CASE PRESENTATION

BY: I Gede Bungas Arisudana

Patient Identity
Name : Mr. M
Birth Date : May, 08th 1965
Age : 52 years old
Gender : Male
Address : Central Jakarta
Nationality : Indonesia
Religion : Islam
Date of admission : August 15th 2017
 History Taking
Autoanamnesis from patient on August 17th 2017.

Chief complain:
Weakness in left Extremity
History of Present Illness
1 day before admission:
Patient complaint of weakness in his left extremity. The weakness come suddenly after the
patient finishing his shalat. Patient also felt an intense headache before the weakness
happened. Patient also had a slurred speech the same time as his weakness occurred. No
nausea and vomiting occurred neither any loss of consciousness. Patient was brought to
clinic by his wife, and the doctor advise him to take the patient to the hospital

day of admission:
Patient still had a complaint of weakness in his left extremity and still had a slurred
speech, his headache still occurred but the intensity is decreasing
 History of Past Illness
Hipercholesterol, controlled

Hypertension, uncontrolled

Denied about : Same Complain, Hyperglicemia, Cardial Prob,

Smoking, Alcohol
 Family History
No one has the same complain as patient
 Physical Examination
Date : August 17th 2017
General Status
General condition : mild ill
Awareness : E4V5M6
Blood Pressure : 170/100
Pulse : 82 x/min, regular, full, strong.
Breathing rate : 20x/min
Temperature : 37oC (per axilla)
Pain Scale :4
Systematic Physical Examination
Head Normocephaly, hair (black, normal distributon, not easily removed) sign of trauma
(-)

Eyes Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- , lacrimation -/-,
sunken eyes -/-, pupils 3mm/3mm isokor, Direct and indirect light response ++/++

Ears Normal shape, no wound, no bleeding, secretion or serumen

Mouth
Lips: dry
Teeth: no caries
Mucous: moist
Tongue: Not dirty
Tonsils: T1/T1, No hyperemia
Pharynx: No hyperemia

Neck Lymph node enlargement (-)

Thorax Symmetric when breathing , no retraction, ictus cordis is not visible
Inspection:
Palpation: mass (-)

Percussion: Sonor/sonor
Auscultation
Cor : regular S1-S2, murmur (-), gallop (-)
Pulmo: vesicular +/+, Wheezing -/- , Rhonchy -/-
Abdomen :
Inspection : normal

Palpation : supple, liver and spleen not palpable, tenderness (-)

Percussion: The entire field of tympanic abdomen, shifting dullness (-)

Auscultation: bowel sound 12 times/min

Anus Not inspected

Extremities Warm, capillary refill time < 2 second, edema ( - )

Skin Good turgor

 Neurological Status
GCS E4 M6 V5 (15)

Meningeal signs Nuchal rigidity :-

Brudzinskis sign (I and II) :-
Kernigs sign :-
Laseques sign :-
Nervus Cranialis N. I: -
N. II: pupillary light reflexes +/+
N. III, IV, VI: no ptosis, pupil size 3mm / 3mm, isocoric, no nystagmus
N. V: sensoric: -, Motoric: -
N. VII: sensoric: -, Motoric: eyebrow lift +, lagoftalmus -
N. VIII: -
N. IX: -
N. X: -
N. XI: -
N. XII: Hypoglossal nerve examination: deviation to the right, slurred speech +
Motoric examination Muscle strength: upper extremity: 555 / 333, lower extremity: 555/333
Muscle clonus: Patella ( - ), Achilles: ( - )

Reflex physiology Biceps: ++ / ++

Triceps: ++ / ++
Patella: ++ / ++
Achilles: ++ / ++
Pathologic reflex Hoffman tromner: - / +
Babinski: - / +
Chanddock: - / -
Shcaefer: - / -
Gordon: - / -
Oppenheim: - / -
Laboratory Investigation Hematology (August 15th 2017)

Hematology Results Normal Value

Haemoglobin 13,2 g/dL 13,2 17,3 g/dL

Leukocytes 9.18/L 3,800 10,600/L

Hematocrits 39% 40 52 %

Trombocytes 284.000/ L 150,000 440,000/L

Erythrocytes 4,75 million/L 4,40 5,90 million/L

Creatinine 1,3 mg/dL < 1,4 mg/dL

Laboratory Investigation Hematology (August 15th 2017)

Hematology Results Normal Value

Calcium 9,3 mg/dL 8,8 10,3 mg/dL

Blood Glucose 104 mg/dL 70 200 mg/dL

Admitting Diagnosis
Clinical Diagnosis:
Hemiparesis sinistra
Slurred speech
Headache
Face Asymmetry
Topical diagnosis:
Ganglia basalis Dextra
Etiological Diagnosis:
Hemmorhagic Stroke
Additional Diagnosis:
Grade 2 Hypertension
Dyslipidemia
MANAGEMENT (August 15th 2017)
O2 3 lpm NK
IVFD Assering / 12 hours
Manitol inf 125 cc/6 hours (tap off per day)
Citicolin inj 500 mg/ 12 hours
Candesartan tab 1 x 8mg
Amlodipin tab 1 x 10 mg
Ranitidin tab 2 x 1
Rehabilitation
PROGNOSIS

Ad Vitam: Bonam
Ad Fungsionam: Bonam
Ad Sanasionam: Dubia
 Follow up
August 16th 2017 August 20th 2017
 August 16th 2017
S Weakness on left extremity, headache, slurred speech
O General condition: Compos mentis
Blood pressure: 170/100, pulse: 80 bpm, respiratory rate:
20 x/min, temperature: 36,5oC
Motoric: 555/333
PN XII and VII central Sinistra

A Intracranial hemmorhage
Grade 2 Hypertension
P - inf Manitol 125 cc/ 6 hours (daily tapp off)
- Aspilet tab 1 x 80 mg
- Inj Citicolin 500 mg/12 hours
- Candesartan tab 1 x 8 mg
- Amlodipine tab 1x 10 mg
- Simvastatin tab 1 x10 mg
 August 17th 2017
S Headache, weakness at left extremity, slurred speech

O General condition: Compos mentis

Blood pressure: 150/100, pulse: 85 bpm, respiratory rate: 20 x/min, temperature: 36,6oC
Motoric: 555/444
PN XII and VII central Sinistra
A Intracranial Hemorrhage
Grade 2 Hypertension
P - Inf Manitol 125 cc/ 6 hours (daily tapp off)
- Aspilet tab 1 x 80 mg
- Inj Citicolin 500 mg/12 hours
- Candesartan tab 1 x 8 mg
- Amlodipine tab 1x 10 mg
- Simvastatin tab 1 x10 mg
 August 18th 2017
S Weakness at left extremity, slurred speech

O General condition: Compos mentis

Blood pressure: 120/80, pulse: 80 bpm, respiratory rate: 20 x/min, temperature: 36,5oC
Motoric: 555/444
PN XII and VII central Sinistra
A Intracranial Hemorrhage
Hypertension
P - Inf Manitol 125 cc/ 12 hours (daily tapp off)
- Aspilet tab 1 x 1
- Citicolin inj 500 mg/12 hours
- Candesartan tab 1 x 8 mg
- Amlodipine tab 1x 10 mg
- Simvastatin tab 1 x10 mg
- Ranitidine inj 1 amp/12 hours
 August 19th 2017
S Weakness at left extremity

O General condition: Compos mentis

Blood pressure: 120/80, pulse: 80 bpm, respiratory rate: 20 x/min, temperature: 36,5oC
Motoric: 555/444
PN XII and VII central Sinistra
A Intracranial Hemorrhage

P - Inf Manitol 125 cc/ 12 hours (daily tapp off)

- Aspilet tab 1 x 1
- Citicolin inj 500 mg/12 hours
- Candesartan tab 1 x 8 mg
- Amlodipine tab 1x 10 mg
- Simvastatin tab 1 x10 mg
- Ranitidine inj 1 amp/12 hours
 August 20th 2017
S Weakness at left extremity

O General condition: Compos mentis

Blood pressure: 120/80, pulse: 80 bpm, respiratory rate: 20 x/min, temperature: 36,5oC
Motoric: 555/444
PN XII and VII central Sinistra
A Intracranial Hemorrhage

P - Inf Manitol 125 cc/ 12 hours (daily tapp off)

- Aspilet tab 1 x 1
- Citicolin inj 500 mg/12 hours
- Amlodipine tab 1x 10 mg
- Simvastatin tab 1 x10 mg
- Ranitidine inj 1 amp/12 hours
LITERATURE REVIEW
What is Stroke?
A clinical syndrome consisting of rapidly developing clinical signs
of focal (or global) disturbance of cerebral function lasting more
than 24 hours or leading to death with no apparent cause other
than a vascular origin
(World Health Organization)
Risk Factor
MODIFIED RISK FACTOR
High blood pressure
Diabetes
Obese
Smoking
Dislipidemia
UNMODIFIED RISK FACTOR
Age
Gender
Signs and Symptoms
Sudden weakness
Paralysis or numbness of the face, arms, legs (especially one side of the body)
Trouble speaking or understanding speech
Sudden and severe headache
Trouble seeing in one or both eyes
Problems breathing
Dizziness, trouble walking, loss of balance coordination and unexplained falls
Confusion
Seizures
Decreased / Loss of consciousness
How to diagnose?
Neurological Examination
Brain CT Scan
MRI
Transcranial Doppler Ultrasound
Siriraj score
Siriraj Score
Formula:
(2,5 x Consciousness) + (2 x vomiting) + (2 x
headache) + (0,1 x DBP) (3 x atheroma) 12
Interpretation:
>1: stroke Hemmorhagic
<-1: Stroke Non Hemorrhagic
1: CT Scan or MRI
How to treat?
General Treatments :
Principle of ABC
Stabilitation of Breathing (0xygenation, ET, NGT, etc)
Vital sign monitoring
Hemodinamic Stabilitation
Early Physical Examinations
Monitoring of ICP
Additional Examinations
ECG
Lab Exam/ LP
Radiology Exam
Daily Activity Support
 Spesific Treatments
Managements of Stroke
Antiplatelets
Anticoagulants
Trombolytics
Neuroprotector
Craniotomy
Manitol
Management of Risk Factors (Blood Pressure/DM/Cardiac problems/Dislipidemia)
Management of Complications (UTI/Electrolyte imbalance/ulkus decubitus
Medical Rehabilitation
Family Education
 Clinical Guidelines for Stroke Management 2010, National Stroke Foundation
Columbia Neurosurgeons, Department of Neurosurgery. Cerebral Ischemia.
Gibbons, Gary H. 2017. Stroke. National Heart, Heart, Lung and Blood Institute.
Kanyal, Neema. 2015. The Science of Ischemic Stroke: Pathophysiology &
Pharmacological Treatment.