
• Suhu : 36,7 oC
• Anemis : (-)/(-)
• Ikterus : (-)/(-)
• Sianosis : (-)
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THORAKS
• Inspeksi : Pergerakan dinding dada simetris
• Palpasi : Nyeri tekan (-); massa (-)
• Perkusi : Bunyi sonor (+)/(+); batas paru normal; batas jantung normal.
• Auskultasi : Suara napas vesikuler (+)/(+); rhonki (+)/(+); wheezing (-)/(-); bunyi jantung 1&2 murni reguler
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ABDOMEN
• Inspeksi : Tampak lemas dan datar
• Auskultasi : Peristaltik (+) kesan normal
• Perkusi : bunyi timpani (+)
• Palpasi : Nyeri tekan (-); hepatosplenomegali (-)
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STATUS NEUROLOGIS
• GCS : E4 M6 V5
• Kepala
• Posisi : sentral
• Penonjolan : (-)
• Ukuran/bentuk : normocefal/mesocefal
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STATUS NEUROLOGIS• Nervus Cranialis
• N.I normosmia
• N.II
• Ketajaman pengelihatan: tidak dilakukan
• Lapangan pengelihatan: tidak dilakukan
• N.III,IV,VI
• Ptosis: (+)/(-)
• Exoftalmus: (-)/(-)
• Posisi bola mata: sentral/sentral
• Ukuran pupil: isokor
• Refleks cahaya:tidak bisa dinilai
• Bola mata kanan tidak dpat digerakkan ke medial.
• Nistagmus (-)/(-)
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STATUS NEUROLOGIS• N.V
• Sensibilitas N.V1 : (+)/(+)
• Sensibilitas N.V2 : (+)/(+)
• Sensibilitas N.V3 : (+)/(+)
• Refleks dagu/masseter : (+)
• Refleks kornea : (+)
• N.VII
• M. Frontalis : normal/normal
• M. Orbikularis Okuli : normal/normal
• M. Orbicularis Oris : parese
• Pengecap 2/3 anterior lidah :tidak dilakukan
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STATUS NEUROLOGIS
• N.VIII
• Pendengaran : normal
• Test rinne/weber : tidak dinilai
• Fungsi vestibularis : tidak dinilai
• N.IX / X
• Posisi arkus faring : simetris
• Refleks menelan/muntah : (+)
• Pengecap 1/3 posterior lidah : normal
• N.XI
• Memalingkan kepala : normal
• Angkat bahu : normal
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STATUS NEUROLOGIS
• N.XII
• Deviasi lidah: (-)
• Fasciculasi : (-)
• Atrofi : (-)
• Tremor : (-)
• Ataxia : (-)
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STATUS NEUROLOGIS
• Leher
• Kaku kuduk : (-)
• Tanda kernig : (-)/(-)
• Arteri karotis : teraba
• Kelenjar gondok : tidak ada pembesaran
• Abdomen
• Refleks kulit perut:
• Kolumna vertebralis: tidak dinilai
(+) (+)
(+) (+)
(+) (+)
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STATUS NEUROLOGIS• Ekstrimitas
• Motorik
• Otot yang terganggu: tidak ada
Superior Inferior
Dextra Sinistra
Dextra Sinistra
Pergerakan
menurun
normal menurun
normal
Kekuatan 3 5 3 5
Tonus otot menurun
normal menurun
normal
Bentuk otot
eutrofi eutrofi eutrofi eutrofi
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STATUS NEUROLOGIS
• Refleks fisiologis
• Klonus
• Lutut : (-)
• Kaki : (-)
Refleks Dextra Sinistra
Biceps (+) (+)
Triceps (+) (+)
Radius (+) (+)
Ulna (+) (+)
KPR (+) (+)
APR (+) (+)
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STATUS NEUROLOGIS
• Refleks patologis
Refleks Dextra Sinistra
Hoffman (-) (-)
Tromner (-) (-)
Babinski (-) (-)
Chaddock (-) (-)
Schaefer (-) (-)
Gordon (-) (-)
Oppenheim (-) (-)
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STATUS NEUROLOGIS
• Sensibilitas
• Nyeri : /n/ /n
• Suhu : n/n/n/n
• Rasa raba halus : /n/ /n
• Rasa nyeri dalam : n/n/n/n
• Rasa diskriminasi : n/n/n/n
• Stereognosis : n/n/n/n
• Pergerakan abnormal yang spontan: (-)
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STATUS NEUROLOGIS
• Gangguan koordinasi
• Tes jari-hidung : tidak dinilai
• Pronasi-supinasi : tidak dinilai
• Tes tumit-lutut : tidak dinilai
• Tes pegang jari : Normal
• Gangguan keseimbangan
• Tes romberg : tidak dinilai
• Gait : tidak dinilai
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PEMERIKSAAN PENUNJANG
Pemeriksaan Hematologi
Nilai Rujukan Hasil pemeriksaan
WBC 4,0 – 12 7,2 X 103
RBC 4,0 – 6,2 5, 36
HGB 11,0 – 17 13, 9
PLT 150 - 400 193
HCT 35 - 55 45,2
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PEMERIKSAAN KIMIA DARAH
RUJUKAN HASIL PEMERIKSAAN
GDS 70 – 115 mg/ dL
172 mg/ dL
KOLESTEROL < 200 mg/ dL 200 mg/ dL
TRIGLISERIDA < 200 mg/ dL 30 mg/ dL
ASAM URAT 3,6 – 8,2 mg/ dL
3,2 mg/ dL
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RESUME
Pasien laki – laki berusia umur 59 tahun, masuk dengan keluhan hemiparese dextra yang terjadi secara tiba-tiba saat sedang beristirahat. Pada pasien juga terdapat aphasia. Riwayat hipertensi (+), TD = 150 / 100 mmHg, N = 96 x/menit, P= 20 x/menit, S = 36,70C. Pemeriksaan fisik ditemukan rhonki basah kasar pada bagian basal. GCS 15
(E4V5M6). Pemeriksaan neurologis didapatkan
adanya paresis N. III ke arah lateral pada oculi dextra, ptosis (+) palpebra dextra
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DIAGNOSIS
• Diagnosa klinis : hemiparese dextra
• Diagnosa topis : lesi di hemisfer cerebrum sinistra
• Diagnosa etiologi : stroke non hemoragik
Diagnosa banding : stroke hemoragik
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TERAPI
• Tirah baring
• Anti hipertensi: golongan kalsium channel blocker (Amilodipin)
• Golongan Neuroprotektan (Piracetam)
• Golongan Neurotropik (Vitamin B12)
• Golongan Anti Platelet (Aspirin)
• Anti hipertensi: golongan kalsium channel blocker (Amilodipin)
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DISKUSI
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PROGNOSA
• Qua ad vitam : dubia ad bonam
• Qua ad sanationam : dubia ad bonam
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