Case Report

ISCHAEMIC STROKE
Syafira Alyani // 030.15.191
Neurology Rotation – dr. Mintohardjo Naval Hospital
Supervising doctor: dr. Ronny, Sp.S
2 PATIENT’S IDENTITY

Name : Mrs. A
Age : 58 years old
Gender : Female
Religion : Islam
Address : Taman Wisma Asri Block AA2 No.67
Bekasi, West Java
Job : Pensionary school teacher
Marital status : Married
Hospital admission date : December 23rd, 2019
3 ANAMNESIS
Autoanamnesis & alloanamnesis with the patient’s sister (27/12/19)

CHIEF COMPLAINT ADDITIONAL COMPLAINT

Weakness since 1 day before Nausea

admitted to hospital.
 HISTORY
4 OF PRESENT ILNESS
Weakness & numb on the
left side of the body,
Weakness &
slurred speech (-),
nausea
choking (-)

D-Day admitted
to hospital
(23/12/19)

1 day before 3 days after

admitted to hospital admitted to hospital
(22/12/19) (26/12/19)

Weakness &
nausea. High blood
pressure (180/100
mmHg)
 HISTORY OF
5 PAST & FAMILY ILNESS & LIFESTYLE

PAST ILNESS FAMILY ILNESS

▹ Appendectomy in 2015 ▹ The patient’s father had DMT 2

▹ Hypertension (-) ▹ Same ilness (-)
▹ Diabetes mellitus (-) ▹ Hypertension (-)
▹ Lungs/liver/kidney disease (-) ▹ Lungs/liver/kidney disease (-)

LIFESTYLE & HABIT

▹ Smoke, alcohol, drugs (-)

▹ Rarely exercise
 PHYSICAL
EXAMINATION

6
 PHYSICAL
7 EXAMINATION

GENERAL CONDITION VITAL SIGN

▹Consciousness ▹ Blood pressure : 150/90 mmHg
GCS (E 4 M 6 V 5 ) ▹ Heart rate : 68x/min
Compos mentis ▹ Resp. rate : 20x/min
▹ Illness impression ▹Temperature : 36,5°C
Moderately pain ▹Oxygen saturation : 97%
▹ Nutritional impression
Adequate nutrition
 GENERAL
8 EXAMINATION
EYES
HEAD & FACE Conjunctival anemia (-),
Normocephali, normal hair sclerical icteric (-), isochoric
distribution, symmetrical pupil 3mm/3mm, direct &
indirect light reflex +/+

NOSE EARS
Symmetrical, septum Normotia, intact tymphanic
deviation (-), mucus (-), membrane, oedema (-),
normal concha hyperemia (-)

NECK
Midline trachea, MOUTH
lymphadenopathy (-), Cyanosis (-), good oral hygiene,
thyroid enlargement (-) mucosal hyperemic (-)
 GENERAL
9 EXAMINATION

THORAX ABDOMEN
Heart •Inspection:
•Ictus cordis not visible Normal shape, flat,
•Ictus cordis palpable on ICS venectation (-), normal
VI linea midclavicula sinistra umbilicus
•Regular S1-S2 rhythm, •Auscultation:
gallop (-), murmur (-) Bowel sound (+) 1-3x/min,
arterial bruit (-)
Lungs •Percussion:
• Symmetrical in static and Tympanic
dynamic state •Palpation:
• Retraction (-) Epigastric tenderness (-),
• Sonor in percussion (+/+) organomegaly (-)
• Vesicular breathing sound
(+/+), rhonchi (-/-), wheezing
(-/-)
 GENERAL
10 EXAMINATION

UPPER LOWER
EXTREMITIES EXTREMITIES
▹ Oedem (-), Deformity (-),
▹ Oedem (-), Deformity
(-),Cyanosis/Clubbing Cyanosis/Clubbing finger(-).
▹ Warm, muscle pain (-),
finger(-).
▹ Warm, muscle pain (-)
pitting oedem (-/-)
▹ CRT < 2 min
▹ CRT < 2 min
 NEUROLOGICAL
11 EXAMINATION
MENINGEAL ▹ N. III, IV, VI SPEECH
Isochoric pupil, direct
SIGN
& indirect light reflexes
+/+, normal movement
of the eyes
▹ N. VII
Lip deviation to the
Neck stiffness: (-) right, forehead
Brudzinski I : (-) wrinkles (+) Slurred speech (-)
Brudzinski II: (-) ▹ N.X Motoric aphasia (-)
Laseque : (-) Normal, doesn’t choke Sensoric aphasia (-)
Kernig : (-) when drinking
▹ N. XII
Tongue deviation to
the left
CRANIAL NERVES
 NEUROLOGICAL
12 EXAMINATION
UPPER EXTREMITIES LOWER EXTREMITIES
Results Results
Examinations Examinations Right Left
Right Left
Motoric 5555 2222 Motoric 5555 2222

Physiologic Physiological
Reflexes Reflexes
 Biseps ++ ++  Patella ++ ++
 Triseps ++ ++  Achilles ++ ++
Pathological Pathological
Reflexes Reflexes
 Hoffman - -  Babinski - -
 Tromner - -  Chaddock - -
Sensory + Hipoesthesia
Sensory + Hipoesthesia
 LABORATORY
13 RESULTS
Items Examined Results Unit Reference
HEMATOLOGY
Complete Blood Test
Leucocyte 10600 * /μL 5000 – 10000

Erythrocyte 5.19 juta/μL 4.60 – 5.40

Hemoglobin 15.9 g/dL 14.0 – 16.0
Hematocryte 46 % 37 – 42
Trombocyte 294000 /μL 150000 – 450000
CLINICAL CHEMISTRY
Blood glucose 126 mg/dL <200
Ureum 30 mg/dL 17-43
Creatinine 0.9 mg/dL 0.7-1.3
 LABORATORY
14 RESULTS
Items Examined Results Unit Reference
ELECTROLYTE
Natrium 135 mmol/L 134 - 138
Kalium 4.61 mmol/L 3.40 - 4.50
Chloride 107 mmol/L 96-108
URINALYSIS
Blood/erythrocyte 2+ * Negative
Urinary glucose Negative mg/dL Negative
Leucocyte 3+ * Negative
Billirubin Negative Negative
Keton Negative Negative
Density 1.020 1.003 – 1.031
pH 6.0 4.5 – 8.5
Protein - mg/dL Negative
Urobilinogen Negative Negative
Nitrit Negative Negative
 LABORATORY
15 RESULTS
Items Examined Results Unit Reference
MICROSCOPIC URINE
Erythrocyte (sedimentation) 10-15 * /LFV >1

Leucocyte (sedimentation) 50 - 60 * /LFV 0.0 – 5.0

Epithel (sedimentation) 1+ /SFV Positive
Bacteria (sedimentation) 1+ * Motile/SFV Negative
Cylinder (sedimentation) - /LFV Negative
Crystal (sedimentation) - /LFV Negative
16 CHEST X-RAY
▹ CTR >50%, embedded apex
▹ Normal hilus
▹ Normal bronchovascular pattern
▹ Infiltrate is not seen
▹ Normal costophrenic sinus
▹ Intact bone
 PLAIN HEAD CT-SCAN
17 AXIAL CUTTING
▹ Hypodens lesion in right thalamus
▹ No hyperdens lesion
▹ Normal sulci & gyri
▹ No midline shifting
18 ECG

▹ Left
ventricular
hypertrophy
 ASSESSMENT

Left hemiparesis
left hemihipethesia Right
central paresis of subcortical
left N.VII & N.XII

Ischaemic Ischaemic/
stroke infarction

19
”
 WORKING DIAGNOSIS
1. Ischaemic stroke
2. Hypertension

20
”
21 SUMMARY
A 58-year-old woman presented with weakness and nausea since one day before admission
(23/12/19). The patient didn’t have history of HT & DM. There is a history of appendectomy on
2015. The patient and family never had similar complaint before. When admitted, the blood
pressure is 180/100 mmHg.
Three days after admission (26/7/19), the patient felt weakness & numb on the left side of the
body, there were no slurred speech and choking.
The physical and neurological examination revealed that she had high blood pressure (150/90
mmHg), left hemiparesis, left hemihipoesthesia, and central paresis of left cranial nerves VII
and XII.
The chest X-ray and ECG revealed that the patient has cardiomegaly, particularly left
ventricular hypertrophy.
The plain head CT-scan revealed that there is infarction on the right hemisphere.
All these examination results indicate the patient has ischaemic stroke.
22 THERAPY

▸ IVFD Ringer Lactate 7 drops/min

▸ Citicholine 2x250 mg
▸ Aspilet 1x80 mg
▸ Clonidine 2x0.75 mg
▸ Concor 1x2 mg
▸ Ramipril 1x10 mg
▸ Amlodipin 1x10 mg
▸ Simvastatin 1x20 mg