STROKE

Ragita Anandhita Putri

1115076
Preceptor : dr. Yenny SpKFR
 Indentity
Name : Ny. A
Age : 52 y.o
Sex : Female
Address : Bandung
Occupation : Houswife
Religion : Moeslem
Marital status : Married
 Anamnesis
Chief complaint : left sided weakness.
Specific history :
A day before examination, patient suddenly
felt weakness of her left arm and left leg when
she woke up in the morning. Patien hard to
stand, she can just raise her arm and leg for
seconds and mouth deviation to the right.
The patient denies feeling headache, nausea,
vomitting, ringing of the ear, seizures, loss of
consciousness, blurred or double vision. Patient
did not fall or had a head injury before.
Past Medical History
Patients had never experienced a complaint like this
before.
Uncontrolled high blood pressure
No history of diabetes, heart disease, or previous stroke
Family Medical History : patient has no families
whose complaint like this.
Habits : rarely exercise, likes eating fatty food. No smoking
or drinking alcohol
Effort in medication : none
Drug allergies : none
 Physical Examination
Consciousness : compos mentis
Weight = 70 kg, Height : 160 cm
BMI= 27,34 kg/m2 ( overweight )
Vital sign
Blood pressure : 130/80 mmHg
Heart rate : 84x/menit
Respiration rate: 20x/menit
Temperature : 360C
 General Examination

Head : within normal limits

Neck : within normal limits
Thorax : within normal limits
Abdomen : within normal limits
Extremity : within normal limits
Blood vessel : within normal limits
 Neurological Examination
Appearance
Head : normal size and shape
Vertebral column : normal
Meningeal sign
Nuchal rigidity -
Brudzinsky I -
Brudzinsky II -
Brudzinsky III -
Kernig -
La seque -
 Cranial Nerve
CN I
Olfactory : normosmia
CN II
Visual acuity test : normal
Confrontation test : good
Funduscopy : not performed
CN III/IV/VI
Ptosis (-)
Pupil round, isochors, 3 mm
Indirect light reflex (+/+), Direct light
reflex(+/+)
Eye movement : good in every direction
 CN V
Sensory
Ophtalmic +/+
Maxillary +/+
Mandibular +/+
Motoric normal
CN VII
Eyebrow movement : normal, symetric
Eye closure : normal
Nasolabial plica : asymmetric, flat at left
nasolabialis plica
Facial movement : asymmetric, mouth is inclined
to the right
2/3 anterior tongue tasting : not performed
CN VIII
Hearing : normal
Balance : not performed
 CN IX/X
Voice : dysphonia (-)
Swalowing : disphagia (-)
Pharyngeal arched : symmetrical
Uvula : central
Palatum contraction: symmetrical
Pharyngeal reflex : not performed
1/3 posterior tasting : not performed
CN XI
Shoulder lift : normal
Left and right head movement : within normal limits
CN XII
Left sided tongue deviation
Atrophy -
Tremor/fasiculation -/-
 Motoric Examination
Kekuatan Tonus atrof fasikulasi

Upper 5|3 normotoni -/- -/-

extremity
Lower 5|3 normotoni -/- -/-
extremity

Gait : not performed

Involuntary movement -
 Sensory Examination
Upper limbs, trunk, lower limbs : within
normal limits
Coordination Test not perfomed
 Physiological Reflex:
Biceps : +/+
Triceps : +/+
Radius: +/+
Ulnar : +/+
KPR : +/+
APR : +/+
Epigastric : not examined
Mesogastric : not examined
Hypogastric : not examined
Cremaster : not examined
 Pathological Reflex:
Hofman trommer : -/-
Babinsky : -/+
Chaddock : -/+
Oppenheim : -/-
Gordon : -/-
Schaeffer : -/-
Clonus : -/-
Primitive reflex : glabella ()
rooting ()
palmo mental ()
 Cognitive Examination
Psychological connection : Good
Motoric aphasia :-
Sensory aphasia :-
Short memory term : within normal
limits
Long memory term : within normal
limits
Calculation ability : Good
 Resume
Chief complaint : left sided weakness.
Specific history :
A 52 yo female suddenly felt weakness of her left
arm and left leg when she woke up in the morning, 1
day before examination. Patien hard to stand, she can
just raise her arm and leg for seconds and mouth
deviation to the right.
Patient denies vomit, vertigo, seizure, headache,
ringing of the ear, loss of conciousness, blurred or
diplopia, injury history (-)
Past Medical History :
Patients had never experienced a complaint like this
before.
Uncontrolled high blood pressure
No history of diabetes, heart disease, or previous
stroke

Family Medical History : patient has no families

whose complaint like this.

Habits : rarely exercise, likes eating fatty food.

No smoking or drinking alcohol
Effort in medication : none

Drug allergies : none

 Physical examination
Consciousness : compos mentis
Weight = 70 kg, Height : 160 cm
BMI= 27,34 kg/m2 ( overweight )
Vital sign
Blood pressure : 130/80 mmHg
Heart rate : 84x/menit
Respiration rate : 20x/menit
Temperature : 360C
 General examination : within normal limits
Meningeal sign -
Cranial Nerve
right sided central CN VII paresis
Right sided central CN XII paresis
Motoric :
Upper limb : 5|3, normotoni
Lower limb : 5|3, normotoni
Sensory within normal limits
Physiological reflex : +/+
Pathological reflex : -/+
 Proposal Checks
Ct scan
PT/apTT
Blood glucose
Lipid profile
 Working Diagnosis
Clinical : left sided hemiparese
Localitation : Right carotid system
Etiology : cerebral infarction
Risk Factor : hypertension
 Proposal Management
Non-Medikamentosa
Medical rehabilitation
Control the hypertention
Medikamentosa
Aspilet tab 80mg 1 x1
Amlodipin tab 5mg 1 x1
 Prognosis
Ad vitam : ad bonam
Ad functionam : dubia ad bonam
Ad sanationam : dubia ad bonam
 Rehabilitation Program in Stroke Patients

Initial Phase
Aims to prevent secondary complications and
protect remaining functions.
Includes proper bed positioning, range-of-motion
exercises, electrical stimulation, and emotional
therapy.
Continuation Phase
Aims to achieve functional independence in daily
mobilization and activities.
 Physiotherapy:
Electrical stimulation for weak muscles
(muscle strength of 2 or less)
Superficial heat therapy (infrared) to loosen
muscle stiffness
Passive or active range of motion exercises
Muscle strength exercises
Muscle facilitation or reduction exercise
Mobilization exercise
 Speech therapy
Mirror exercises to train tongue and lip movements
and word pronunciations
Word articulation exercises in dysarthria patients
Therapy may be performed by the medical team or
the patients family
Psychological therapy
Social therapy