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CASE

PRESENTATION
Hemorrhagic Stroke
Putri Maharani
030.11.235

Patients ID

Name : Mrs. A
Age

: 60 y.o

Sex

: Female

Marital Status

: Married

Education Background : Senior High


School

Address : Maluku
Date of Entry : March, 14th 2016
Medical Record : 15.26.XX

Anamnesa
alloanamnesa March 16th - Selayar Ward 3C dr. Mintohardjo Navy Hospital

Chief Complaint
Loss of consciousness
20 mins before entering E.R

Present Illness
//
Illness
JakartaMaluku

In 20 min
enter E.R

Severe
Headache

Loss of
conciousn
ess

BP 200 at
home

Talking
with
family

Past

ICU

(-) ;
o History of
weakness in
extremities
o Speech
disturbance
o Fever
o Nausea and
vomiting

Never had any loss of consciousness

History of stroke 2 years ago (non-hemorrhagic)

History of Chronic Hypertension (+)

History of Diabetes (-)

History Heart & Lung Disease (-)

History of Ashtma (-)

Family History
//
Eco Status

Social-

Have 3 kids
History of ;
Stroke
Lives in Maluku
Hypertesion
Non smoker
DM
No routine exercise
Seafood consumption on
In family all denied by the family
daily basis

Consciousness

: Soporous,

Vital

E1M4V2
Blood Pressure : 150 / 100
mmHg
Pulse
: 104x / min,
regular,
strong,
equal
Breathing
: 24x / min

Signs

Temperature

PHYSICAL EXAM

: 37 Celsius

PHYSICAL EXAM
GENERAL

HEAD : Normocephal, Lesion (-)


EYES : Irregular pupil
EARS : Otorrhea (-/-), no local lesion
NOSE : Rhinorrhea -/-, lesion (-/-)
MOUTH

: Lesion (-), cyanosis (-)

NECK : Lesion (-), rigidity (-)


HEART
: Heart sound I-II (+), regular,
murmur (-), gallop (-)

LUNG : Vesicular breathing sound +/+,


rhonchi /-, wheezing -/-

STATUS

ABDOMEN : Defense muscular (-), lesion (-)


EXTREMITIES : Warm extremities /

Neurological Assessment
MENINGEAL SIGN
Brudzinsky I : Not Examined
Brudzinsky II : Not Examined
Laseque : (-)
Kernig : (-)
HEAD
Shape : Normocephal
Tenderness : (-)
Pulse : (-)
Symmetrical : (+)

NECK
Posture
Movement

: Normal
: (-)

APHASIA
Motoric Aphasia : Difficult to asses
Sensory Aphasia : Difficult to asses
Dysarthria
: Difficult to
asses

----- Cranial Nerves ----- N. I - Olfactory Nerve

N. VI Abducent Nerve

N. II Optic Nerve

N. VII Facial Nerve

Pupil isochor : Difficult to asses

N. VIII Vestibulocochlear Nerve

Light Reflex : Negative

N. IX Glossopharyngeal Nerve

N. III Oculomotor Nerve

N. X Vagus Nerve

N. IV Troclear Nerve

N. XI Accessory Nerve

N. V Trigeminal Nerve

N. XII Hypoglossal Nerve

Upper Extremities
SENSORY

Pain : Not Examined


Temperature : Not Examined
Point Discrimination : Not Examined

PHYSIOLOGICAL REFLEX

Biceps : +1 / +1
Triceps

: +1 / +1

Radius : Not Examined


Ulna

: Not Examined

MOTORIC

Movement

: Difficult to assess -

Power : Left hemiparesis impression


Trophy

: -/-

Tonus : +/+

PATHOLOGICAL REFLEX

Hofman Tromner

:-/-

Lower Extremities
SENSORY
Pain : Not Examined
Temperature : Not Examined
Point Discrimination : Not

PHYSIOLOGICAL REFLEX
Patella : +1 / +1
Achilles : +1 / +1

Examined

MOTORIC
Movement: Difficult to assess
Power : Left hemiparesis
impression

Trophy
: -/ Tonus : +/+

PATHOLOGICAL REFLEX

Babinsky : + / +
Chaddock : - / Schaeffer : - / Oppenheim
Gordon

:-/-

:-/-

COORDINATON, GAIT, AND BALANCE

Walking

: Not Examined

Romberg Test

: Not Examined

Dysdiadokinetic : Not Examined


Ataxia : Not Examined
Dissymmetrical

: Not Examined

ABNORMAL MOVEMENT

Tremor

:-/-

Athetose : - / Myoclonic : - / Chorea

:-/-

OTONOM REFLEX

Micturition

; by Catheter

Defecation

: by Diaper

Anal Reflex

: Not Examined

Cremaster Reflex : Not Examined


Bulbocavernosus Reflex : Not Examined

LASEQUE
Patrick
: Not Examined
Contra Patrick : Not Examined

Type of

Results

Normal

Examinatio

SUPPORTING
EXAMINATION
Laboratory
March 14th 2016

Value

n
HEMATOLOGY
ROUTINE BLOOD
10,400
Leucoyte

/uL

5000-

Eritrocyte

4,64

juta/uL

10.000
4,6-6,2

Hemoglobi

12,0

g/dL

14-16

n
Hematocrit
Trombocyte

37
210.000

%
ribu/uL

42-48
150.000450.000

CLINICAL
RENAL FUNCTION
24
Ureum
0,8
Creatinine
154
Glukosa
Test

mg/dL
mg/dL
mg/dL

17-43
0,6-1,1

CLINICAL
BLOOD GAS

SUPPORTING
EXAMINATION
Laboratory
March 14th 2016

pH

7,437

7,35-7,45

PCO2

33,8

mmHg

32-48

PO2

192,0

mmHg

83-108

HCO3 act

22,2

mmol/L

21-28

HCO3 std

23,4

mmol/L

BE (ecf)

-1,9

mmol/L

-2 3

SBE

-1,3

mmol/L

-3 3

Ct CO2

23,3

mmol/L

23-27

AnGap

25,3

mmol/L

O2 SAT

99,4

95-98

O2 Ct

17,2

ml/dl

Natrium

142

mmol/L

134-146

3,14

mmol/L

3,4-4,5

97

mmol/L

96-108

(Na)
Kalium
(K)
Clorida
(Cl)

CT-SCAN
March 15th 2016

Non Contrast/Head/Axial/No
Bone Window
Hyperdensitic Lesion in Right
Temporal Lobe and Basal
ganglia
Midline shifting contralateral
Estimated bleeding volume
P x L x T/2 =
5 x 3 x 10 /2 = 75 ml
Results :
Right Intracerebral
Hemorrhage
Cerebral Atrophy

ECG
March 14th 2016

Sinus : Sinus
rhythm, reguler
QRS rate : 75
x/menit
Axis : Left Axis
Deviation (II, AvF
negative)
Terdapat T inverted
di I, Avl, V4-V6
(anterolateral
ischemia)

Ax1
Clinical Diagnosis
ASSESSMENT

: loss of
consciousness, Left hemiparesis
Etiological Diagnosis :
Hemorrhagic Stroke
Topical Diagnosis: Intracerebral
Hemorrhage (temporal right lobe)

Pathological Diagnosis :
Hemorrhagic
Ax2 : Grade II

Hypertension

IVFD NaCl 20
drops/min

PLANNING
PROGNOSIS
Ad vitam

: Dubia ad Malam

Ad fungtionam
: Dubia ad
Malam
Ad sanationam : Dubia ad
Malam

ICU
Bedrest with 300

Manitol loading
150 cc,

maintenance 4 x
elevation
125 cc
Oxygen10 L/min
Naso Gastric Tube Sanmol drip 3 x 1
Inj Ranitidin 2 x 1
(NGT)
amp
Urine Cathether
Captopril 3 x 25
mg
Kalnex 3 x 500 mg
Inj Ceftriaxone 2 x

Introduction
Blood
flow

Hemorrhagic
16-19% of all
strokes

Acute
CVD

Loss of
neurologi
cal
function

stro
ke

During
24 hours
lead to
death

Risk factors :
Gender
Age
Race
Smoking
Obesity
Hypertension
Diabetes
etc

Chronic
Hypertension

80-85% cause of
stroke

Elasticity
Hyalinization of basal
membrane

Grade II Hypertension
4,9x risk ICH

High intravascular
pressure

30-45% Recurrence after


5 year of attack

Ruptured vessels

Intracerebral
Hemorrhage

Pathophysiology

unmodifia
ble
>65 2x the risk
Age

modifiabl
e
Chronic

Hypeprtens
hypertension
ion

Men>women
Gender

Non white
correlated more
often ICH

Smoking

Seafood daily
consumption
Race

High
Cholesterol

Cerebral
Amyloid
Angiopathy

Alcohol
Consumptio
n

Intracerebral
Hemorrhagic

Hematom
formation

Cut off blood supply

Mass effectherniation

Loss of consciousness in
15-20 sec complete
hypoxia

Ischemic tissue

Antedecent infection ;
raised temperature,
leucocyte,hematocrit,

Pressing
brainstem
Loss of
consciousness
Transtentorial
herniation
anisocor
pupils

Diagnosi
ng
SIRIRAJ
Score
Gajah
Mada
Algorith
m

Symptoms;
Severe headache
Acute loss of
consciousness
Left hemiparesis
impression
0 (suspect )
Hemorrhagic Stroke
(+) 3 out of 3 ; headache,
loss of consciousness
babinsky (+)

ICU

Indications

Loss of consciousness, GCS score <7


Difficulty retain patent airway GCS <9
Complication; sepsis, hypertension

Bedrest

Elevation 15-30o

Decrease intracranial pressure

Convulsion Management
Diazepam 5-20 mg bolus followed by phenytoin 15-20 mg/kg max
bolus speed 50mg/min
ICH Prophylaxis for 1 month, tappered-then stop if theres no
convulsion

Etc

Guedel patent airway


NGT prevent aspiration
Urine catheter monitoring urine output

ABC

Vital signs monitoring

Oxygenation if saturation <95%


Intubation if PCo2 >50mmHg atau PO2< 60 mmHg.

Maintain

Hemodynamic Stability

Crystalloids/ colloids Saline infusion 0,9% 20 drops/min


Control BP ; IF BP 150-200 mmHg Target 140 mmHg

ICP

Intracranial Pressure Management

Osmotherapy Manitol 20% 0,25-0,5 g/kg for 20 min, per 6


hour

Temperatur Control
e

Give acetaminophen 650mg if ; temp >38,5/>370C

Supporting exam
ECG-routine blood- renal functionelectrolyte, Blood sugar- Thorax xray

Anti fibrinolytic
Prevent risk of rebleeding transamin
injection (kalnex 3x500mg

Nausea prevention
Cause of elevated ICP
H2 receptor inhibitor Ranitidin
injection 2x1

prognosis
Bad prognosis ;
High mortality rate 26,8% (age 55-64)
high disability rate

resume
Ny. A 60 year old. Was admitted to dr. Mintohardjo Navy Hospital E.R on 14 th
March 2016 with loss of consciousness 20 mins before. Theres no signs of
lesion, speech disturbance, fever, nausea & vomiting. (+) History of nonhemorrhagic stroke 2 years ago and chronic hypertension. Patient do not
smoke, consume seafood on daily basis and lives with her two children.Physical
Exam, GCS ; E1 M4 V2 , BP 150/100 hr 104x/min, RR 20x/min, Temp 37C.
Neurological examination found, meningeal sign (-), Cranial Nerve Lesion (-),
Normal physiological reflex, Patological reflex babinsky (+/+). With Siriraj
score 0 and Gajah Mada Algorhytm : Hemorrhagic stroke. Lab results shows,
leukocytosis, hipocalemia, hiperdens lesion in right temporal lobe and basal
ganglia with midline shifting in CT-Scan

THANK YOU