HEMORRHAGIC STROKE

: dr. Ronny Yoesyanto, Sp.S

Hasnania Rilanty Munaf

03013090
 PATIENT’S IDENTITY
▶ Name : Mr. S
▶ Age : 72 years old
▶ Sex : Male
▶ Marital status : Married
▶ Religion : Islam
▶ Educational background : Middle High School
▶ Occupation : Unemployee (retired)
▶ Address : Karet, Tanah Abang
▶ Admission date : 19 June 2017
▶ Medical record number : 173940
 ANAMNESIS

Additional
Chief Complaints
Complaints

•Unconscious • Shortness of
breath
 HISTORY OF PRESENT ILLNESS
• Alloanamnesis with wife on Monday, June 19th, 2017:
• The patient was brought into RSAL DR. Mintohardjo Emergency Room after losing
consciousness at home in the morning around 3.30 am on Monday, June 19th, 2017.
Patient was not able to woke up from his sleep. The day before admission, patient
was still active, patient was still able to help his wife cleaned the house. Upon
admission, patient was seen having shortness of breath. Patient also coughed a
week before admission to the hospital.
 • Controlled hypertension
Past medical (diagnosed on 2010)
history • High level of uric acid (controlled
with Allopurinol)

Family medical
• Younger brother had stroke
history
 PHYSICAL EXAMINATION
• Counciousness :
• Glasgow Coma Scale : E3 M6 V aphasia motoric

• Vital sign :
• Blood pressure : 180/90

• Pulse rate : 80 x/min, regular

• Respiratory rate : 28 x/min

• Temperature : 37,6oC

• Oxygen saturation : 99%

 PHYSICAL EXAMINATION
Head
Size Normocephal

Hair Strong, grey hair and evenly distributed

Eyes

Conjunctiva pallor -/-

Scleral icterus -/-

Pupil Isocoria, DLR +/+, NDLR +/+

 PHYSICAL EXAMINATION
Mouth
Cyanosis, dryness -
Tongue
Fasiculation -
Deviation -

Neck
Lymph nodes Not palpable
Neck stiffness -
 PHYSICAL EXAMINATION
Thorax
Lungs
Vesicular breathing sounds +/+

Ronchi +/+

Wheezing -/-

Pulsasi ictus cordis Tidak tampak jelas

Heart
S1S2 Regular

Murmur, gallop -
 PHYSICAL EXAMINATION
Abdomen
Supple +
Bowel sound +, normal
Organ enlargement -

Upper and Lower Extremities

Warm
extremities

Edema
 NEUROLOGICAL EXAMINATION
• Meningeal Signs
• Neck stiffness (-)
• Brudzinsky I (-)
• Brudzinsky II - / -
• Laseque - / -
• Kernig - / -

• Speech
• Motor aphasia (+)
• Sensory aphasia (-)
 NEUROLOGICAL EXAMINATION
• Coordination, gait, & balance • Abnormal movements
• Gait : Not examined • Tremor : -/-
• Romberg test : Not examined • Athetose : -/-
• Disdiadokinetic : Not examined • Myoclonic : -/-
• Finger to Nose : Not examined • Chorea : -/-
• Dix-Hallpike : Not examined

• Autonomic reflexes
• Micturition : Not examined
• Defecation : Not examined
• Anal Reflex : Not examined
 CRANIAL NERVES EXAMINATION
• N.I (Olfactory nerve)
• Not performed
• N. II (Optic nerve)
• Not performed
• N. III (Oculomotor nerve)
• Strabismus (-)
• Nystagmus (-)
• Exophtalmos (-)
• Pupils 3 mm / 3 mm; isocoria
• Direct light reflex +/+
• Indirect light reflex +/+
• N. IV (Throchlear nerve)
• Eye movement (downward-inside)
+/+
• Diplopia (-)
• N. V (Trigeminal nerve)
• Mouth opening: Patient
unresponsive
• Chewing: Not examined
• Biting: Not examined
• Cornea reflex (+/+)
• Face sensibility: Not responding
• N. VI (Abducens nerve)
• Eye movement (lateral) +/+
• Diplopia (-)
 CRANIAL NERVES EXAMINATION
• N. VII (Facial nerve)
• Furrowing forehead: (+),
symmetrical
• Closing eyes: Not responding
• Puffing cheeks: Not responding
• Showing teeth: Asymmetrical,
weakness on the right side
• Taste sensibility: Not examined
• N. VIII (Vestibulocochlear nerve)
• Swabach: Not examined
• Rinne: Not examined
• Weber: Not examined
• N. IX (Glossopharyngeal nerve)
• Taste sensibility: Not examined
• Pharynx sensibility: Not examined
• N. X (Vagus nerve)
• Pharyngeal arch: Not examined,
patient unresponsive
• Speaking: Patient unresponsive
• Swallowing: patient unresponsive
• N. XI (Accessory nerve)
• Uplifting shoulders: Not examined
• Turning head aside: Not examined
• N. XII (Hypoglossal nerve)
• Tongue out: Patient unresponsive
to open his mouth
• Tongue movement: Cannot be
seen
• Articulation: Cannot be seen
 UPPER EXTREMITIES EXAMINATON
• Sensory
• Pain : Right side unresponsive
• Temperature : Not examined
• Motoric
• Lateralization on the right side
• No mucles atrophy
• Physiological reflexes
• Biceps ++ / ++
• Triceps ++ / ++
• Pathological reflexes
• Hoffman - / -
• Tromner - / -
 LOWER EXTREMITIES EXAMINATON
• Sensory
• Pain : Right side unresponsive
• Temperature : Not examined
• Motoric
• Lateralization on the right side
• No mucles atrophy
• Physiological reflexes
• Patella ++ / ++
• Achilles ++ / ++
• Pathological reflexes
• Babinsky + / -
• Chaddock + / -
 SUMMARY
A 72 years old male was brought to the Emergency Room after suddenly losing
consciousness at home. Patient was not able to woken up from his sleep and
had shortness of breath. Upon admission, patient opened his eyes after called
his name but soon slept again. On examination, patient is aphasia motoric with
E3M6, BP 180/100 RR 28 x/min. There’s a facialis nerve (N.VII) paralysis on the right
side, observed from face reaction to pinch at temporomandibular junction which
shows weakness on the right side. The muscle strength also showed lateralization
of the right side. Sensory also weaker on the right side. Pathological reflex also
showed on right side of lower extremities.
 LABORATORY EXAMINATION
Hematology (19 June 2017)

Haemoglobin 11,6 g/dL 14 ~ 16

Erythrocytes 4,54 million/µL 4,6 ~ 5,2

Leukocytes 6.300 /µL 5.000 ~ 10.000

Thrombocytes 193 thousand/µL 150 ~ 400

Hematocrit 36 % 42 ~ 48

Blood Chemistry (19 June 2017)

Blood glucose 139 mg/dL < 200

 Renal Function (19 June 2017)

Ureum 45 mg/dL 17 ~ 43

Creatinin 2,2 mg/dL 0,7 ~ 1,3

Electrolyte (19 June 2017)

Natrium 137 mmol/L 134 ~ 146

Kalium 4,11 mmol/L 3,4 ~ 4,5

Chloride 115 mmol/L 96 ~ 108

Arterial Blood Gas Analysis (19 June 2017)

PO2 109,6 mmHg 83 ~108

HCO3 19,1 mmol/L 21 ~ 28

BE -6,3 mmol/L -2 ~ 3

SBE -5,5 mmol/L -3 ~ 3

ct CO2 20,1 mmol/L 23 ~ 27

 Blood Chemistry (20 June 2017, 6 AM)

Blood glucose 139 mg/dL < 200

Blood Chemistry (20 June 2017, 16 PM)

Blood glucose 140 mg/dL < 200

Hemostasis (20 June 2017)

Bleeding time 3 minutes 1~3

Clotting time 11 minutes 5 ~ 15

 RADIOLOGY
EXAMINATION
 ASSESMENT

• Working diagnose
• Clinical : Paralysis N. VII right central, lose of consciousness,
hemiparesis on the right side

• Etiological : Vascularization

• Topical : Left cerebral cortex

• Pathological : Hemorrhage

• Non-pharmacological :
TREATMENT
Bedrest
Rehabilitation  physiotherapy
Nasogastric tube insertion
Folley catheter insertion

• Pharmacological:
• IV line: RL 14 drip/min
• Injections:
• Ceftriaxone 2x 1g
• Ranitidine 2x 50 mg
• Transamine 3x50 mg
• Vitamin K 3x 1 amp (2 mg)
• Manitol 200 cc (bolus)
• Manitol 4 x 125 cc (after 4 hours)
• Oral:
• Amlodipin 2x10 mg
• Valsartan 1x160 mg
• Ambroxol 3x 30 mg
FOLLOW UP: DAY 1 MONDAY, JUNE 19, 2017
S Patient losing conciousness
O Consciousness : GCS E4M1V aphasia motoric
BP 180/100 mmHg PR 82x/min T: 37,3oC RR 28x/min SPO2 98%
Pupil isocoria, DRL +/+, NDRL +/+
General examination : Normal
Neurological examination :
- Cranial nerve lesions : N.VII paresis right central
- Meningeal signs: (-)
- Physiological reflexes : upper ++/++ lower ++/++
- Pathological reflexes: upper -/- lower +/-
- Muscle strength: Lateralization on the right side
A Clinical:Lose of consciousness, paralysis N. VII right central, hemiparesis on the right side
Etiological : Vascularization
Pathologic : Hemorrhage
Topical : Left cerebral cortex
P IV: NaCl 0,9% 14 drip/min
Injections : Ceftriaxone 2x 1g
Ranitidine 2x 50 mg
Oral : Ambroxol 3 x 30 mg
FOLLOW UP: DAY 2 TUESDAY, JUNE 20, 2017
S Patient losing conciousness, weakness of the right side of the body
O Consciousness : GCS E4M1V aphasia motoric
BP 180/90 mmHg PR 80x/min T: 37,6oC RR 24x/min SPO2 99%
Pupil isocoria, DRL +/+, NDRL +/+
General examination : Normal
Neurological examination :
- Cranial nerve lesions : N.VII paresis right central
- Meningeal signs: (-)
- Physiological reflexes : upper ++/++ lower ++/++
- Pathological reflexes: upper -/- lower +/-
- Muscle strength: Lateralization on the right side
A Clinical:Lose of consciousness, paralysis N. VII right central, hemiparesis on the
right side
Etiological : Vascularization
Pathologic : Hemorrhage
Topical : Left cerebral cortex
P IV line: RL 14 drip/min Vitamin K 3x 1 amp (2 Oral:
Injections: mg) Amlodipin 2x10 mg
Ceftriaxone 2x 1g Manitol 200 cc Valsartan 1x160 mg
Ranitidine 2x 50 mg Manitol 4 x 125 cc (after Ambroxol 3x 30 mg
Transamine 3x50 mg 4 hours)
FOLLOW UP: DAY 3 WEDNESDAY, JUNE 21, 2017
S Patient losing conciousness, weakness of the right side of the body
O Consciousness : GCS E4M1V aphasia motoric
BP 150/90 mmHg PR 82x/min T: 37,2oC RR 20x/min SPO2 98%
Pupil isocoria, DRL +/+, NDRL +/+
General examination : Normal
Neurological examination :
- Cranial nerve lesions : N.VII paresis right central
- Meningeal signs: (-)
- Physiological reflexes : upper ++/++ lower ++/++
- Pathological reflexes: upper -/- lower +/-
- Muscle strength: Lateralization on the right side
A Clinical:Lose of consciousness, paralysis N. VII right central, hemiparesis on the
right side
Etiological : Vascularization
Pathologic : Hemorrhage
Topical : Left cerebral cortex
P IV line: RL 14 drip/min Vitamin K 3x 1 amp (2 Oral:
Injections: mg) Amlodipin 2x10 mg
Ceftriaxone 2x 1g Manitol 4 x 125 cc Valsartan 1x160 mg
Ranitidine 2x 50 mg Ambroxol 3x 30 mg
Transamine 3x50 mg
THANK YOU