Case Report

By:
Sabella Gustika Vernanda
NIM 1408466188
Supervisor:
dr. Enny Lestari, Sp.S

MEDICAL CLERKSHIP
NEUROLOGY DEPARTEMENT
FACULTY OF MEDICINE RIAU UNIVERSITY
PEKANBARU
2016
Name Mrs. M
Age 48 years old
Gender Female

Address Jl. Meranti Gg. Sempurna, Pekanbaru

Religion Moeslim

Marital’s Status Married

Occupation Housewife

Entry Hospital December, 13th 2016

Medical Record 9245XX

 Present Illnes
• Weakness of right History • Blood pressure were
extremities since 2 hours 220/120
before admitted to the • It was occurred suddenly • Headache (-) , vomiting
hospital while patient was resting. (-), losing of vision (-)
• She was found unable to loss conciousness (-).
speak, distortion of lips, Trauma (-)
and unable to move his
right side
Chief
Complain
 Past Illness History Daily routine history Occupation

Hypertension since 8 years

Smoke (-) Housewife
ago

Diabetes Mellitus was

Alcohol (-) The family disease history
unknown.

History of stroke (-) vascular Long term drug Stroke (-) DM (-)
or heart disease (-) consumption (-) Hypertension (-)
 Weight : 70 kg
Blood
Respiratory Height : 155
Pressure Heart Rate Temperature
rate cm
220/120 80 bpm 36,70 C
22x/minute BMI: 29,13
mmHg
(Obesity I)
 Consciousness:
GCS: E4M6VAphasia
Composmentis

Meningeal Sign:
Cognitive Function: Neck stiffnes (-)
Motoric Aphasia (+)
Brudzinki I, II, III, IV
(-)
N. I: Normal N. III: Normal
N. IV: Normal
N. II: Normal N. VI: Normal

N. VII: Parese N. V: Normal

N.VII dextra
central type
3 5 N. VIII: Normal
N. IX: Normal
N. X: Normal N. XII: Parese N.
XII dextra
N. XI: Normal
Physiologic Reflex: (+)
Motor System: 3 5 Pathologic Reflex: (-)
Hemiparese
Dextra
Coordination: Difficult to
Sensory System: Normal Asses
Other Examination: Normal
Autonom: Normal
 Gadjah Mada Stroke Algorythm

Loss of Non
Pathology
consciousness Headache (-) hemorrhagic
reflex (-)
(-) stroke

Siriraj Stroke Score

SSS = 2.5 C + 2 V + 2 H + 0.1 DBP – 3A – 12

SSS = 2,5 (0) + 2 (0) + 2 (0) + 0,1 (120) - 3 (0) –

12 = 0
Interpretation : <-1 sd 1: Uncertain
 Consciousness : Composmentis (E4M5VAphasia)
 Blood Pressure : 220/120 mmHg
 Heart Rate : 80 bpm
 Respiratory Rate : 22 cycle/min
 Temperature : 36,7°C
 Cognitive Function
: Motoric aphasia (+)
 Meningeal sign : Neck stiffness (-), Brudzinski I-IV (-)
 Cranial Nerves : Right Central N.VII paresis & Right N. XII
paresis
 Motoric : Right Hemiparesis
 Sensory : Normal
 Coordination : Difficult to assess
 Autonomy : Normal
 Reflex : Physiology (+), Pathology (-)
 Gajah Mada Score : Non hemorrhagic stroke
 Siriraj score : Uncertain
 CLINIC • Stroke
DIAGNOSIS

TOPIC • Carotid system sinistra

DIAGNOSIS

ETIOLOGIC • Non hemorrhagic stroke

DIAGNOSIS

DIFFERENTIAL • Hemorrhagic stroke

DIAGNOSIS
 ECG
Chest X-Ray AP

Head CT Scan
without
contrast
Blood
chemistry
• Random blood
glucose, ureum,
Blood creatinin, SGOT,
SGPT, kolesterol
routine total, HDL, LDL,
• Hb, Ht, Trigliserida
leucocyte,
thrombocyte
 General Special

• Bed rest with head position • rTPA IV 0,9mg/kgBB (max.90

elevated 300 mg)
• Monitoring of vital sign
• IVFD NaCl 0,9%
(30cc/kgBB/day)
• Calorie needs 25-30
kkal/kg/day: Carbohydrate 30-
40% of total calories, fat 20-
35% of total calories, protein
20-30% of total calories
• Medical rehabilitation
 Blood Routine (December, 13th 2016)
 Hemoglobin : 13 gr%
 Hematocrit : 36,7 vol%
 Leucocyte : 9.700/mm3
 Thrombocyte : 279.000/mm3
 Electrolyte (December 13th 2016)
 Na+ : 149,1 mmol/L (135 – 145) 
 K+ : 2,76 mmol/L (3,5 – 5,5) 
 Cl++ : 101,7 mmol/L (97 – 107)
 Blood Chemistry (December 13th 2016)
 Glucose : 109 mg/dl (74 – 106) 
 Ureum : 15 mg/dl (15 – 41)
 Creatinin : 0,57 mg/dl ( 0,55 – 1,30)
 AST : 15 U/L (15 – 37)
 ALT : 23 U/L (12 – 78)
 Blood Chemistry (December 14th 2016)
 Cholesterol : 234 mg/dl (0-200) 
 HDL-Cholesterol : 49 mg/dl (40-60)
 Total Bilirubin : 0,89 mg/dl (0,20-1,00)
 Direct Bilirubin : 0,16 mg/dl (0,00-0,20)
 Indirect Bilirubin : 0,73 mg/dl (0,30-1,10)
 Ureum : 12 mg/dl (15-41) 
 Creatinin : 0,52 mg/dl (0,55-1,30) 
 Uric acid : 4,7 mg/dl (2,6-7,2)
 AST : 16 U/L (15 – 37)
 ALT : 28 U/L (12 – 78)
 Albumin : 4,3 g/dl (3,4-5,0)
 Albumin/Globulin Ratio : 1,4 (0,8-2,0)
 Total protein : 7,7 g/dl (6,4-8,2)
 Globulin : 3,2 g/dl (0,4-8,2)
INTERPRETATION

 Normal
INTERPRETATION

 Rhythm : sinus rhythm,

reguler
 Frequency: 75x/minute
 Axis: normoaxis
 P wave: normal
 PR interval : normal
 QRS complex: normal
 ST segment: isoelectric
 T wave : normal
 Interpretation : Normal
INTERPRETATION

 Normal
Non
Hemorrhagic
Stroke

Hypokalemia
Follow up (December 14th 2016) Follow up (December, 15th 2016)
S: Weakness of right extremity, inability to Weakness of right extremity, inability to speak
speak
Consiousness : Composmentis Consiousness : Composmentis
BP : 200/100 mmHg BP : 180/100 mmHg
HR : 80x/minutes, regular HR : 80x/minutes, regular
RR : 23 x/minutes RR : 22 x/minutes
T : 36,6 °C (Axila) T : 36,4 °C (Axila)
Cognitive function : Motoric Aphasia (+) Cognitive function : Motoric Aphasia (+)
Meningeal Sign : Negative Meningeal Sign : Negative
Cranial Nerves : Right N.VII paresis, Right N.XII Cranial Nerves : Right N.VII paresis, Right N.XII
paresis paresis
Motoric : Hemiparese dextra Motoric : Hemiparese dextra
Strength : arm (3:5) leg (3:5) Strength : arm (3:5) leg (3:5)
Reflex Physiologic : (+) Reflex Physiologic : (+)
Patologic : (-) Patologic : (-)
Sensory : Normal Sensory : Normal
A: Non hemorrhagic stroke + Hypokalemia A: Non hemorrhagic stroke + Hypokalemia
P: IVFD (30cc/kgBB/day)  NaCl 0,9% + KCl 1 P: IVFD (30cc/kgBB/day)  NaCl 0,9% + KCl 1
fls (29dpm) fls (29dpm)
Citicolin IV 1000 mg/12hours Citicolin IV 1000 mg/12hours
Aspirin 1 x 325 mg p.o Aspirin 1 x 325 mg p.o
Follow up (December 16th 2016) Follow up (December, 17th 2016)
S: Weakness of right extremity, inability to S: Weakness of right extremity, inability to
speak speak
Consiousness : Composmentis Consiousness : Composmentis
BP : 160/100 mmHg BP : 150/100 mmHg
HR : 82x/minutes, regular HR : 82x/minutes, regular
RR : 22 x/minutes RR : 22 x/minutes
T : 36,5 °C (Axila) T : 36,6 °C (Axila)
Cognitive function : Motoric Aphasia (+) Cognitive function : Motoric Aphasia (+)
Meningeal Sign : Negative Meningeal Sign : Negative
Cranial Nerves : Right N.VII paresis, Right N.XII Cranial Nerves : Right N.VII paresis, Right N.XII
paresis paresis
Motoric : Hemiparese dextra Motoric : Hemiparese dextra
Strength : arm (3:5) leg (3:5) Strength : arm (4:5) leg (4:5)
Reflex Physiologic : (+) Patologic: (-) Reflex Physiologic : (+)
Sensory : Normal Patologic : (-)
Laboratory Sensory : Normal
Na+ : 146 mmol/L
K+ : 3,5 mmol/L
Cl : 102 mmol/L
A: Non hemorrhagic stroke A: Non hemorrhagic stroke
P: IVFD NaCl 0,9% (30cc/kgBB/day)  29 dpm P: IVFD NaCl 0,9% (30cc/kgBB/day)  29 dpm
Citicolin IV 1000 mg/12hours Citicolin 1000 mg/12hours p.o
Follow up (December 19th 2016) Follow up (December, 20th 2016)
S: Weakness of right extremity, inability to S: Weakness of right extremity, difficulty to
speak speak
Consiousness : Composmentis Consiousness : Composmentis
BP : 150/100 mmHg BP : 150/100 mmHg
HR : 84x/minutes, regular HR : 86x/minutes, regular
RR : 20 x/minutes RR : 21 x/minutes
T : 36,5 °C (Axila) T : 36,7 °C (Axila)
Cognitive function : Motoric Aphasia (+) Cognitive function : Motoric Aphasia (+)
Meningeal Sign : Negative Meningeal Sign : Negative
Cranial Nerves : Right N.VII paresis, Right N.XII Cranial Nerves : Right N.VII paresis, Right N.XII
paresis paresis
Motoric : Hemiparese dextra Motoric : Hemiparese dextra
Strength : arm (4:5) leg (4:5) Strength : arm (4:5) leg (4:5)
Reflex Physiologic : (+) Reflex Physiologic : (+)
Patologic: (-) Patologic : (-)
Sensory : Normal Sensory : Normal

A: Non hemorrhagic stroke A: Non hemorrhagic stroke

P: IVFD NaCl 0,9% (30cc/kgBB/day)  29 dpm P: Patient referred home and control to
Citicolin 1000 mg/12hours p.o policlinic
DISCUSSION
 is a collection of symptoms
characterized by the development
of clinical manifestations of
cerebral function disorders either
STROKE focal or global, which happens
quickly and more than 24 hours or
ended up with death without being
discovered other causes than
vascular disorders.
increasing change in
the the blood
viscocity vessels
permeabilty

Emboli ruptur
of blood
vessels

trombus

Stroke
 Non
Hemorrhagic
Hemorrhagic
Symptom or examination Infarction Intracerebral haemorrhage

Prodormal sign TIA (+) 50% TIA (-)

Doing activity/resting Rest, right after wake up Often while doing physical activity
Headache and vomit Rarely Often or severe
Lost of consciousness at onset Rarely Often
Hypertension moderate/ Moderate-severe
normotension
Meningeal sign No Yes
High intracranial pressure Rarely Subhialiod bleeding
symptom
Bloody LCS No Yes
Head CT Scan Hypodensity area Intracranial mass with hyperdensity
area
Angiography Stricture appearance aneurism, AVM, massa intrahemisfer
or vasospasme
 Acute stroke  Lost of consciousness
Headache
Pathology reflex

All criteria or two of the three

Lost of consciousness (+), headache (-), pathology reflex (-) Haemorrhage
Lost of consciousness (-), headache(+), pathology reflex (-) stroke
Lost of consciousness (-), headache(-), pathology reflex (+) infarction
Lost of consciousness (-), headache (-), pathology reflex (-) infarction
 SSS = 2.5 C + 2 V + 2 H + 0.1 DBP - 3A – 12

C = Consciousness (composmentis = 0, somnolen = 1, sopor/koma = 2)

V = Vomit (none = 0, yes = 1)
H = Headache (none = 0, yes = 1)
DBP = Diastolic blood pressure
A = Ateroma (none = 0, one or more: DM, Angina, vaskular disease = 1)

SSS DIAGNOSE
>1 Hemorrhagic
stroke
<-1 Infarction stroke

-1 to 1 Uncertain
 • Done at the emergency room
• O2 2L/min, crystalloid/coloid, avoid administration of dextrose
• Brain CT, ECG, Chest X-ray, complete peripheral blood and platelet count,
Hyperacute PT/ INR, APTT, blood glucose, blood chemistry (including electrolytes),if
hypoxiablood gas analysis.
stadium

• General treatment
• Place patient head 300, mobilization, O2 1-2L/min, fluid nutrition, blood
glucose, headache, hypotension, seizure, etc.
Acute • Special treatment
stadium • rt-PA (combinant tissue Plasminogen Activator), and neuroprotective
agent, such as citicoline or piracetam
 • Medical measures may include cognitive
therapy, behavior, swallowing, speech
therapy, and bladder training (including
physical therapy)
• Special intensive treatment of post-stroke
in the hospital with the goal of
Subacute independence of the patient, understand,
comprehend and implement primary and
Stadium secondary prevention programs
 Neurological Non neurological
complications complications

• Increased the blood

• Cerebral edema pressure
• Hemorrhagic • Hiperglikemia
transformation • Cardio-respiratory
• Seizures disorder
• Recurrent stroke • Stress ulcer
• Depression
• Decubitus ulcer
 Anamnesis
no history of loss of
weekness of her right
Unable to speak distortion of the lips consciousness, severe
extremity, when she rested
headache or vomit

Physical examination

Motoric : Hemipharase dextra, Cranial Nerve: Parese N. VII dextra central type,
Gadjah mada score: Non hemorrhagic stroke
parese N. XII dextra

Stroke

It is consistent with the WHO definition that clinical symptoms of stroke is cerebral disorders, either focal or global attack
in 24 hours or more, no illness is found other than vascular disorders
hemiparese
dextra
parese N.VII dextra
central type

parese N.XII dextra

Carotid system
sinistra
 Hemiparese
dextra, sudden
onset

Loss Non
counciousness
(-) severe hemorrhagic
headache (-) stroke

Gadjah mada
score
 Non-
Hemorrhagic
Hemorrhagic
stroke
stroke CT Scan as the
Gold Standard
 Chest X ray
Laboratory
 to find wether the
to find the risk
patient had
factor for stroke and
cardiomegaly or not
general condition of
as the result of heart
patient.
disease.

Head CT-scan
 to know the final
ECG
pathology of
to know if there
diagnose from the
was cardiac disease.
location and the wide
of the lesion.
• weekness of her right
extremity, when she rested
• Inability to speak
• distortion of the lips
• no history of loss of
consciousness, severe
headache or vomit.
Anamnesis
Physical
examinations • Non- Hemorrhagic stroke
• Motoric : Right hemipharase
• Motorik aphasia (+)
• Cranial Nerve : Parese N. VII right
central type, parese N.XII right
• Gadjah mada score: Non
hemorrhagic stroke
Diagnosis
 • to
maintance
The aim of bed
the
rest with head
adequate
position elevated
circulation
20-30º
to the
brain.
• to maintance
the euvolemik
The aim of IVFD
condition and
(30cc/kgbb/day)
glucose level
needed.
• reperfusion
and lysis of
The aim of thrombus
trombolytic rt-PA and
cerebral
cell repair.

The aim of
injection • as the
citicoline 1000 neuroprotector.
mg/12 hours

The aim of • prevent from

Aspirin 1 x 325 recurrent
mg stroke attack