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8/17/2019 Presentation PKB SH Edy Bismillah.. 12
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HAEMORRHAGE STROKE
By:
Edy Irwanto
Moderator :
dr. Yovita Andhitara, Msi.Med, Sp.S, FINS
WARD CASE PRESENTATION
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Definition of stroke•
WHO : a clinicalsyndrome consisting ofrapidly developing clinicalsigns of focal (or global in
case of coma) disturbanceof cerebral functionlasting more than 24hours or leading to deathwith no apparent cause
other than a vascularorigin.
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According to AHA/ASA 2013
Definition of ischemic stroke: An episode of neurological
dysfunction caused by focal cerebral, spinal, or retinal infarction.
Definition of stroke caused by intracerebral hemorrhage:
Rapidly developing clinical signs of neurological dysfunction
attributable to a focal collection of blood within the brain parenchyma or
ventricular system that is not caused by trauma.
Definition of stroke caused by subarachnoid hemorrhage: Rapidlydeveloping signs of neurological dysfunction and/or headache because of
bleeding into the subarachnoid space (the space between the arachnoid
membrane and the pia mater of the brain or spinal cord), which is not
caused by trauma
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Epidemiology
USA Cause of
death in the 3rd
ranks after heart
disease and
cancer.
Riskesdas
20078,3/1000
population
201312,1/1000
population
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Blood Vessels Anatomy of The Brain
•The main supply of bloodto the brain by two internal
carotid arteries and two
vertebral arteries. These
four artery located inside
subarachnoid space and
the branches anastomoses
on the inferior surface of
the brain to form the circle
of Willis
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Classification of Stroke
• Based on the anatomical pathology and its causes
Ischemic Stroke
Transient ischemic attack
Cerebral Thrombosis
Cerebral EmbolismHaemorrhage Stroke
Intracerebral haemorrhage
Subarachnoid haemorrhage
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Classification of Stroke
• Based on the stage / time considerations
TIA
Stroke-in-evolution
Completed stroke
•Based on the vascular system
Carotid system
Vertebrobasilar system
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Rupture of blood vessels of the brainICH
SAH ICH
PrimarySecondary
•Pathogenesis
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Chronic HypertensionC aused by chronic
hypertension which causes
cerebral vasculopathyleading to rupture of blood
vessels in the brain
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ICH usually occur due to rupture of microaneurysms (Berryaneurysm) as a result of malignant hypertension. It mostoften occurs in subcortical regions, cerebellum, pons and
brainstem.
In this type of bleeding, artery that serves the vascularitationin to the brain ruptures, so will cause leakage of blood to thebrain and sometimes cause brain depressed due to theaddition of fluid volume
Chronic hypertension causes arterioles vessel with 100-400micrometers in diameter changes in to pathological conditionin blood vessel walls in the form of hipohialinosis, fibrinoidnecrosis and the occurrence of Bouchard aneurysms
ICH
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secondary hemorrhage
•C ongenital vascular
anomalies, coagulopathy,brain tumors, non-
hypertensivevasculopathy (cerebralamyloid), vasculitis,moya-moya, post
ischemic stroke,anticoagulant medication(fibrinolytic orsympathomimetic)
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S
Subarachnoid hemorrhage (SAH) is the extravasation of
blood into the subarachnoid space between the arachnoid
membrane and the piamater
SAH ½ of spontaneous intracranial hemorrhage
Etiology ruptured aneurysm, vascular malformations
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severe headacheand vomiting.
•Can be accompanied by astiff neck .
• Residif during the first 24-
72 hours
severecerebral vasospasm+ brain infarction
• Symptoms Suddenly
Subarachnoid hemorrhage
SAH
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Risk Factors& Etiology
Hypertension(modifiable)
Aneurysms
Arteriovenous
malformation
(AVM)
Anticoagulationtherapy
Leukemia andThrombocytopenia
Gangguan FaktorPembekuan
Darah
Amyloidangiopathy
Antiplatelettherapy
Hemorrhagictransformation
Excessive
Alcohol
Consumption
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Clinical Manifestations
• Headache
• Focal Neurologic Deficits
• Weakness or paresis to one side
of extremities
•
Disturbances of sensibility inone or more extremity
(hemihipestesi)
• A sudden change in mental
status (somnolence, delirium,
lethargy, stupor or coma)
• Facial weakness
F.A.S.T
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Clinical Manifestations
• Monocular and binocularblindness
• Blurred vision or visual field
defects
• Dysarthria or comprehensiondisorders
• Vertigo or ataxia
• Aphasia
• Seizure
F.A.S.T
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Pemerikasaan Penunjang
• aboratory
Routine blood testBlood chemistry test
Random blood sugar: in acute stroke can occur reactive
hyperglycemia, blood sugar can reach 250 mg in the
serum and then gradually then gradually decrease
Urea, creatinine, uric acid, liver function (SGOT / SGPT /
CPK) and lipid profile (total cholesterol, triglycerides,
LDL, HDL)
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Pemerikasaan Penunjang
Examination of hemostasisProthrombin time
APTT
Fibrinogen levelsD-dimer
INR
Plasma viscosity
Additional examination depend on indicationsProtein S
Protein C
ACA
Hemosistein
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Pemeriksaan Penunjang
• CT ScanNon contrast computedtomography (CT) is a
standard imaging modalityfor the initial evaluation ofpatients with acute strokesymptoms. The mainadvantage of the diagnostic
CT in hyperacute phase (0-6hours) that can showbleeding
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• In ICH bleeding volume was estimated by calculating
validated method that can give you a prognosis at the time of
initial clinical evaluation. The formulas used are as below
(A x B x C) / 2
A = length of lesions
B = width of lesion
C = high of lesions
(the number of
pieces contained
CT picture of
bleeding)
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Prevalent findings on CT scan in patients ICH
based on the onset of events
Onset 7-10 first day
Onset 11 days – 2 month
Onset > 2 monthIsodens area with a decrease in the
intensity enhancement
In the lesions area become the low-
density with ring enhancement in the
vicinity (hemosiderin deposition).
homolateral ventricular enlargement(in small hematoma in hipodens area
can be a isodens area)
Clearly defined, homogeneous lesions,
hiperdens, oval or irregularly shaped
frequently accompanied by edema in
the surrounding areas with hipodens
picture with narrow limits.
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MRIExamination of magnetic resonance imaging
(MRI) including diffusion-weighted imaging
(DWI) has an excellent ability to display the
appearance, size, location and extent of
ischemia
C b l i h
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Cerebral angiography
Angiography is strengthened by processing
of digital images accurately showedstenosis and occlusion of blood vessels andthe extracranial and intracranialaneurysms, vascular malformations andother vascular disorders such as arteritis
and vasospasm
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T ranscranial Doppler (TCD)•u ntuk meneliti kelainan
neurovaskular termasuk USG
doppler, yang dapat
menunjukkan plak ateroma dan
stenosis pembuluh darah besarterutama di karotis dan juga
arteri vertebrobasiler
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General Management
• Fast imaging examinations with CT or MRI
• CT angiography and CT with contrast
• Patients deficiency of coagulation factor replacement
therapy or severe thrombocytopenia or platelet
coagulation factors
• In ICH Patients and ↑ INR related to oral anticoagulant
drug ≠ warfarin, therapy to replace with vitamin K-dependent factor + Correcting INR + intravenous
vitamin K
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General Management
• Correction of coagulation disorders Vitamin K 10mg intravenously, FFP 2-6 units of correcting adeficiency of blood clotting factors
• Preventing venous thromboembolism with intermittent pneumatic compression
• Heparin effect can be overcome by administration of protamine sulfate 10-50 mg IV within 1-3 minutes
• Systole BP (SBP)> 200 mmHg or mean arterial pressure (MAP) > 150 mmHg, derived usingcontinuous intravenous antihypertensive drugs with
blood pressure monitoring every 5 minutes.
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General Management
• If the SBP > 180 mmHg or MAP > 130 mmHgaccompanied by symptoms and signs of increasedintracranial pressure (ICP) ICP have to monitored.
• ↓ BP withintravenous antihypertensive drugs
continuously or intermittent and monitoring ofcerebral perfusion pressure ≥ 60 mmHg.
• If the SBP > 180 mmHg or MAP > 130 mmHg absenceof symptoms and signs of increased ICT, ↓ BP carefullyusing continuous intravenous antihypertensive
medication or intermittent monitoring of bloodpressure every 15 minutes until the MAP 110 mmHg orBP 160/90 mmHg , SBP up to 140 mmHg are stillallowed
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General Management
• In ICH patients with SBP 150-220 mmHg, decreased
SBP rapidly to 140 mmHg quite safe. After
craniotomy the target of MAP is 110 mmHg
• Pain management is important in reducing BP in patients with intracerebral hemorrhage stroke
• Management of seizure with anti-epileptic drugs.
Continuous ECG monitoring.
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Best surgery is in
patients with initial
GCS < 14 and
hematoma volume
> 40 ml• ur ry
• Meanwhile patients with higher GCS andsmaller lesions tend to have good results withconservative measures or non-surgical
management.• Ventricular drainage as the treatment of
hydrocephalus can be considered in patientswith a decreased level of consciousness.
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pRognoSis• Depending on the severity
of stroke as well as the
location and extent of
bleeding
• GCS ↓ associated with
poor prognosis and ↑
mortality.• ↑ bleeding volume is also
associated with poor
prognosis.
• ↑ bleeding volume poor
functional outcome and
mortality ↑
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Score intracerebral hemorrhage is often used to predict outcome in
hemorrhagic stroke. The score is calculated as below
GCS score 3 – 4 : 2 points
GCS score 5 – 12 : 1 point
GCS score 13 – 15 : 0 point
Age ≥ 80 years : Yes 1 point, No 0 point
Infratentorial origin : Yes 1 point, No 0 point
Intracerebral hemorrhage volume ≥ 30 cm3 : 1 point
Intracerebral hemorrhage volume < 30 cm3 : 0 point
Intraventicular hemorrhage : Yes 1 point, No 0 point
Hemphill et.al study, all patients with intracerebral hemorrhage score = 0 can survive
and all patients with a score of 5 died.
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WARD CASE REPORT
Haemorrhage Stroke
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I. Patient’s Identity
• Name : Mrs. S
• Age : 46 yo
• Sex : Woman• Marriage status : Married
• Last education : Senior High School
• Occupation : Private employees
• Address : Boyolali, Central Java
• Hospital admission : February 09th, 2015
• MR Number : A552909
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III. Subjective Data
Autoanamnesis on Februari 09th, 2015
1. Chief complaint : weakness of left extremity
2. Recent history :
- Location : left extremity
- Onset : ± 1 day before hospital admission (suddenly)
- Quality : left extremity can only hold light to middle resistance
- Quantity : ADL helped by family
- Cronology :
+ 1 day before hospital admission while wake up in the morning andgoing to prayers, patient suddenly fell down because weakness and got
heavy of the left extremity. Left extremity can only hold light to middle
resistance. Patient can work as usual. Numbness in the left extremity (+)
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III. Subjective Data
Slurred speech (-), shifting of the mouth (-), headache (+), vomiting (-),
swallowing impairment (-), seizures (-), fever (-), loss of consciousness (-),
bowel and bladder (+) normal. In the late afternoon patient feel the left
extremity more weakened so patient more difficult to doing an activity,
slurred speech (+) and mouth shifting to the right and headache was not
reduced, vomiting (-), seizures (-), loss of consciousness (-) then patient
brought into the ER Dr. Kariadi. Hospital
- Aggravating Factors : (-)
- Relieving Factors : (-)
- Concomitant Symptoms : headache, slurred speech, the mouth shiftingto the right
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3. Past Medical History:o History of Hypertension (+) since 14 y ago, routine consumption
captopril.
o DM (+) routine consumption metformin 500 mg and glimepirid,
o Heart disease (+) since 1 y ago with pain in the left chest and has
done a treadmill stress test with the results is positive of stress tests
of ischemia, patient regularly take amlodipine 10 mg and 2.5 mg
bisoprolol
o History of stroke before was denial
o History of trauma was denial
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4. Family Medical History:
o History of stroke before was denial
o History of HT was denial
o History of DM was denial
o History of Heart disease was denial
5. Social-economy :
Patients works as a cashier at the tofu factory, her husband works as a
construction worker with 2 sons dependent, medical expenses covered by
National Insurance (BPJS).
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IV. Objective Data
1. Present States
General state : Looked moderately ill
Vital sign : BP : 150/80 mmHg
HR : 94 times / minute, regular
RR : 20 times / minute
T : 36,7 C
VAS : 3
2. Internal state
Head : symmetrical, mesochepal
Eyes : Anemia of conjunctiva -/-, icteric of scleral -/-
Neck : Nuchal rigidity (-), lymph node enlargement (-), struma (-)
Chest
Cor : Normal heart sound, murmur (-),gallop (-)
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Lungs : normal breathing, Rhonchi -/-, Wheezing -/-
Abdomen :normal peristaltic sound, unpalpable liver and spleen
Extremity : Edema (-/-), turgor normally, cyanosis -/-
Nutrition Status
Height : 158 cm
Weight : 70 KgBMI : BB = 70 Kg = 29,1 Kg/m2 (overweight)
TB2 (1.58m)2
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3. Psychological Status
Way of thinking : realistic
Mood : normothymic
Behavior : normoactive
Memory : adequate
Cognitive : adequate
4. Neurologic status
Level of Consiousness : GCS: E4M6V5=15
Eyes : pupil round isocor, Ф 2,5 mm/2,5 mm, light reflex +/+
Leher : nuchal rigidity (-)Cranial nerves : The mouth shift to the right and the tongue shift to the left
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Motoric : Superior Inferior
Movement + / ↓ + / ↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex ++/++ ++/++
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Within normal
Coordination, Gait & Balance Test
Gait : Not perfomedRomberg Test : Not perfomed
Dysdiadochokinesis : (-)
Ataxia : (-)
Rebound phenomen: (-)
Dysmetria : (-)
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Abnormal movement
Tremor : (-)Athetose : (-)
Myoclonic : (-)
Chorea : (-)
ECG result (21/3/2013):
Impression : Normo sinus rythme, LAD,LVH
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Thorax Foto AP (09-02-2015)
Impression : Cor dan Pulmo within normal
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CT Scan Non Contras (09-02-2015)
Impression:
Intracerebral
hemorrhage on
lentiformis nucleus and
right external capsule
(± 5.78 cc volume)
which causes anarrowing of the right
lateral ventricle and
corticalis sulcus and
fissures sylvii at lession
area. No sign ofincreased ICP
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Laboratory Result Unit Normal Value
HEMATOLOGI
Hemoglobin 14.3 g/dL 12.00 – 15.00
Hematocryte 40.8 % 35 – 47
Erythrocyte 4.8 10^6/uL 4.4 – 5.9MCH 29.8 pg 27.00 – 32.00
MCV 84.9 fL 76 – 96
MCHC 35.1 g/dL 29.00 – 36.00
Leucosite 8.4 10^3/uL 3.6 – 11
Thrombocyte 277.1 10^3/uL 150 – 400
RDW 13.1 % 11.60 – 14.80
MPV 7.7 fL 4.00 – 11.00
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Clinical Chemistry
Random GlucoseLevel
117 mg/dL 80 – 160
Ureum 17 mg/dL 15 – 39
Creatinin 0.80 mg/dL 0.60 – 1.30
ELECTROLYTE
Sodium 144 mmol/L 136 - 145
Potassium 3.2 mmol/L 3.5 – 5.1
Chlorida 106 mmol/L 98 – 107
Impression: hypocalemiaOsmolarity: 2(144 + 3.2) + 117/18 + 17/6 = 303.7
Fluid defisit: (303.7 – 295)/295 x 0.6 x 56 = 0.9 liter
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V. Summary
Subjective :
A woman 46 y.o coming to the RSDK ER with hemiparese sinsitra (UMN
Type), 1 day onset accompanied with parese N.VII and XII of the left (UMN
Type), chepalgia and hemihipestesi sinistra.
Objective :
Praesens Status : BP: 150/80 mmHg, HR: 94 times / minute,
RR: 20 times / minute, T: 36,7 C, VAS: 3
Internal Status : Within normal
Neurologic StatusGCS : E4M6V5 = 15
Eyes : pupil round isocor, Ф 2,5 mm/2,5 mm, light reflex +/+
Neck : nuchal rigidity (-)
Cranial Nerves : Parese of N.VII and XII sinistra (UMN Type)
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Motoric : hemiparese sinsitra (UMN Type)
Sensibility : hemihipestesi sinistraVegetative : Within normal
ECG : Normo Sinus Rhythm, LAD, LVH
Thorax Foto : cor and lungs within normal
CT Scan : Intracerebral hemorrhage on lentiformis nucleus and rightexternal capsule (± 5.78 cc volume) which causes a narrowing
of the right lateral ventricle and corticalis sulcus and fissures
sylvii at lession area. No sign of increased ICP
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VI. DIAGNOSIS :
Clinical Diagnosis : Hemiparese sinistra (UMN Type)Parese N.VII and XII sinistra (UMN Type)
Hemihipestesi sinistra
Chepalgia
Topical Diagnosis : lentiform nucleus and right external capsula
Etiological Diagnosis : Haemorrhage Stroke (ICH)
Hypertension stage I
Hypocalemia
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V. Initial Plan
Haemorrhage Stroke
IpDx : Lab: GD I/II, HbA1c, profil lipid, urid acid, PPT, PTTK
- Consult cardiologist (history of heart disease)
- Consult to clinical nutrition
- Consult to opthalmologist (funduscopy)- Consult to physic rehabilitation
IpTx : Infus RL 20 gpm
O2 3 liter/min
Inj. Citicolin 500 mg intravena
Inj Tranexamic Acid 1 gr/6 hr intravena
Inf. Manitol 125 mg/6 hr intravena
Inj Ranitidin 50 mg intravena
Paracetamol 500 mg/8 hr p.o
IpMx : General state of conciousness, neurological deficit, VS
IpEx : Explaining about the disease, the management plan.
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Hypertension
IpDx : Consult to opthalmologist (funduscopy)IpTx : Amlodipin 10 mg/24 hr p.o
IpMx : General state of conciousness, neurological deficit, VS
IpEx : Explaining about the disease, examination plan
Hipokalemia
IpDx : -IpTx : KCL tab / 8 hr p.o
IpMx : General state of conciousness, neurological deficit, VS
IpEx : Explaining about the disease, management plan
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VIII. DAILY PROGRESS REPORT
ay - -
S H d h W k f h l f i
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S Headache, Weakness of the left extremity
O
GCS : E4M6V5 = 15
VS : BP:150/80 mmHg , HR:84x/minute, RR:20x/minute, T : 36,80C VAS=3
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke Hipertension Hypocalemia
P
Head elevation 30⁰ Inf. RL 20 tpm,
Inj. Citicoline 500 mg/8 hr, Inj.AsamTraneksamat 1 gr/6 hr, Inj. Ranitidin
50 mg/12 hr, Paracetamol 500
mg/8 hr p.o
Amlodipin 10
mg/24 hr p.o
KCL tab/8 hr
MX : KU, GCS, vital sign, neurologic defisit
Ex : Tetap
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Result of consult to opthalmology:
ODS: Grade III hipertension retinopathy, grade II arteriolosclerosis, non
proliperative DM retinopathy, non CSME mild.SuggestionManaging of risk factor of DM and HT
Result of consult to clinical nutrition dept:
Nutrition status: obesity
metabolic Status : hypermetabolicgastrointestinal status : functional
Energy demand: 1600 kcal/day
Protein demand : 60 gr/day
carbohydrate demand : 195 gr/day
Fatty demand: 31 gr/day
Dietary Plan:Diit given from 80% of the target and increased gradually with low salt, DM
1300 kcal
ay - -
S H d h W k f th l ft t it
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S Headache, Weakness of the left extremity
O
GCS : E4M6V5 = 15 VAS = 2
VS : BP:140/80 mmHg , HR:88x/minute, RR:22x/minute, T : 36,40C
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke HipertensionHypocalemia,
Hypertriglyserid
Ischemic heart
disease
P
Head elevation 30⁰
Inf. RL 20 tpm,Inj. Citicoline 500 mg/8 hr, Inj.Asam
Traneksamat 1 gr/6 hr, Inj. Ranitidin
50 mg/12 hr, Paracetamol 500
mg/8 hr p.o
Amlodipin 10mg/24 hr p.o
-KCL tab/8 hr-Fenofibrate 300
mg/24 hr
-Simvastatin10 mg/24 hr
MX : KU, GCS, vital sign, neurologic defisit
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Result of Consult to Physic Rehabilitation Dept:
Breathing exercise, Gentle AAROM exercise, Mobilitation, backrestsitting in bed
Result of Consult to Cardiology Dept
A: Ischemic heart disease
P: If no contra indication
Valsartan 160 mg/24 hr (if the BP target has not been reached)Amlodipin keep on
Simvastatin 10 mg/24 hr (@night)
Echo if possible
Lab Result (11-02-2015)
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Laboratory Result Unit Normal Value
HEMATOLOGY
HbA1c 5.4 % 6.0 – 8.0PPT 10.3 detik 10 -15PTTK 30,7 detik 23.4-36.8
CLINICAL CHEMISTRY
Fasting Glucose Level 97 mg/dL
80 – 109: Good;
110 – 125: Average;
> 126: Bad.
Reduction I -
2 Hours Post Prandial 104 mg/dL80 – 140: Good; 145 – 170:
Average; > 180: Bad.
Reduction II -
Total Cholesterol 152 mg/dL < 200
Triglycerides 180 mg/dL < 150
HDL Cholesterol 29 mg/dL 40 – 60
LDL direct 84 mg/dL 0 – 100
Ureum 30 mg/dL 15 – 39
Creatinin 0.81 mg/dL 0.60 – 1.30
Urid Acid 4.4 mg/dL 2.6 – 6.0
Impression: Hipertriglyserides
ay - -
S Headache Weakness of the left extremity Can’t defecate for 5 days
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S Headache, Weakness of the left extremity, Can’t defecate for 5 days
O
GCS : E4M6V5 = 15 VAS = 2
VS : BP:140/70 mmHg , HR:85x/minute, RR:24x/minute, T : 36,70C
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke HypertensionHypocalemia
Hypertriglyserid
Ischemic heart
disease
P
Head elevation 30⁰
Inf. RL 20 tpm,Inj. Citicoline 500 mg/8 hr, Inj.Asam
Traneksamat 1 gr/6 hr, Inj. Ranitidin
50 mg/12 hr, Paracetamol 500
mg/8 hr p.o, dulcolax supp I extra
Amlodipin 10
mg/24 hr p.o
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
MX : KU, GCS, vital sign, neurologic defisitEx : Teta
ay - -
S Headache Weakness of the left extremity defecate (+)
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S Headache, Weakness of the left extremity, defecate (+)
O
GCS : E4M6V5 = 15 VAS = 3
VS : BP:140/100 mmHg , HR:90x/minute, RR:20x/minute, T : 36,30C
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke HipertensionHypocalemia
Hypertriglyserid
Ischemic Heart
Disease
P
Head elevation 30⁰ Inf. RL 20 tpm,Inj. Citicoline 500 mg/8 hr, Inj.Asam
Traneksamat 1 gr/6 hr, Inj. Ranitidin
50 mg/12 hr, Paracetamol 500
mg/8 hr p.o
Amlodipin 10
mg/24 hr p.o
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
MX : KU, GCS, vital sign, neurologic defisitEx : Teta
ay - -
S Headache Weakness of the left extremity
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S Headache, Weakness of the left extremity
O
GCS : E4M6V5 = 15 VAS = 3
VS : BP:150/100 mmHg , HR:90x/minute, RR:20x/minute, T : 36,30C
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke HipertensionHypocalemia
Hypertriglyserid
Ischemic Heart
Disease
P
Head elevation 30⁰ Inf. RL 20 tpm,Inj. Citicoline 500 mg/8 hr, Inj.Asam
Traneksamat 1 gr/6 hr, Inj. Ranitidin
50 mg/12 hr, Paracetamol 500
mg/8 hr p.o
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
Simvastatin 10
mg/24 hr
MX : KU, GCS, vital sign, neurologic defisitEx : Teta
ay - -
S Headache Weakness of the left extremity
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S Headache, Weakness of the left extremity
O
GCS : E4M6V5 = 15 VAS = 3
VS : BP:140/90 mmHg , HR:80x/minute, RR:20x/minute, T : 36,70C
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke HipertensionHypocalemia
Hypertriglyserid
Ischemic Heart
Disease
P
Head elevation 30⁰ Inf. RL 20 tpmAff, Citicoline 500 mg/12 hr po,
Asam Traneksamat 500 mg/8 hr po,
Ranitidin 150 mg/12 hr po,
Paracetamol 500 mg/8 hr p.o
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
MX : KU, GCS, vital sign, neurologic defisitEx : Teta
ay - -
S Weakness of the left extremity
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S Weakness of the left extremity
O
GCS : E4M6V5 = 15 VAS = 1
VS : BP:150/70 mmHg , HR:82x/minute, RR:20x/minute, T : 36,70C
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke HipertensionHypocalemia
Hypertriglyserid
Ischemic Heart
Disease
P
Head elevation 30⁰, Citicoline 500mg/12 hr po, Asam Traneksamat 500
mg/8 hr po, Ranitidin 150 mg/12 hr
po, Paracetamol 500 mg/8 hr p.o
Program TCD (on Friday, 20/02/2015)
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
MX : KU, GCS, vital sign, neurologic defisitEx : Teta
ay - -
S Headache Weakness of the left extremity
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S Headache, Weakness of the left extremity
O
GCS : E4M6V5 = 15 VAS = 3
VS : BP:140/80 mmHg , HR:86x/minute, RR:20x/minute, T : 36,70C
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke HipertensionHypocalemia
Hypertriglyserid
Ischemic Heart
Disease
P
Head elevation 30⁰, Citicoline 500mg/12 hr po, Asam Traneksamat 500
mg/8 hr po, Ranitidin 150 mg/12 hr
po, Paracetamol 500 mg/8 hr p.o
Program TCD (on Friday, 20/02/2015)
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Program Echo
(on Monday
23/02/2015)
MX : KU, GCS, vital sign, neurologic defisitEx : Teta
ay - -
S Weakness of the left extremity
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S Weakness of the left extremity
O
GCS : E4M6V5 = 15 VAS = 1
VS : BP:120/70 mmHg , HR:84x/minute, RR:22x/minute, T : 36,30C
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke HipertensionHypocalemia
Hypertriglyserid
Ischemic Heart
Disease
P
Head elevation 30⁰, Citicoline 500mg/12 hr po, Asam Traneksamat 500
mg/8 hr po, Ranitidin 150 mg/12 hr
po, Paracetamol 500 mg/8 hr p.o
Program TCD today
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Program Echo
(on Monday
23/02/2015)
MX : KU, GCS, vital sign, neurologic defisitEx : Teta
ay - -
S Weakness of the left extremity
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S Weakness of the left extremity
O
GCS : E4M6V5 = 15 VAS = 1
VS : BP:120/80 mmHg , HR:90x/minute, RR:24x/minute, T : 36,70C
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke HipertensionHypocalemia
Hypertriglyserid
Ischemic Heart
Disease
P
Head elevation 30⁰, Citicoline 500
mg/12 hr po, Asam Traneksamat 500
mg/8 hr po, Ranitidin 150 mg/12 hr
po, Paracetamol 500 mg/8 hr p.o
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Program Echo
(on Monday
23/02/2015)
MX : KU, GCS, vital sign, neurologic defisitEx : Teta
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Result of TCD:
An increase in resistance to blood flow in the internal carotid artery right / left.
The speed and resistance to blood flow in the right middle cerebral artery,
posterior cerebral artery right and left, right and left vertebral artery and basilar
artery is still within normal limits.
Left middle cerebral artery can not be accepted by the wave doppler
(hyperostosis?)
Impression: suspicious of atherosclerosis in the carotid artery right & left
ay - -
S Weakness of the left extremity
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S Weakness of the left extremity
O
GCS : E4M6V5 = 15 VAS = 1
VS : BP:100/70 mmHg , HR:80x/minute, RR:20x/minute, T : 36,30C
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke HipertensionHypocalemia
Hypertriglyserid
Ischemic Heart
Disease
P
Head elevation 30⁰, Citicoline 500
mg/12 hr po, Asam Traneksamat 500
mg/8 hr po, Ranitidin 150 mg/12 hr
po, Paracetamol 500 mg/8 hr p.o
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
Program Echo
today
MX : KU, GCS, vital sign, neurologic defisitEx : Teta
ay - -
S Weakness of the left extremity
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S Weakness of the left extremity
O
GCS : E4M6V5 = 15 VAS = 1
VS : BP:100/70 mmHg , HR:80x/minute, RR:20x/minute, T : 36,30C
Nn Cranialis : Parese N.VII and XII sinistra (UMN Type)
Motoric : Superior InferiorMovement +/↓ +/↓
Strength 5-5-5/4-4-4 5-5-5/4-4-4
Tonus N/N N/N
Trophy E/E E/E
Physiologic reflex +/+ +/+
Pathologic reflex -/- - / -
Clonus - / -Sensibility : Numbness in the left extremity
Vegetative : Defecate and urinate normally
A Haemorrhage Stroke HipertensionHypocalemia
Hypertriglyserid
Ischemic Heart
Disease
P
DischargeHead elevation 30⁰, Citicoline 500
mg/12 hr po, Asam Traneksamat 500
mg/8 hr po, Ranitidin 150 mg/12 hr
po, Paracetamol 500 mg/8 hr p.o
Amlodipin 10
mg/24 hr p.o
Valsartan 80
mg/24 hr po
KCL tab/8 hr
Fenofibrate 300
mg/24 hr
-Simvastatin
10 mg/24 hr
MX : KU, GCS, vital sign, neurologic defisitEx : Teta
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Result of Echocardiography:
LVH(+) consentric,
Fungsional sistolic LV global is good, LVEF : >70%
diastolic Disfuncsion LV gr 1, E/A: 0,68
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10 – 2 – 2015(Day-0)
S: A woman 46 y.o coming to the RSDK ER with hemiparese sinsitra spastic, 1 day
onset accompanied with parese N.VII and XII of the left central, chepalgia and
hemihipestesi sinistra
O:
Status praesen : BP: 150/80mmHg, HR: 94 times / minute,
RR: 20 times/ minute,T: 36,7
C,VAS: 3Statusinternus : Withinnormal
Status neurologi
Motoric : Weakness of left extremity
Sensbil ity : Numbness in the left extremity
CT Scan : Intracerebral hemorrhage on lentiformis nucleus and right external
capsule. No sign of increased ICP.
Lab : Potassium 3.2
ECG : Normo Sinus Rhythm, LVH, LAD
Thorax Foto : cor dan lung within normal
A : Haemorrhage Stroke (ICH),Hypertension st I, Hypocalemia
P : lab GD I/II, HbA1c, Profil lip id, urid acid, PPT, PTTK
Consult : Cardiologist, Clinical nutrition,opthalmologist, physic rehabilitation
Tx: Infus RL 20 tpm, O2 3 liters/mnt, Inj. Citicolin 500 mg/8 hr i.v, Inj Tranexamic
Acid 1 gr/6 hr i.v, Inj Ranitidin 50 mg i.v, Paracetamol 500 mg/8 hr p.o
12-2-2015 ( Day - 3)
S : Headache, Weakness of the left
extremity, Can’t defecate for 5 days
O :
PE : GCS: E4M6V5 = 15BP : 140/70 mmHg, N : 85x/mnt, RR :
24x/mnt, t : 36,7oC VAS:2
A : Haemorrhage Stroke (ICH),
Hypertension st I, Hypocalemia,
Hypertriglycerid
P : tx : Dulcolax supp I, Fenofibrate
300 mg/24 hr
10-2-2015 (Day 1) :
S : Headache, Weakness of the left extremity
O : GCS: E4M6V5= 15
BP: 150/80mmHg,N : 84x/mnt,RR : 20x/mnt,t : 36,8oCStatus internus : tetap
Status neurologis: tetap
Result of consult to opthalmology (+)
Result of consult to clinicalnutritiondept (+)
A : Haemorrhage Stroke (ICH),Hypertension st I, Hypocalemia
P : Waitingfor lab result
Tx : Infus RL 20 tpm, O2 3 liter/menit, Inj. Citicolin 500 mg/8 jam i.v,
Inj Asam traneksamat 1 gr/6 jam i.v, Inf. Manitol 125 mg/6 jam i.v, Inj
Ranitidin 50 mg i.v, Paracetamol 500 mg/8 jam p.o, amlodipin 10
mg/24 jam p.o, KCL tab/8 jam p.o
14-2-2015 (Day-5) :S : Headache, Weakness of the left extremity
O : GCS: E4M6V5 = 15
BP:150/100 mmHg, HR:90x/mnt, RR:20x/mnt,
t : 36,3oC, VAS:3
A : tetap
P: Tx: valsartan80 mg/24hr p.o
11-2-2015 (Day-2) :
S : Headache, Weakness of the left extremityO : GCS: E4M6V5= 15
BP : 140/80 mmHg, HR :88x/mnt,RR : 22x/mnt,
t : 36,4oC, VAS:2
Result of Consult to Cardiology Dept (+)
Result of Consult to Physic Rehabilitation(+)
A: Haemorrhage Stroke (ICH), Hyper tens ion st I,
Hypocalemia, Hypertriglycerid, Ischemic heart disease
P: Echoif possible
Tx: Fenofibrate 300 mg/24 hr,Simvastatin 10 mg/24 hr
p.o (night)
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23-2-2015 (Day-14) :
S : Weakness of the left extremity
O : GCS: E4M6V5= 15
BP:120/70 mmHg,HR : 86x/mnt,
RR : 22x/mnt, t : 36,6oC
Hasil TCD (+)
A: Haemorrhage Stroke (ICH),
Hypertension st I, Hypocalemia,
Hypertriglycerid, Ischemic heart
disease
P: Waiting schedule for echo
Tx: : Head elevation 30⁰, Citicoline
500 mg/12 hr po, Asam Traneksamat
500 mg/8 hr po, Ranitidin 150 mg/12 hr
po, Paracetamol 500 mg/8 hr p.o
Tanggal 18-2-2015 (Day-9) :
S : nyeri kepala, lemah anggota gerak kiri
O : GCS: E4M6V5= 15
TD : 150/70 mmHg, N : 82x/mnt, RR :20x/mnt, t : 36,7oC
A : Haemorrhage Stroke (ICH), Hypertension
st I, Hypocalemia, Hypertriglycerid, Ischemic
heart disease
P : Program TCD Friday (20/02/2015)
Tx : Head elevation 30⁰, Citicoline 500 mg/12
hr po, Asam Traneksamat 500 mg/8 hr po,
Ranitidin 150 mg/12 hr po, Paracetamol 500
mg/8 hr p.o
24-2-2015 (Day-15) :
S : Weakness of the left extremity
O : GCS: E4M6V5 = 15
BP : 140/90 mmHg, HR : 90x/mnt, RR : 20x/mnt, t :
36,3oC
Result of Echo (+)
A:Haemorrhage Stroke (ICH), Hypertension st I,
Hypocalemia, Hypertriglycerid, Ischemic heart disease
P: Discharge after echocardiography
Tx: Head elevation 30⁰, Citicoline 500 mg/12 hr
po, Asam Traneksamat 500 mg/8 hr po, Ranitidin
150 mg/12 hr po, Paracetamol 500 mg/8 hr p.o
20-2-2015 (Day-11) :
S : Weakness of the left extremity
O : GCS: E4M6V5 = 15
TD : 120/70 mmHg, N : 86x/mnt, RR :22x/mnt, t : 36,3oC
A: Haemorrhage Stroke (ICH), Hypertension
st I, Hypocalemia, Hypertriglycerid, Ischemic
heart disease
P: Program for TCD today
Tx: : Head elevation 30⁰, Citicoline 500
mg/12 hr po, Asam Traneksamat 500 mg/8 hr
po, Ranitidin 150 mg/12 hr po, Paracetamol
500 mg/8 hr p.o
19-2-2015 ( Day- 10)
S : Weakness of the left extremity
O :
PF : GCS: E4M6V5 = 15
TD : 140/80 mmHg, N : 86x/mnt,RR : 20x/mnt, t : 36,5oC VAS:2
A : Haemorrhage Stroke (ICH),
Hypertension st I, Hypocalemia,
Hypertriglycerid, Ischemic heart disease
P : Registering Echo schedule
24/02/2015
tx : : Head elevation 30⁰, Citicoline
500 mg/12 hr po, Asam Traneksamat
500 mg/8 hr po, Ranitidin 150 mg/12
hr po, Paracetamol 500 mg/8 hr p.o
16-2-2015 ( Day- 7)
S : Headache, Weakness of the left
O :
PF : GCS: E4M6V5 = 15
BP : 140/90 mmHg, HR : 80x/mnt,RR : 20x/mnt, t : 36,7oC VAS:3
A : Haemorrhage Stroke (ICH),
Hypertension st I, Hypocalemia,
Hypertriglycerid, Ischemic heart disease
P : tx : Head elevation 30⁰ Inf. RL 20
tpm Aff, Inj. Citicoline 500 mg/12 hr
po, Inj.Asam Traneksamat 500 mg/8 hr
po, Inj. Ranitidin 150 mg/12 hr po,
Paracetamol 500 mg/8 hr p.o
8/17/2019 Presentation PKB SH Edy Bismillah.. 12
http://slidepdf.com/reader/full/presentation-pkb-sh-edy-bismillah-12 72/74
VI Li f P bl
8/17/2019 Presentation PKB SH Edy Bismillah.. 12
http://slidepdf.com/reader/full/presentation-pkb-sh-edy-bismillah-12 73/74
VI. List of Problems
No Active Problem Tgl No Pasive Problem Tgl
1.
2.3.
4.
5.
6.
7.8.
Hemparesis sinistra (UMN) 6
Chepalgia 6Paresis of N.VII sinistra (UMN) 6
Paresis N.XII sinistra (UMN) 6
Hemihipestesi sinistra 6
Haemorrhage Stroke
Stage I HypertensionHypocalemia
09-02-2015
09-02-201509-02-2015
09-02-2015
09-02-2015
09-02-2015
09-02-201509-02-2015
.
8/17/2019 Presentation PKB SH Edy Bismillah.. 12
http://slidepdf.com/reader/full/presentation-pkb-sh-edy-bismillah-12 74/74
Thanx You...
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