CASE REPORT A woman, 48 years old, medical record : 818490, went in neurologys ward on February 18 th 2013 with : (autoanamnesis)

Chief Complaint : Weak on the right limb History of Present Illness : Weak on the right limb since 12 hours before hospital admission, occurred suddenly when patient in activity ( getting ready for a shower), patient was found with her family in sitting condition, patient remains conscious, but didnt respond when asked to communicate ( patient couldnt talk and follow the order. Her family said that her mouth twisted to the left and her right limbs movement less active (patient couldnt hold objects with her right hand and couldnt stand up). There is no headache complaint, nausea, vomit, and seizure.

Past Medical History : Patient was known have diabetes mellitus since 3 years ago with uncontrolled treatment. There is no history of hypertension, stroke, and heart disease Patients mother had a stroke There is no family members that have hypertension, diabetes mellitus, and heart disease.

Family History of Disease :

Works History, Social, and Economic : Patient is a housewife and lives with her children Daily activities and exercise less active

Physical Examination General condition Consciousness Blood Pressure Pulse Breath Temperature : Looks ill : Compos mentis aphasia : 140/80 mmHg : 78x/minute : 24x/minute : 37,3oC

Internists status : Eye Head : conjunctiva ( no anemis), sclera (no icteric) : In normal condition

Lymph node : No enlargement in neck, axilla, and inguinal Lung : Inspection Palpation Percussion : Symmetric in right and left lung : Same fremitus in the both of lung : Sonor in the both of lung

Auscultation : Vesicular +/+, rale -/-, wheezing -/Heart : Inspection Palpation : Ictus not visible : Ictus palpable in one finger from medial sinistra claviculas midline in intercostal space V Percussion : margin of heart in normal condition

Auscultation : regular rhythm, no bruit Abdomen : Inspection Palpation Percussion : no mass : hepar and lien are not palpable : tympanic

Auscultation : bowels noise normal

Neurological status : Glasgow Coma Scale Stimulation of Meningeal Sign Stiff neck Brudzinki I Brudzinki II Kernig Test :::::: Compos Mentis Aphasia :-

Increased Intracranial Sign Cranialis Nervis Examination N. I N. II N. III,IV,VI

: Smelling is good : Visus is normal, field of view is normal : Isocor pupil, pupil is round with size 3 mm/3 mm

Light Reflex +/+ Cornea Reflex +/+ No diplopia Free movement in all eyes direction N. V N. VII N. VIII N. IX, X N. XI N. XII Motoric : Cant be examined : Plica nasolabialis in the right side more flat than left side : Cant be examined : Cant be examined : Cant be examined : Cant be examined : with fall test there is lateralization to the right Physiologic reflex : upper limb ++/++, lower limb ++/++ Patological reflex : Sensoric : there is respond with pain stimuli

Otonom function : neurogenic bladder (-) Micturition Defekation Sweat secretion : in normal condition : in normal condition : in normal condition

Other Examination Laboratory Examination : Hb 17 g/dl Hematocrit 52% Leukocyte 10.700/mm3 Trombocyte 179.000/mm3 Glucose level 349 mg/dl Natrium 144 mmol Kalium 3,4 mmol Chloride 115 mmol Ureum 53 Creatinine 0,7 EKG : In normal condition

Gajah Madas Score SSS Aphasia modality

: Stroke infark : Stroke infark : Spontanous talking (-) Repeat word and sentence (-) Comprehension (-) Naming (-) Reading (-) Writing (-)

Clinical Diagnosis

: Dextra hemiparesis with paresis of nerve VII in central type and global aphasia

Topic Diagnosis Etiology Diagnosis

: Cortex cerebri hemisphere sinistra : Tromboembolism of cerebri

Secondary Diagnosis : Diabetes Mellitus Planning of Examination : Clinical Chemistry Laboratory : HDL, LDL, Trigliseride, Ureum, Creatinine, Electrolyte Rontgen of thorax Brain CT Scan without contrast

Theraphy : Intravenous Fluid Drip RL 12 hours/kolf Diet low salt 1900 kkal Aspilet 2 x 80 g Piracetam 4 x 3 g Paracetamol 3 x 500 mg Sliding Scale of insulin based on strokes guideline

Follow Up 20 February 2013 Subjective Objective : Weak on the right limb and global aphasia :

General condition Consciousness Blood Pressure Pulse Breath Temperature Internist status Neurological status

: Looks ill : Compos mentis aphasia : 110/70 mmHg : 100x/minute : 20x/minute : 36,7oC : Margin of heart is bigger than normal :

GCS 15, stimulation of meningeal sign (-), increased intracranial pressure (-) Anisocor pupil with size 3 mm/ 4mm Light reflex +/+, reflex of cornea +/+ Vomit reflex (+) Motoric : lateralization to the right side Sensoric : Respond with pain stimuli Physiology reflex ++/++/++/++ Pathology reflex -/-/-/+ : Tromboembolism cerebri : Rontgen of thorax and brain CT scan without contrast :

Assesment Planning Theraphy Head elevation 300

Intravenous Fluid Drip RL 12 hours/kolf Diet low salt 1900 kkal Fluid balance Aspilet 2 x 80 g Piracetam 4 x 3 g Paracetamol 3 x 500 mg Sliding Scale of insulin based on strokes guideline

21 February 2013 Subjective Objective : Weak on the right limb and global aphasia :

General condition Consciousness Blood Pressure Pulse Breath Temperature Internist status Neurological status -

: Looks ill : Compos mentis aphasia : 110/60 mmHg : 104x/minute : 22x/minute : 37,4oC : cardiomegaly :

GCS E3M5VAphasia, stimulation of meningeal sign (-), increased intracranial pressure (-)

Anisocor pupil with size 3 mm/ 4mm Light reflex +/+, reflex of cornea +/+ Vomit reflex (+) Motoric : lateralization to the right side Sensoric : Respond with pain stimuli Physiology reflex ++/++/++/++ Pathology reflex -/-/-/+ : Tromboembolism cerebri DM type 2 Dislipidemia

Assesment

Planning Theraphy Head elevation 300

::

Intravenous Fluid Drip RL 8 hours/kolf Diet low salt 1900 kkal and low cholesterol Fluid balance Aspilet 2 x 80 g Piracetam 4 x 3 g Paracetamol 3 x 500 mg Sliding Scale of insulin based on strokes guideline Simvastatin 1 x 40 mg

22 February 2013 Subjective Objective General condition Consciousness Blood Pressure Pulse Breath Temperature Internist status Neurological status : Weak on the right limb and cant talking, diarrhea (+) : : Looks ill : Compos mentis aphasia : 110/80 mmHg : 80x/minute : 22x/minute : 37oC : cardiomegaly :

GCS E3M5VAphasia, stimulation of meningeal sign (-), increased intracranial pressure (-)

Anisocor pupil with size 3 mm/ 4mm Light reflex +/+, reflex of cornea +/+ Vomit reflex (+) Motoric : lateralization to the right side Sensoric : Respond with pain stimuli Physiology reflex ++/++/++/++ Pathology reflex -/-/-/+ : Tromboembolism cerebri DM type 2 Dislipidemia

Assesment

Planning Theraphy Head elevation 300

::

Intravenous Fluid Drip RL 8 hours/kolf Diet low salt 1900 kkal and low cholesterol Fluid balance Aspilet 2 x 80 g Piracetam 4 x 3 g

Paracetamol 3 x 500 mg Sliding Scale of insulin based on strokes guideline Simvastatin 1 x 40 mg Loperamide 3 x 1

23 February 2013 Subjective Objective General condition Consciousness Blood Pressure Pulse Breath Temperature Internist status Neurological status : Weak on the right limb and cant talking, diarrhea (+) : : Looks ill : Compos mentis aphasia : 160/110 mmHg : 88x/minute : 21x/minute : 36,8oC : cardiomegaly and rale +/+ :

GCS E3M5VAphasia, stimulation of meningeal sign (-), increased intracranial pressure (-)

Anisocor pupil with size 3 mm/ 4mm Light reflex +/+, reflex of cornea +/+ Vomit reflex (+) Motoric : lateralization to the right side Sensoric : Respond with pain stimuli Physiology reflex ++/++/++/++ Pathology reflex -/-/-/+ : Tromboembolism cerebri DM type 2 Dislipidemia Duplex Tuberculosis

Assesment

Planning Theraphy

: EKG, BTA I,II,III examination, consul to eye department :

Head elevation 300 Intravenous Fluid Drip RL 8 hours/kolf Diet low salt 1900 kkal and low cholesterol Fluid balance Aspilet 2 x 80 g Piracetam 4 x 3 g Paracetamol 3 x 500 mg Simvastatin 1 x 40 mg Loperamide 3 x 1 Cotrimoxazole 2 x 960 mg

26 February 2013 Subjective Objective General condition Consciousness Blood Pressure Pulse Breath Temperature Internist status Neurological status : Weak on the right limb and cant talking, fever (+) : : Looks ill : Compos mentis aphasia : 110/70 mmHg : 88x/minute : 21x/minute : 37,5oC : cardiomegaly and rale +/+ :

GCS E2M4VAphasia, stimulation of meningeal sign (-), increased intracranial pressure (-)

Anisocor pupil with size 3 mm/ 4mm Light reflex +/+, reflex of cornea +/+ Vomit reflex (+) Motoric : lateralization to the right side Sensoric : Respond with pain stimuli Physiology reflex ++/++/++/++ Pathology reflex -/-/-/+

Laboratory test : Na/K/Cl 130/2,5/104 : Tromboembolism cerebri DM type 2 Dislipidemia Duplex Tuberculosis

Assesment

Planning Theraphy Head elevation 300

: EKG, BTA I,II,III examination, consul to eye department :

Intravenous Fluid Drip RL 8 hours/kolf Diet low salt 1900 kkal and low cholesterol Fluid balance Aspilet 2 x 80 g Piracetam 4 x 3 g Paracetamol 3 x 500 mg Simvastatin 1 x 40 mg Loperamide 3 x 1 Mannitol 20% tapering off KCL 2 fl in 500 cc RL 8 hours/kolf

27 February 2013 Subjective Objective General condition Consciousness Blood Pressure Pulse Breath Temperature Internist status Neurological status : Weak on the right limb and cant talking : : Looks ill : Compos mentis aphasia : 110/70 mmHg : 88x/minute : 21x/minute : 37,5oC : cardiomegaly and rale +/+ :

GCS E2M4VAphasia, stimulation of meningeal sign (-), increased intracranial pressure

(-) Anisocor pupil with size 3 mm/ 4mm Light reflex +/+, reflex of cornea +/+ Vomit reflex (+) Motoric : lateralization to the right side Sensoric : Respond with pain stimuli Physiology reflex ++/++/++/++ Pathology reflex -/-/-/+ : Tromboembolism cerebri DM type 2 Dislipidemia Duplex Tuberculosis Planning Theraphy Head elevation 300 Intravenous Fluid Drip RL 8 hours/kolf Diet low salt 1900 kkal and low cholesterol Fluid balance Aspilet 2 x 80 g Piracetam 4 x 3 g Paracetamol 3 x 500 mg Simvastatin 1 x 40 mg : BTA I,II,III examination, consul to eye department :

Assesment

28 February 2013 Subjective Objective General condition Consciousness Blood Pressure Pulse Breath : Weak on the right limb and cant talking : : Looks ill : Compos mentis aphasia : 110/70 mmHg : 88x/minute : 21x/minute

Temperature Internist status Neurological status -

: 37,5oC : cardiomegaly and rale +/+ :

GCS E2M4VAphasia, stimulation of meningeal sign (-), increased intracranial pressure (-)

Anisocor pupil with size 3 mm/ 4mm Light reflex +/+, reflex of cornea +/+ Vomit reflex (+) Motoric : lateralization to the right side Sensoric : Respond with pain stimuli Physiology reflex ++/++/++/++ Pathology reflex -/-/-/+ : Tromboembolism cerebri DM type 2 Dislipidemia Duplex Tuberculosis

Assesment

Planning Theraphy Head elevation 300

: BTA I,II,III examination, consul to eye department :

Intravenous Fluid Drip RL 8 hours/kolf Diet low salt 1900 kkal and low cholesterol Fluid balance Aspilet 2 x 80 g Piracetam 4 x 3 g Paracetamol 3 x 500 mg Simvastatin 1 x 40 mg Loperamid 3 x 1

1 March 2013 Subjective Objective : Weak on the right limb and cant talking :

General condition Consciousness Blood Pressure Pulse Breath Temperature Internist status Neurological status -

: Looks ill : Compos mentis aphasia : 110/70 mmHg : 88x/minute : 21x/minute : 37,5oC : cardiomegaly and rale +/+ :

GCS E2M4VAphasia, stimulation of meningeal sign (-), increased intracranial pressure (-)

Anisocor pupil with size 3 mm/ 4mm Light reflex +/+, reflex of cornea +/+ Vomit reflex (+) Motoric : lateralization to the right side Sensoric : Respond with pain stimuli Physiology reflex ++/++/++/++ Pathology reflex -/-/-/: Tromboembolism cerebri DM type 2 Dislipidemia Duplex Tuberculosis

Assesment

Planning Theraphy Head elevation 300

::

Intravenous Fluid Drip RL 12 hours/kolf Diet low salt 1900 kkal and low cholesterol Fluid balance Aspilet 2 x 80 g Piracetam 4 x 3 g Paracetamol 3 x 500 mg Simvastatin 1 x 40 mg

Loperamid 3 x 1 Levemir 1 x

4 March 2013 Subjective Objective General condition Consciousness Blood Pressure Pulse Breath Temperature Internist status Neurological status : Weak on the right limb and cant talking : : Looks ill : Compos mentis aphasia : 130/80 mmHg : 80x/minute : 20x/minute : 37,1oC : cardiomegaly and rale +/+ :

GCS E2M4VAphasia, stimulation of meningeal sign (-), increased intracranial pressure (-)

Anisocor pupil with size 3 mm/ 4mm Light reflex +/+, reflex of cornea +/+ Vomit reflex (+) Motoric : lateralization to the right side Sensoric : Respond with pain stimuli Physiology reflex ++/++/++/++ Pathology reflex -/-/-/: Tromboembolism cerebri DM type 2 Dislipidemia Duplex Tuberculosis

Assesment

Planning Theraphy Head elevation 30

0

::

Intravenous Fluid Drip RL 12 hours/kolf

Diet low salt 1900 kkal and low cholesterol Fluid balance Aspilet 2 x 80 g Piracetam 4 x 3 g Simvastatin 1 x 40 mg Novorapid Levemir 1x 10 IU