CASE PRESENTATION

BY: I Gede Bungas Arisudana

Patient Identity
• Name : Mr. M
• Birth Date : May, 08th 1965
• Age : 52 years old
• Gender : Male
• Address : Central Jakarta
• Nationality : Indonesia
• Religion : Islam
• Date of admission : August 15th 2017
• Date of examination : August 17th 2017
History Taking
• Autoanamnesis from patient on August 18th 2017.

Chief complain:
• Weakness in left Extremity
History of Present Illness
• 1 day before admission:
• Patient complaint of weakness in his left extrimity. The weakness come suddenly after the
patient finishing his shalat. Patient also felt an intense headache before the weakness
happened. Patient also had a slurred speech the same time as his weakness occurred. No
nausea and vomitting occurred neither any loss of consciousness. Patient was brought to
clinic by his wife, and the doctor advise him to take the patient to the hospital

• day of admission:
• Patient still had a complaint of weakness in his left extrimity and still had a slurred speech,
his headache still occurred but the intensity is decreasing
 History of Past Illness
• Hipercholesterol, controlled

• Hypertension, uncontrolled
 Family History
No one has the same complain as patient
Physical Examination
• Date : August 17th 2017

• General Status
• General condition : mild ill

• Awareness : E4V5M6

• Blood Pressure : 170/100

• Pulse : 82 x/min, regular, full, strong.

• Breathing rate : 20x/min

• Temperature : 37oC (per axilla)

Systematic Physical Examination
Head Normocephaly, hair (black, normal distributon, not easily removed) sign of trauma
(-)

Eyes Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- , lacrimation -/-,
sunken eyes -/-, pupils 3mm/3mm isokor, Direct and indirect light response ++/++

Ears Normal shape, no wound, no bleeding, secretion or serumen

Mouth
Lips: dry
Teeth: no caries
Mucous: moist
Tongue: Not dirty
Tonsils: T1/T1, No hyperemia
Pharynx: No hyperemia

Neck Lymph node enlargement (-)

Thorax Symmetric when breathing , no retraction, ictus cordis is not visible
 Inspection:
 Palpation: mass (-)

 Percussion: sonor on left lungs

 Auscultation
Cor : regular S1-S2, murmur (-), gallop (-)
Pulmo: vesicular +/+, Wheezing -/- , Rhonchy -/-

Abdomen :
Inspection : normal

 Palpation : supple, liver and spleen not palpable, tenderness (-)

 Percussion: The entire field of tympanic abdomen, shifting dullness (-)

 Auscultation: bowel sound 12 times/min

Anus Not inspected

Extremities Warm, capillary refill time < 2 second, edema ( - )

Skin Good turgor

 Neurological Status
GCS E4 M6 V5 (15)

Meningeal signs Nuchal rigidity :-

Brudzinski’s sign (I and II) :-
Kernig’s sign :-
Laseque’s sign :-
Nervus Cranialis N. I: -
N. II: pupillary light reflexes +/+
N. III, IV, VI: no ptosis, pupil size 3mm / 3mm, isocoric, no nystagmus
N. V: sensoric: -, Motoric:
N. VII: sensoric: -, Motoric: laterali
N. VIII: -
N. IX: not tested
N. X: -
N. XI: -
N. XII: Hypoglossal nerve examination: deviation to the right, slurred speech +
Motoric examination Muscle strength: upper extremity: 555 / 333, lower extremity: 555/333
Muscle clonus: Patella ( - ), Achilles: ( - )

Reflex physiology Biceps: ++ / ++

Triceps: ++ / ++
Patella: ++ / ++
Achilles: ++ / ++
Pathologic reflex Hoffman – tromner: - / +
Babinski: - / +
Chanddock: - / -
Shcaefer: - / -
Gordon: - / -
Oppenheim: - / -
Laboratory Investigation Hematology (August 15th 2017)

Hematology Results Normal Value

Haemoglobin 13,2 g/dL 13,2 – 17,3 g/dL

Leukocytes 9.18/µL 3,800 – 10,600/µL

Hematocrits 39% 40 – 52 %

Trombocytes 284.000/ µL 150,000 – 440,000/µL

Erythrocytes 4,75 million/µL 4,40 – 5,90 million/µL

Creatinine 1,3 mg/dL < 1,4 mg/dL

Laboratory Investigation Hematology (August 15th 2017)

Hematology Results Normal Value

Calcium 9,3 mg/dL 8,8 – 10,3 mg/dL

Blood Glucose 104 mg/dL 70 – 200 mg/dL

Admitting Diagnosis
• Clinical Diagnosis:
• Hemiparesis sinistra
• Slurred speech
• Headache
• Topical diagnosis:
• Middle Cerebral Artery
• Etiological Diagnosis:
• Stroke Hemmorhagic
• Additional Diagnosis:
• Grade 2 Hypertension
• Dislipidemia
MANAGEMENT (August 15th 2017)
• O2 3 lpm NK
• IVFD Assering / 12 hours
• Manitol 4 x 125 cc/6jam (tap off per day)
• Citicolin 2 x 500 mg
• Candesartan 1 x 8mg
• Amlodipin 1 x 10 mg
• Ranitidin 2 x 1
• Rehabilitation
PROGNOSIS

•Ad Vitam: Bonam

•Ad Fungsionam: Bonam
•Ad Sanasionam: Dubia
 Follow up
• August 16th 2017 – August 20th 2017
 August 16th 2017
S Weakness on left extremity, headache, slurred speech
O General condition: Compos mentis
Blood pressure: 170/100, pulse: 80 bpm, respiratory rate:
20 x/min, temperature: 36,5oC
Motoric: 5555/3333
PN XII and VII central Sinistra

A Intracranial hemmorhage
Grade 2 Hypertension
P - inf Manitol 125 cc/ 6 hours (daily tapp off)
- Aspilet tab 1 x 80 mg
- Inj Citicolin 500 mg/12 hours
- Candesartan tab 1 x 8 mg
- Amlodipine tab 1x 10 mg
- Simvastatin tab 1 x10 mg
 August 17th 2017
S Headache, weakness at left extremity, slurred speech

O General condition: Compos mentis

Blood pressure: 150/100, pulse: 85 bpm, respiratory rate: 20 x/min, temperature: 36,6oC
Motoric: 5555/4444
PN XII and VII central Sinistra
A Intracranial Hemorrhage
Grade 2 Hypertension
P - Inf Manitol 125 cc/ 6 hours (daily tapp off)
- Aspilet tab 1 x 80 mg
- Inj Citicolin 500 mg/12 hours
- Candesartan tab 1 x 8 mg
- Amlodipine tab 1x 10 mg
- Simvastatin tab 1 x10 mg
 August 18th 2017
S Weakness at left extremity, slurred speech

O General condition: Compos mentis

Blood pressure: 120/80, pulse: 80 bpm, respiratory rate: 20 x/min, temperature: 36,5oC
Motoric: 5555/4444
PN XII and VII central Sinistra
A Intracranial Hemorrhage
Hypertension
P - Inf Manitol 125 cc/ 12 hours (daily tapp off)
- Aspilet tab 1 x 1
- Citicolin inj 500 mg/12 hours
- Candesartan tab 1 x 8 mg
- Amlodipine tab 1x 10 mg
- Simvastatin tab 1 x10 mg
- Ranitidine inj 1 amp/12 hours
 August 19th 2017
S Weakness at left extremity

O Disorganized speech
General condition: Compos mentis
Blood pressure: 120/80, pulse: 80 bpm, respiratory rate: 20 x/min, temperature: 36,5oC
Motoric: 5555/4444
PN XII and VII central Sinistra
A Intracranial Hemorrhage

P - Inf Manitol 125 cc/ 12 hours (daily tapp off)

- Aspilet tab 1 x 1
- Citicolin inj 500 mg/12 hours
- Candesartan tab 1 x 8 mg
- Amlodipine tab 1x 10 mg
- Simvastatin tab 1 x10 mg
- Ranitidine inj 1 amp/12 hours
 August 20th 2017
S Weakness at left extremity

O General condition: Compos mentis

Blood pressure: 120/80, pulse: 80 bpm, respiratory rate: 20 x/min, temperature: 36,5oC
Motoric: 5555/4444
PN XII and VII central Sinistra
A Intracranial Hemorrhage

P - Inf Manitol 125 cc/ 12 hours (daily tapp off)

- Aspilet tab 1 x 1
- Citicolin inj 500 mg/12 hours
- Amlodipine tab 1x 10 mg
- Simvastatin tab 1 x10 mg
- Ranitidine inj 1 amp/12 hours
LITERATURE REVIEW
What is Stroke?
• A clinical syndrome consisting of rapidly developing clinical signs
of focal (or global) disturbance of cerebral function lasting more
than 24 hours or leading to death with no apparent cause other
than a vascular origin
(World Health Organization)
Risk Factor
• MODIFIED RISK FACTOR
• High blood pressure
• Diabetes
• Obese
• Smoking
• Dislipidemia
• Heart diseases
• UNMODIFIED RISK FACTOR
• Age
• Gender
Signs and Symptoms
• Sudden weakness
• Paralysis or numbness of the face, arms, legs (especially one side of the body)
• Confusion
• Trouble speaking or understanding speech
• Trouble seeing in one or both eyes
• Problems breathing
• Dizziness, trouble walking, loss of balance coordination and unexplained falls
• Loss of consciousness
• Sudden and severe headache
How to diagnose?
• Siriraj score
• Neurological Examination
• Brain CT Scan
• MRI
• Transcranial doppler Ultrasound
Siriraj Score
Formula:
• (2,5 x Consciousness) + (2 x vomiting) + (2 x
headache) + (0,1 x DBP) – (3 x atheroma) – 12
Interpretation:
• >1: stroke Hemmorhagic
• <-1: Stroke Non Hemorrhagic
• 1: CT Scan or MRI
How to treat?
• O2
• Urin catether
• Nasogastric tube
• Laboratory Examination
• Neuroprotector
• Manitol
• Craniotomy
• Trombolytics
• Antiplatelets
• Anticoagulants
• Medical Rehabilitation
• Clinical Guidelines for Stroke Management 2010, National Stroke Foundation
• Columbia Neurosurgeons, Department of Neurosurgery. Cerebral Ischemia.
• Gibbons, Gary H. 2017. Stroke. National Heart, Heart, Lung and Blood Institute.
• Kanyal, Neema. 2015. The Science of Ischemic Stroke: Pathophysiology &
Pharmacological Treatment.