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    LAPORAN KASUSSTROKE HEMORAGIK PADA PERDARAHAN INTRASEREBRI (PIS)

    Pembimbing :dr. C!"r Bn"#i$ S%.S

    Disusun Oleh :

    Dini &!rini

    14.1022.1032

    KEPANITERAAN KLINIK ILMU PEN'AKIT SARA&RSUPPERSAHABATAN

    PERIODE APRIL * +, MEI +,-

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    STATUS PASIEN

    IDENTITAS PASIEN

    Nama : Ny. S

    Umur : 58 ahun

    !enis "elamin: Perem#uan

    Alama : Pen$$ilin$an% &a"un$

    Saus #er"a'inan : (eni"ah

    Pe"er)aan : I*u +umah Tan$$a N,. +( : 02.24.5-.25

    Tan$$al Pemeri"saan : 2 (ei 201-

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    ANA(NESIS

    eluhan uama:lemah an$$,a$era" se*elah

    "anan

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    +i'aya Penya"i Se"aran$

    11 hari S(+S #asien men$alami "elemahanan$$,a $era" "anan. elemahan /irasa"anmunul seara i*ai*a saa #asie* *an$un

    i/ur .Selain iu )u$a /irasa"an e*al #a/a 'a)ahse*elah "iri /iserai se/i"i #usin$ "eluar$amem*a'a #asien "e +S Persaha*aan !a"ara%

    nyeri "e#ala masih namun i/a" se#erise*elumnya% "e)an$ % #enurunan "esa/aran% mual % munah % mulu men,n$ %lemah an$$,a $era" se*elah "anan. Pasien/an "eluar$a menyan$"al a/anya raumase*elumnya.

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    +i'aya Penya"i Dahulu

    +i'aya sr,"e : /isan$"al

    +i'aya hi#erensi : Pasien men/eriahi#erensi se)a" 5- ahun yan$ lalu% ",nr,li/a" eraur% "a/an$ men$",nsumsi aml,/i#in

    +i'aya D( : /isan$"al

    +i'aya #enya"i )anun$: /isan$"al

    +i'aya ",leser,l in$$i : /isan$"al

    +i'aya asam ura in$$i : /isan$"al +i'aya rauma "e#ala : /isan$"al

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    +i'aya Penya"i eluar$a +i'aya hi#erensi : a"a" "an/un$ #asien

    mem#unyai #enya"i hi#erensi

    +i'aya D( : /isan$"al

    +i'aya #enya"i )anun$: /isan$"al +i'aya #enya"i seru#a : /isan$"al

    +i'aya e*iasaan (er,"," : /isan$"al

    (inum Al",h,l : /isan$"al

    Olahra$a : #asien )aran$ ,lahra$a

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    +i'aya Pen$,*aan

    Unu" "eluhan saa ini% #asienmen$a"u *elum mela"u"an#en$,*aan a#a#un

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    PE(E+ISAAN ISI

    ea/aan Umum : Tam#a" lemah

    esa/aran : &,m#,s menis% &S 15 E465(-

    6ial Si$n

    Te"anan /arah : 14070mm9$

    Na/i : 84 7meni

    ++ : 18 7meni Suhu : 3-%40&

    ;; : -5 $

    T; : 150 m

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    Saus

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    Saus eneralis

    Paru

    Ins#e"si : N,rm,hes% #er$era"an /in/in$/a/a simeris sais /an /inamis%

    =re"uensi #erna#asan 187meni% rera"si

    Pal#asi : Ta"il >,al =remius "anan ? "iri

    Per"usi : S,n,r #a/a seluruh la#an$ #aru

    Aus"ulasi : Suara na#as >esi"uler @ %'heein$ % rh,n"i

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    !anun$

    Ins#e"si : Ius ,r/is i/a" am#a"

    Pal#asi : Ius ,r/is era*a% "ua an$"a

    Per"usi : ;aas aas )anun$: I&S II#arasernal sinisra

    ;aas "anan )anun$ :

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    A*/,men

    E"sremias

    Inspeksi : datar, mengikuti gerakan nafas

    Palpasi : Supel, hepar dan lien tidak teraba,

    nyeri tekan (-), massa tumor (-)

    Perkusi : Timpani pada seluruh lapang

    abdomen

    Auskultasi : peristaltik (+) kesan normal

    A"ral han$a% sian,sis % e/ema% &+T C 3

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    STATUS NEU+O

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    Ner>i &ranialis

    N. I Ol=a",riusn,rm,smia @[email protected]

    N. II O#i"us>isus : i/a" *isa /ila"u"an

    la#an$ #an/an$ : i/a" *isa /ila"u"an

    #emeri"saan =un/us",#i /an #en$enalan'arna sillin$ ishihara es ar/F : i/a"/ila"u"an

    $ela# eran$ @% mem*aa ulisan )ara"

    /e"a )auh *ai"

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    N III Ner>us O"ul,m,,rius G N I6Ner>us Tr,"hlearis G N 6I Ner>us

    A*/usen "e/u/u"an *,la maa : ,r,#,sisi @[email protected]

    #er$era"an *,la maa : *ai" "ese$alaarah

    #,sis : 7

    nisa$mus : 7#emeri"saan #u#il :

    *enu" : #u#il *ula% is,",r% /iameer

    3mm73mm

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    N. 6 Tri$eminus

    m,,ri": $era"an rahan$ : *ai"

    men$$i$i : *ai"

    sens,ri": ,#halmius : hi#esesi [email protected]

    ma"silaris : hi#esesi [email protected] man/i*ularis : hi#esesi [email protected]

    reHe"s: ",rnea : @[email protected]

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    N 6II Ner>us asialis

    m,,ri" :

    "esan 'a)ah : simeris men$an$"a alis /an men$eru"an /ahi : *ai"7*ai"

    meme)am"an maa: *ai"7*ai"

    menyerin$ai menun)u""an $i$i $eli$i : simeris

    sens,ri" : #en$ea#an li/ah 273 /e#an: *ai"

    N. 6III 6esi*ul,","learis

    #en/en$aran : es $ese" )ari @[email protected]% es

    *isi" @[email protected] "eseim*an$an : i/a" /ila"u"an

    es $ar#uala : i/a" /ila"u"an

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    N I Ner>us l,s,=arin$eusG N Ner>us>a$us

    m,,ri" : isiraha"e/u/u"an #alaum m,lle : *ai"

    "e/u/u"an arus =arin$ : i/a" a/a /e>iasi

    "e/u/u"an u>ula : *era/a /ien$ahm,,ri" : *er$era"

    "e/u/u"an #alaum m,lle : *ai"

    "e/u/u"an arus =arin$ : i/a" a/a /e>iasi"e/u/u"an u>ula : *era/a /ien$ah

    sens,ri" : reHe"s munah i/a" /ila"u"an

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    N. I Asess,rius

    men$an$"a *ahu : simeris% *ahu "anan

    sama /en$an "irimen,leh : simeris% "anan sama /en$an "iri

    N. II l,ss,#harin$eus

    #er$era"an li/ah : *ai"

    men)ulur"an li/ah : li/ah se/i"i

    menyim#an$ "e sisi "ananar,J :

    =asi"ulasi :

    rem,r :

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    PE(E+ISAAN (OTO+I

    - E"sremias Su#eri,r /an In=eri,r

    anan iri

    E"sremias

    aas

    3 5

    E"sremias

    *a'ah

    3 5

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    Sens,ri"

    Pr,#i,se#i= : i/a" /ila"u"an

    E"ser,se#i=Nyeri : *ai"7*ai"

    Suhu : *ai"7*ai"

    +a*a : *ai"7*ai"

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    +eHe"s Jsi,l,$is

    +eHe"s su#erJsial:

    +eHe"s ",rnea : @[email protected]

    +eHe"s /alam:+eHe"s *ie#s *ie#s #ees reHe"s : @@[email protected]@

    +eHe"s rise#s rise#s #ees reHe"s : @@[email protected]@

    +eHe"s #aella "nee #ees reHe"s : @@[email protected]@+eHe"s ahiles ahilles #ees reHe"s : @@[email protected]@

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    +eHe"s #a,l,$is

    +eHe"s h,Kman r,mner : 7

    +eHe"s ,##enheim : 7+eHe"s *a*ins"i : 7

    +eHe"s ha//,"s : 7

    un$si

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    Per/arahaninra#aren"himal /ihalamus /an "a#sulainerna "iri /en$anesimasi >,lume L 3 In=ar" muli#el /i *asal

    $an$lia "anan "iri

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    DIANOSIS

    Dia$n,sis "linis : hemi#arese /e"ra/iserai #arese ner>us 6 /an II

    Dia$n,sis ,#is : #er/arahan /ia*an$ areri ere*ri #,seri,r

    Dia$n,sis ei,l,$i : sr,"ehem,rrha$i" e #er/arahan inra

    sere*ralG sr,"e is"emi"

    Dia$n,sis #a,l,$iana,mi :#er/arahan

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    PENATA

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    PROGNOSIS

    A/ >iam : Du*ia a/ *,nam

    A/ =uni,nam : a/ *,nam A/ sanai,nam : Du*ia a/ *,nam

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    an$$uan ner>us 6 #a/a#asien

    ;ila rasa ra*a er$an$$u menun)u""an a/anya lesi /i nuleusin/u" s,ma,sens,ri" /i #,ns

    Da#a )u$a /ise*a*"an "arna a/anya$an$$uan #a/a areri >ere*r,*asilarisaau sisem "ar,is.

    Tea#i% #a/a #asien ini #enye*a* suli/inilai "arna hasil &T San menun)u""an/aerah #,ns /alam *aas n,rmal.

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    O(P