3.mr.dodotcva
blledingmultazam 7
4mr.suharmadjiDM tipe 2 and ICH in
hemyspher subcorticalmarwah 3
Chief complaint :
Loss of consciousness
Present illness history :
since 3 hours SMRs, patients discharged wash
motor. Suddenly complained of headache and
dizziness spinning, pasien jatuh, pasien tidak
nyambung saat diajak bicara,muntah (-),kejang
(-),demam (-).
Previous Illness History :
HT (+), does not control routine
Family History of Disease
HT (-)
DM (-)
Sociality History
farmer
Vital sign:
BP: 204/121 mmHg
HR: 138 x/mnt
RR: 24 x/mnt
Temp: 38,90C
Primary survey:
A : clear, gargling (-), snoring (+), speak
frequently (-), potential obstruction (-)
B : spontaneous, RR 24x/mnt, ves/ves, rh -
, wh -/-, O2 saturation 94% with O2 NRM 8
lpm support
C : acral dry red warm, CRT < 2’, N 138
x/mnt, BP 204/121 mmHg
D : GCS 115, lateralisation sinistra, PBI 1
mm/1 mm, LR +/+ slow
E : Temp 38,9 0C
Secondary survey:
GCS 115
H/N : a -/ I -/ c -/d-;Enlargement of Lymph
node -
Tho : simestris, ret -/-
P : ves/ves, rh -/-, wh -/-
C : S1S2 single, murmur (-), gallop (-)
Abd : Soepel, met -, bowel loudness (+) N, H/L
unpalpable,
Extr: aie -, acral dry red warm
SIRIRAJ SCORE :
(2,5x2)+(2x1)+(2x0)+(0,1x121)-(3x0)-12 = 7,1
CVA Bleeding
1. Head : Position : Normal, middle
Mass :-
Shape | size : normal | normal
Auskultation : bruit a. carotis(-)
2. Nervus Cranialis :
N.I (Olfaktorius)
Penghidu : hard to evaluated
N.II (Optikus)
Visual acuity : hard to evaluated
Field of vision : hard to evaluated
Funduscopy : not evaluated
N. III (Okulomotorius)
slit eye: Ptosis : -| -
Exoftalmus : -| -
Movement of eye ball : hard to evaluated
Pupil : Pupil round isokor 1 mm / 1 mm
Light Reflek : direct :-|-
non-direct :-|-
nistagmus : -|-
N.IV (Troklearis)
Position of eye ball : normal | normal
movement of eye ball : hard to evaluated
N.VI (Abdusen)
movement of eye ball : hard to evaluated
N.V (Trigeminus)
Sensibility : N. V I : hard to evaluated
N. V II : hard to evaluated
N. V III : hard to evaluated
Motorik :
Inspeksi : symmetris
Palpasi : hard to evaluated
chewing : hard to evaluated
Bitting : hard to evaluated
Reflek masseter: hard to evaluated
Reflek cornea : + / +
N.VII (Fasialis)
Motorik: facial palsy
m. frontalis : hard to evaluated
m. oblik okuli : hard to evaluated
m. oblik oris : hard to evaluated
taster of 2/3 front tongue : not evaluated
N.VIII (Vestibulokoklearis)
wrist watch : hard to evaluated
whispered voice: hard to evaluated
Tes weber : not evaluated
Tes Rinne : not evaluated
N.IX (Glossofaringeus)
taster 1/3 (back side): not evaluated
sensibilitas faring : hard to evaluated
N.X (Vagus)
the arc of arcus faring : hard to evaluated
(rest |AAH) : hard to evaluated
Reflek swallow/vomit : not evaluated
N.XI (Acsessorius)
Shruging : hard to evaluated
Looked away : hard to evaluated
N.XII (Hipoglossus)
Tongue deviation : hard to evaluated
Fasiculation, Tremor, Atrofi, Ataxia: hard to
evaluated
Neck
Reflek fisiologis :
BPR : +2 | +2
TPR : +2 | +2
KPR : +2 | +2
APR : +2 | +2
Reflek patologis :
Hoffman-tromner : -|-
Babinski : -| -
Chaddock : -|-
Gordon : -|-
Schaefer : - |-
Oppenheim : -|-
Mendel B : -|-
Rossolimo : -|-
Trofi : -|-
Sensibilitas
Eksteroseptif
Pain : hard to evaluated
Temperature : not evaluated
Rasa raba halus : hard to evaluated
Proprioseptif
Rasa sikap : hard to evaluated
Rasa nyeri dalam : hard to evaluated
Fungsi kortikol
Discrimination function : hard to evaluated
Stereognosis : hard to evaluated
Barognosis : hard to evaluated
Abnormal spontan movement : -
Impaired coordination
Tes finger nose : hard to evaluated
Tes pronasi supinasi : hard to evaluated
Tes knee to toe : hard to evaluated
Diffcount GDA 127
1,8/2,1/84/9/3.1 Kalium 3.4
Hct 41,3 Natrium 142
Hb 13,1 Clorida 104
LED 1 83 ↑ SGOT 25
LED 2 93 ↑ SGPT 22
Leukosit 17.000 ↑ Cholesterol 215
Trombosit 240.000 HDL 42,9
Urea 61 ↑ LDL 153,7 ↑
Creatinin 2.7 ↑ TG 178
MCV 90.20
MCH 28.60
MCHC 31.70
RDW 12
Male, 51 yo
Loss of consciousness
Nausea (+)
Vomit (+)
Takipneu
Takikardi
Hipertension
Febris
Laterasisasi sinistra
Leukositosis
Siriraj score +7,1
• Loss of • pons • CVA Bleeding
Diagnosis Topis
Clinical Diagnosis
Etiological Diagnosis
consciousness ICH at Pons
• Nausea (+)
• Vomit (+)
• Hipertension
• Takikardi
• takipneu
• Febris
• Laterasisasi
sinistra
• Leukositosis
• Siriraj score
+7,1
General therapy :
O2 simple mask 4 lpm
Head up 300
DK
IVFD. Assering 1500cc/24jam
Inj. Citicolin 2x250 mg
Inj. Metamizole 3x1g
Inj Ranitidine 2 x 50 mg
Pump Nifedipine 3 mg/jam , target TDS < 160
P.O Tranesamat Acid 3x 500 mg
Loading manitol 200 cc 6x100 cc