RESUME

STROKE PERDARAHAN
OLEH:
Galuh Puspa Ayu W 011011137
LABORATORIUM/SMF ILMU PENYAKIT SARAF
FAKULTAS KEDOKTERAN UNIVERSITAS AIRLANGGA
RSUD DR SOETOMO SURABAYA
2014
STATUS PENDERITA
IDENTITAS PENDERITA
Nama : Ny. NQ
Usia : 47 tahun
Jnis !lamin : P"mpuan
A#ama : $slam
Alamat : %u"a&aya
%tatus 'a"ital : %u(ah mni)ah
*an##al Pm"i)saan : ++ Ap"il +014
*an##al ',% : +0 Ap"il +014
ANAMNESIS
Keluha U!a"a# !lmahan stn#ah &a(an
R$%a&a! Pe&a'$! Se'a(a)
Pasin mn(a(a) mn#alami )lmahan stn#ah &a(an s&lah )anan s-a) satu ha"i s&lum
masu) "umah sa)it. .isampin# itu/ pasin -u#a m"asa)an )t&alan0)smutan (i stn#ah &a(an
s&lah )anan. %&lumnya pasin -u#a mn#alami pl1 (an &i2a"a n#lantu" pa(a saat a)ti3itas.
Pasin "i4ayat mn#1nsumsi pil !5 slama 7 tahun (an s)a"an# mma)ai spi"al. *i(a) (i(apat)an
ny"i )pala 678/ mual 678/ (an mutah 678/ 5A5 (an 5A! (alam &atas n1"mal.
R$%a&a! Pe&a'$! Dahulu
Hip"tnsi 698 s-a) tahun +007 ti(a) t")1nt"1l/ t: : aml1(ipin
,i4ayat .ia&ts 'llitus 678
,i4ayat pnya)it -antun# 678
*i(a) p"nah st"1) s&lumnya
R$%a&a! Pe&a'$! Kelua()a
O"an# tua pasin mnin##al (i)a"na)an .ia&ts 'llitus (an hip"tnsi
PEMERIKSAAN FISIK
S!a!u* I!e(a S$)'a!
;ital %i#n :
*)anan .a"ah 1400<0 mmH# Na(i =>:0mnit
,, +0:0mnit *mp"atu" a?&"is
!pala0Lh" : anmia 678 i)t"us 678 sian1sis 678 (yspnu 678
*h1"a)s : simt"is/ "t"a)si 678
@1" %
1
%
+
tun##al/ mu"mu" 678 #all1p 678
Pulm1 3si)ul" 909/ "1n)hi 707 4hAin# 707
A&(1mn : supl/ &isin# usus n1"mal. Hpa" (an lin ti(a) t"a&a.
E)st"mitas : a)"al han#at )"in# m"ah/ (ma 77077
S!a!u* P*$'$a!($ S$)'a!
A?)0m1si : a()uat
P"1ss &"pi)i" : t(
$ntli#nsi : t(
P"spsi : t(
!mauan : t(
Psi)1m1t1" : t(
S!a!u* Neu(+l+)$
Ke*a u"u"
!a(aan : lmah
!sa(a"an : &ai) G@% 4>B
Pm&i2a"aan : 1"intasi &ai)
!pala : &sa" n1"mal/ simt"is
Ra)*a)a *ela,u! +!a'
!a)u )u(u) : 7
LasCu : 7
!"ni# : 7
5"u(Ains)i $ : 7
5"u(Ains)i $$ : 7
5"u(Ains)i $$$ : 7
5"u(Ains)i $;: 7
Sa(a- K(a$al$*
Ne(.u* I # 'aa '$($
Hyp1smia0an1smia t( t(
Pa"1smia t( t(
Halusinasi t( t(
Ne(.u* II# 'aa '$($
;isus D+0B0 D+0B0
E1-ana pn#lihatan n1"mal n1"mal
'lihat 4a"na t( t(
Fun(us)1pi t( t(
Ne(.u* III/IV/VI# 'aa '$($
!(u(u)an &1la mata tn#ah tn#ah
P"#"a)an &1la mata
! nasal 9 9
! tmp1"al 9 9
! atas 9 9
! &a4ah 9 9
! tmp1"al &a4ah 9 9
E)s1?talmus 7 7
Pt1sis 7 7
Pupil &ulat is1)1" &ulat is1)1"
L&a" 3mm 3mm
P"&(aan L&a" 7 7
,?l)s 2ahaya lan#sun# 9 9
,?l)s 2ahaya )1nsnsuil 9 9
,a)si a)1m1(asi 9 9
,a)si )1n3"#nsi 9 9
Ne(.u* V# 'aa '$($
@a&an# m1t1"i)
Ot1t masst" simt"is )"i7)anan
Ot1t tmp1"al t( t(
Ot1t pt"y#1i(us t( t(
@a&an# sns1"i)
N ;1 hipsthsi 9
N ;+ hipsthsi 9
N ;3 hipsthsi 9
,?l)s )1"na lan#sun# 9 9
,?l)s )1"na )1nsnsuil 9 9
Ne(.u* VII# 'aa '$($
Wa)tu (iam:
!"utan (ahi simt"is )i"i7)anan
*in##i alis simt"is )i"i7)anan
%u(ut mata simt"i )i"i7)anan
Lipatan nas1la&ial (an#)al n1"mal
Wa)tu &"#"a)
'n#"ut (ahi simt"is )i"i7)anan
'nutup mata simt"is )i"i7)anan
5"siul t(
Lipatan nas1la&ial (an#)al n1"mal
Pn#2apan +03 (pan li(ah t(
Hip"a)usis mnu"un n1"mal
%)"si ai" mata t(
Ne(.u* VIII# 'aa '$($
;sti&ula":
;"ti#1 7 7
Nista#mus 7 7
*innitus t(
*s )al1"i t(
@12hla":
W&" t(
,inn t(
%2h4a&a2h t(
Ne(.u* I0/0#
'1t1"i):
%ua"a (alam &atas n1"mal
'nlan (alam &atas n1"mal
P1sisi a"2us pha"yn: (i tn#ah/ simt"is
P1sisi u3ula (i tn#ah simt"is
%ns1"i):
Pn#2apan 103 &la)an# li(ah t(
,?l)s 12ul172a"(ia2 t(
,?l)s 2a"1ti2172a"(ia2 t(
,?l)s muntah n1"mal
,?l)s palatum m1ll t(
Ne(.u* 0I# 'aa '$($
'n#an#)at &ahu n1"mal n1"mal
'malin#)an mu)a n1"mal n1"mal
Ne(.u* 0II#
!(u(u)an li(ah 4a)tu isti"ahat ) )i"i
!(u(u)an li(ah 4a)tu #"a) ) )anan
At"1?i 7
Fasi)ulasi0t"m1" 7
!)uatan mn)an &a#ian (alam pipi l&ih )uat )i"i
S$*!e" M+!+($'#
Le)a# 'aa '$($
A&(u)si ln#an atas >7 >
Fl)si sn(i p"#lan#an tan#an 4 >
E)stnsi sn(i p"#lan#an tan#an 4 >
'm&u)a -a"i7-a"i tan#an >7 >
'nutup -a"i7-a"i tan#an >7 >
Tu)'a$# 'aa '$($
Fl)si a"ti)ulus 21:a 3 >
E)stnsi sn(i lutut 3 >
Planta" ?l)si p(is 4 >
.1"s1 ?l)si p(is 4 >
T+u* O!+!# 'aa '$($
Hip1t1ni 7 7
%pasti) 7 7
,i#i( 7 7
Ge(a'a I.+lu!e(#
,stin# t"m1" n#ati?
$ntnti1n t"m1" n#ati?
K++(1$a*$#
Ja"i tan#an7-a"i tan#an : (alam &atas n1"mal
Ja"i tan#an7hi(un# : (alam &atas n1"mal
P"1nasi7supinasi : (alam &atas n1"mal
*umit7lutut : t(
Gait0stati1n : t(
S$*!e" Se*+($'#
Ra*a e'*!e(+*e,!$'
*an#an 'aa '$($
,asa ny"i sup"?isial mn"un (&n
,asa "a&a "in#an mn"un (&n
,asa suhu mn"un (&n
*un#)ai
,asa ny"i sup"?isial mn"un (&n
,asa "a&a "in#an mn"un (&n
,asa suhu mn"un (&n
Ra*a ,(+,($+*e,!$'
*an#an 'aa '$($
,asa #ta" mn"un (&n
,asa t)an mn"un (&n
,asa ny"i t)an mn"un (&n
,asa #"a) (an p1sisi (&n (&n
*un#)ai
,asa #ta" mn"un (&n
,asa t)an mn"un (&n
,asa ny"i t)an mn"un (&n
,asa #"a) (an p1sisi (&n (&n
Ra*a e!e(+*e,!$' 'aa '$($
,?""( pain t( t(
Ra*a '+"2$a*$ 'aa '$($
%t"1#n1sia (alam &atas n1"mal
5a"1#n1sia (alam &atas n1"mal
G"aphstsia (alam &atas n1"mal
+7p1int ta2til (is2"iminati1n (alam &atas n1"mal
%ns1"y :tin2ti1n (alam &atas n1"mal
L1ss 1? &1(y ima# (alam &atas n1"mal
Fu)*$ Luhu(#
A?asia : 7
Ap"a)sia : 7
A#"aphia : 7
A)al)ulia : 7
Al:ia : 7
Fin#" a#n1sia : 7
,i#ht7l?t (is1"intati1n : 7
Re-le'*3(e-le'*# 'aa '$($
Re-le'* -$*$+l+)$*
,?l)s (in(in# p"ut mnu"un
,?l)s &i2ps 93 9+
,?l)s t"i2ps 9+ 9+
,?l)s patlla 9+ 9+
,?l)s A2hills 9+ 9+
Re-le'* ,a!+l+)$*
Ln#an
H1??man7*"1mn" 707 707
*un#)ai
5a&ins)i 9 7
@ha((12) 7 7
Oppnhim 7 7
,1ss1lim1 7 7
G1"(1n 7 7
%2ha??" 9 7
'n(l752ht"4 7 7
%t"ans)y 7 7
G1n(a 7 7
Re-le'* ,($"$!$-
Palm1mntal "?l)s 7
Su*ua *a(a- +!++"
'i)si : (alam &atas n1"mal
.?)asi : (alam &atas n1"mal
%)"si )"in#at : (alam &atas n1"mal
4+lu"a .e(!e2(al$*
!i?1sis/ l1"(1sis/ s)1li1sis : 7
Gi&&us : 7
*um1" : 7
Ny"i )t1) : 7
RESUME
Ny. NQ mn(a(a) mn#alami )lmahan stn#ah &a(an s&lah )anan s-a) satu ha"i s&lum
masu) "umah sa)it. .isampin# itu/ pasin -u#a m"asa)an )t&alan0)smutan (i stn#ah &a(an
s&lah )anan. %&lumnya pasin -u#a mn#alami pl1 (an &i2a"a n#lantu" pa(a saat a)ti3itas.
Lipatan nas1la&ial )anan pa(a pasin l&ih (an#)al (i&an(in#)an )i"i (an pa(a saat pasin
mn-ulu")an li(ah/ p1sisi li(ah ) sisi )anan. Pnu"unan pn(n#a"an pa(a tlin#a )anan.
.i(apat)an lat"alisasi (:t"a pa(a pasin/ "?l)s ?isi1l1#is &isps mnin#)at (an "?l)s pat1l1#is
&a&ins)i (an s2ha??" p1siti?.
PROBLEM LIST
Anamnsa:
1. !lmahan stn#ah &a(an s&lah )anan
+. !smutan (i stn#ah &a(an s&lah )anan
3. 5i2a"a pl1
Pm"i)saan ?isi):
1. Lat"alisasi (:t"a
+. Lipatan nas1la&ial )anan (an#)al
3. Pnu"unan pn(n#a"an tlin#a )anan
4. ,?l)s ?isi1l1#is &i2ps mnin#)at
>. ,?l)s pat1l1#is &a&ins)i (an s2a??" p1sit?
%i"i"a- st"1) s21":
6+.> : ("a-at )sa(a"an8 9 6+ : muntah8 9 6+ : ny"i )pala8 9 60.1 : t)anan (a"ah (iast1l8 G 63 :
tan(a ath"1ma8 G 1+
6+.> : 08 9 6+ : 08 9 6+ : 08 9 60.1 : 1>08 G 63 : 08 G 1+
H 3
DIAGNOSIS
!L$N$%
Hmipa"s (:t"a
Hipsthsia (:t"a
Hip1a)usis (:t"a
Fa2ial an( lin#ual palsy (:t"a tip 2nt"al
Hip"tnsi
*OP$%
%u&21"t: sinist"a
E*$OLOG$%
%t"1) p"(a"ahan
.$AGNO%A 5AN.$NG
%t"1) in?a")
%E!UN.E,
Hip"tnsi m"#n2y
PLANNING
D$a)+*!$'
E!G
F1t1 *h1"a: AP
@* %2an tanpa )1nt"as
P"i)sa (a"ah ln#)ap/ #ula (a"ah puasa 0 + JPP/ p"1?il lipi(/ asam u"at/ FH/ ,F/ ?aal hm1stasis/
5GA/ al&umin/ s"um l)t"1lit.
Te(a,$
U'U'
P"hati)an 0 sta&il)an B5
Ha( an( t"un) up 30
$n?us ,A + ?lash 0 +4 -am
!HU%U%
$"&sa"tan 1>0 m# G 0 G 0 p.1
Ni2a"(ipin 0/>71 m2#0)#550mnit
,aniti(in + : 1 amp i.3
;it. 5 @1mpl: 3 : 1 ta& p.1
M+$!+($)
G@%/ ;ital si#n/ )luhan
E1u'a*$
'n-las)an )pa(a pasin mn#nai pnya)it/ "n2ana tin(a)an (an t"api yan# a)an (ila)u)an/
)1mpli)asi yan# mun#)in t"-a(i (an p"1#n1sis pasin t"s&ut.