RESUME STATUS STROKE

Bag. NEUROLOGI Fak. Kedokteran UHO/RSU Bahtramas

1.Tgl dra!at " ############..
$. No. Rekam %edk " #########..
&. Nama " ##############..
'. (lamat/tl) " ############..
* . R+angan "#####.
,. Usa "####.tah+n
-. Kelamn " 1. .erem)+an $. Lak/lak
0. Etns " 1.1a!a $.S+nda &.%nang '. Batak
*.%ela2+ ,. 3na -. .................
4. Stat+s " 1.Tdk ka!n $.Ka!n &.5+da/1anda
16. .eker7aan " 1.Tdk Beker7a $. .NS &. .eg.S!asta
'.(BRI/.ols *.8ras!asta ,. .ro9esonal
-. .ens+nan
11. .enddkan tertngg " 1.Tdk sekolah $.S5 &.S%.
'.S%U *.S% ke7+r+an
,.(kadem -. .T
/Stroke $/
1$. 3ekat tangan " 1.Kanan $.Kdal
1&. 8akt+ onset sam)a mas+k RS3% " ## 7am
1'. (lasan keterlam:atan ;<,7am= "
1.Trans)ortas $.men+ngg+ kel+arga &.1arak RS 7a+h
'.Sos/ek *.ketdaktah+an
1*. R!a2at stroke/TI( " 1.Tdak $.TI( &.Stroke
'.TI( > stroke *.Tdak tah+
1,. R!a2at h)ertens " 1. Tdak ada $. ?a@ :ero:at terat+r
&. ?a@ :ero:at tdak terat+r '. Tdak tah+
1-. R!a2at 5% " 1. Tdak ada $. ?a@ :ero:at terat+r
&. ?a@ :ero:at tdak terat+r '. Tdak tah+
10. %erokok " 1. Tdak $. ?a@ sam)a sekarang
&. Berhent A * tah+n '. Berhent */16 tah+n
*. Berhent <16 tah+n
14. Stroke dalam kel+arga " 1. Tdk $. ?a &. Tdk tah+
$6. R!a2at alkohol " 1. Tdk $. ?a &. Tdk tah+
$1. .l KB " 1. Tdk $. ?a
$$. R!a2at )en2akt 7ant+ng "
/Stroke &/
1. Tdak ada $. .en2. Kat+) &. .en2. 1ant. Iskemk
'. .en2. 1ant. Kongest9 *. (rtma ,. Tdk tah+
$&. N2er ke)ala " 1. Tdk ada $. .+lsatl ;:erden2+t=
&. Tenson t2)e '. lan/lan##
$'. %+ntah " 1. Tdk ada $. (da
$*. Bertgo " 1. Tdk ada $. (da
$,. O:estas " 1. Tdk $. ?a
$-. Gangg+an motork " 1. Tdk ada $. Hem)aress kanan
&. H. kr '. H.alternans
*. H.d+)leks ,. Lan/lan ##..
$0. Gangg+an sensork " 1. Tdk ada $. Hemh)estes kanan
&. H.kr '. .eroral n+m:ness
*. ThalamC )an ,. Lan/lan#..
$4. .aress Nn. Kranales " 1. Tdak ada $. N.I 5D/Sn
&. N. III 5D/Sn '. N. IB 5D/Sn
*. N. B 5D/Sn ,. N. BI 5D/Sn
-. N. BII 5D/Sn Sentral/.er9er
0. N. BIII 5D/Sn 4. N. IE 5D/Sn
16. N. E 5D/Sn 11. N. EII 5D/Sn Sentral/.er9er
&6. Gangg+an Fs+al " 1. Tdk ada $. Hemano)a
&. H. altt+dnal '. B+ta kortkal
*. (ma+ross 9+gaD ,. Bs+s men+r+n O5/OS/:lat
-. Lan/lan###.
&1. Gangg+an 9+ngs l+h+r " 1. Tdk ada $. (9asa sensork
&. (. motork '. (.glo:al
*. (. kond+kt9 ,. (leksa
- . Transent glo:al amnesa ;TG(=
0. Bs+os)atal negleCt 4. lan/lan###
&$. G3S ;saat mas+k RS= " E"#.%"#.B"#.
&&. Ke7ang " 1. Tdk ada $. Fokal
&. Um+m '. R!. e)le)s2
&'. Onset Ke7ang###
1. Se:lm ke7adan $. $' 7am )ertama
&. Har ke $/- '. Setelah har ke/- *. Tdk tah+
&*. Br+t " 1. Tdk ada $. B.karots &. B.s+:ClaFa
&,. Gangg+an gerakan :ola mata " 1.Tdk ada $..aress n.III
&. .aress n.IB '. .aress n.BI
*. 5eFas kon7+gat/ gaGe )als2
,. BertCal gaGe )als2 -. INO
0.Lan/lan##
&-. Tanda Rangsang %enngeal " 1.Tdk ada $.(da
&0. F+nd+sko) " 1.Normal $.F.h)ertens9
&.Retno)at 5% '.R.h)ertens9
*..a)ledema ,..erdarahan s+:halod
-.Lan/lan##
&4. Gangg+an kesem:angan " 1. Tdk ada $.Lm: ataksa
&.Gat ataksa '.Tr+nCal ataksa *. Lan/lan##
'6. Ht " ##.FolH '1. H: " ##g/dl
'$. Le+kost ##.. '&. 599 Co+nt ##
''. Trglserda " #.. H5L " #.. L5L " #.. @ Kolesterol total "##.
'*. (s +rat " #.. ',. Trom:ost "###.
'-. F:rnogen "####### '0. INR #.. ####.
'4. .T ###.###.. / (.TT #########
*6. (gregas trom:ost ####
*1. 5/dmer " #######.. *$. .roten 3 "###..
*&. .rot S " ##.. *'. (3( " ##..
**. G+la darah " Se!akt+ " ## N " ##. .. " ##.mgH
*,. Foto toraks " 1.Normal $.3TR<*6H &. Lan/lan ###.
*-. EKG " 1.Normal $.LBH &.RBH
'.(F *.ST Changes ,. Lan/lan##.
*0. 3T/sCan/%RI " 1.Normal $..erdarahan &.In9ark '. Lan/lan##.
*4. 3T/sCan har ke ##..;har s7k onset=
,6. 1ens Stroke Iskemk ;Bam9ord 3lass9Caton@ dses+akan dengan
gam:aran klns=
1.SS(T $.SS(. &.SL(K '.SS.O
,1 Gam:aran 3T/%RI stroke skemk
1. Normal $. Iskemk d gangla :asal/thalam+s
&. Iskemk d sere:ll+m '. Iskemk :atang otak
*. Iskemk d lo:+s #########.
,. Lan/lan ############..
,$ Bla Stroke hemoragk@ lokas )erdarahan ;3T/%RI=
1. S(H $..erdrhn gangla :asal/talam+s
&..erdrhn sere:elar '..erdrhn :atang otak
4.)erdrhn lo:ars 16.)erdrhn ntraFentrkel
11. Lan/lan ###
,&. Bol+me )erdarahan " 1.lo:ars/s+)ratentoral ..#..ml
$.n9ratentoral#..ml &.IBH ##ml
,'. 3arotd 5+)leD " 1. Normal $. I%T ######
&. .laI+e sta:l Tdk/?a@ d #.. '. Trom:+s Tdk/?a@ d ###.
*. Besar Stenoss Tdk / ?a@ d #. ,. Okl+s Tdk / ?a@ d ##
-. Lan/lan ######
,*. T35 " 1.Normal $.Stenoss dseCt@ d ####
&.Lan/lan####
,,. (ngogra9 " 1.Normal $.%al9ormas (B
&.(ne+rsma Berr2 '.Stenoss karots
*.Lan/lan##.
,-. Lama )era!atan ##. Har.
,0. Tera) " 1.(ntagregas trom: $.Ne+rotro)k &.(ntedema
'.Em:olsas *.He)arnsas ,.r/T.( -.(ntkoag+lan oral
0.O)eras 4.lan/lan###
,4. Tera) anth)ertens " 1.(l9a:loCker####.. $.Beta:loCker####.
&.(3EI/(RB## '. 3a antagonst#### *.5+retk#### ,.Lan/lan####.
-6. Kom)lkas selama )era!atan " 1.Tdk ada $..ne+mona
&.5ek+:t+s '.5ekom) kords *.5ee) Fen throm:oss
,.3ardaC arrest -.Stress +lCer 0.lan/lan##..
-1. 5s9aga " 1.(:sol+t J NGT dt Car
$. .artal J NGT det Car &. Tdak ada
-$. Inkontnensa +rn " 1.Tdk ada $.(da
-&. Tekanan darah saat mas+k " Sstole ### 5astole "###.
-'. Srra7 Stroke SCore " ##..
-*. Gad7ah %ada SCore " N2er ke)ala J// %+ntah J//
Re9leD .atologs J//
-,. NIHSS " Saat mas+k ## Kel+ar ######..
--. Barthel IndeD ;saat kel+ar= #########..
Kendar@ ######$6#
5okter .enangg+ng 1a!a: .emerksa@
; = ; =
3atatan "
SS(T " Sndroma Srk+las (nteror Total
SS(. " Sndroma Srk+las (nteror .arsal
SL(K " Sndroma Lak+nar
SS.O " Sndroma Srk+las .osteror