CHAPTER I

INTRODUCTION

1.1. Background
Cardiovascular system are the ten block in the 3rd semester competency-based
curriculum in medical faculty of Muhammadiyah Palembang University. Learning in
this block is very important to learn in medical faculty of Muhammadiyah Palembang
University.
On this occasion, a case study tutorial of scenario a which presents cases that
related to the Cardiovascular system. Mr. R, A 60 years old, brought to ER with chief
complain sudden onset of weekness of right side since 3 hours ago. On examination, he
had a slurred speech, right facial drop, aphasia, right hemiplegy, and right homonous
hemianopsia. Mr. R is known as heavy smoker and has history of hypertention and
cardiac disease since 10 years ago. There is no family history of this complain and this
is first time for him.

1.2. Purpose and advantages

1. As a group task report which is a competency-based curriculum learning system in
the medical faculty of Muhammadiyah Palembang.
2. Can solve cases given in a scenario by group analysis and learning methods.
3. The purpose of the tutorial learning method is reached.

1
 CHAPTER II
DISCUSSION

2.1. Data Tutorial

Lecturer : dr. Ratih Pratiwi, Sp.OG
Moderator : Arrum Asharmi
Secretary : Tia Nurul Hidayah
Minutes : Adliah Zahira Padya Sinta
Time : Monday, December 11, 2017. 01.00 – 03.00 PM
Wednesday, December 13, 2017. 01.00 – 03.00 PM

2.2. Rules
1. Switch the phone off or in silence.
2. Raise your hand when going to argument
3. Permission when going out of the room
4. Relax and watch as the tutor gives directions
5. During the tutorial takes care of attitude and speech

2.3. Scenario
Mr. R, A 60 years old, brought to ER with chief complain sudden onset of
weekness of right side since 3 hours ago. On examination, he had a slurred speech, right
facial drop, aphasia, right hemiplegy, and right homonous hemianopsia. Mr. R is known
as heavy smoker and has history of hypertension and cardiac disease since 10 years ago.
There is no family history of this complain and this is first time for him.
Physical examination :
General situation : GCS : E4 M6 Vx
Vital sign : BP 170/90 mmHg, HR 112x/minutes, irregular; RR 24x/minutes; T 37,2o C.
- Head : Conjunctiva anemis (-), icteria sclera (-), pupils isokor, flat right
plicanasolabialis, right tongue deviation.
- Thorax : symmetrial, retraction (-)
- Cor : left cor enlargement, HR 112 x/minutes, irreguler
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 - Pulmo : normal
- Abdomen : normal
- Superior extremity:
Right : limited movement, muscle strength 2, physiology reflex increase, pathology
reflex (+)
Left : normal
- Inferior extremity
Right : limited movement, muscle strength 2, physiology reflex increase, Babinsky
Reflex (+)
Left : normal

2.4. Term Classification

1. Weakness : Disorder of motoric function on the body that
caused by lession on nerve muscle
2. Aphasia : Defect or loss of the power of expression by
speech, writing, or sign or of comprehending
3. Slurred Speech : Inability to speak cleary
4. Homonous hemianopsia : Visual field loss on the same side of both eyes
5. Hemiplegy : Paralyze on one side of the body
6. Facial drop : Sagging of the face caused by loss of facial
muscle tone. This is usually caused by an
impairment of nerve function that supply the
facial muscles, particularly involving the facial
nerve.
7. Hypertension : Also known as high blood pressure (HBP), is a
long-term medical condition in which the blood
pressure in the arteries is persistently elevated.
8. Tongue Deviation : Tongue weakness caused the tongue to deviate
toward the weakside
9. Babinsky Reflex : Obtained by stimulating the outside of the sole of
the foot, causing extension of the big toe while
fanning the other toes

2.5. Problem Identification

3
 1. Mr. R, A 60 years old, brought to ER with chief complain sudden onset of
weekness of right side since 3 hours ago. On examination, he had a slurred speech,
right facial drop, aphasia, right hemiplegy, and right homonous hemianopsia.
2. Mr. R is known as heavy smoker and has history of hypertension and cardiac
disease since 10 years ago. There is no family history of this complain and this is
first time for him.
3. Physical examination
General situation : GCS : E4 M6 Vx
Vital sign : BP 170/90 mmHg, HR 112x/minutes, irregular; RR 24x/minutes; T
37,2o C.
- Head : Conjunctiva anemis (-), icteria sclera (-), pupils isokor, flat right
plicanasolabialis, right tongue devition.
- Thorax : symmetrial, retraction (-)
- Cor : left cor enlargement, HR 112 x/minutes, irreguler
- Pulmo : normal
- Abdomen : normal
- Superior extremity :
Right : limited movement, muscle strength 2, physiology reflex increase,
pathology reflex (+)
Left : normal
- Inferior extremity :
Right : limited movement, muscle strength 2, physiology reflex increase,
Babinsky Reflex (+)
Left : normal

2.6. Problem Analyze

1. Mr. R, A 60 years old, brought to ER with chief complain sudden
onset of weekness of right side since 3 hours ago. On examination, he had a slurred

4
speech, right facial drop, aphasia, right hemiplegy, and right homonous
hemianopsia.
a. What is the anatomy and physiology of head ?
Answer :
Functionally, the brain can be divided into sections. Each part has a
function and coordinate with other organs. The main functions of these parts of
the brain are described in the following table:
Brain Section Main Function
Cerebrum cortex 1. Sensory perception
2. Control volunteer movement
3. Language skills
4. Nature and personality
5. Thinking, memory, decision making, creativity, and
self-awareness
Basal ganglia 1. Inhibition of muscle tone
2. Coordination of repetitive and slow movements
3. Unnecessary movement suppression
Thalamus 1. Station of sensory input relay
2. Awareness of the sensation
3. Awareness 4. Role in motor control
Hypothalamus 1. Regulation of homeostatic functions such as
temperature control, thirst, urinary excretion, and
hunger
2. Liaison between the nervous system and endocrine
system
3. Regulatory emotions and patterns of nature
Cerebellum 1. Balance
2. Regulation of muscle tone
3. Coordination of movement
Brain stem 1. Place out of the cranial nerve
(mesenchepalon, 2. Respiratory, cardiovascular, and digestive center
pons, and medulla 3. Regulation of muscle reflex associated with

5
 oblongata) development and posture
4. Receiver and synthesis of synaptic input of the
spinal cord, activation of the cerebrum cortex
5. Sleep cycle regulator
  (Sherwood, 2011)
In general, there are 4 lobes in the brain of the frontal lobe, parietalis,
temporalis, and occipital. The table below describes the cerebral cortex
function of each lobe.
Lobes Location Function
Frontalis Anterior frontal 1. Voluntary motor activity on the opposite
Sulcus side of the body (located in the gyrus
presentralis).
2. As a motor area of speech is often called
broca area (located in the inferior frontal
gyrus).
3. Elaboration of the mind
Parietalis In central sulcus Responsible in the sensory areas of
receiving and mengintreprestasikan
sensation of pain, touch, pressure from the
surface of the body (located in
postsentralis gyrus).
Temporalis On the lateral side Receiving and interpreting sounds. The
wernicke area acts as an area of
understanding the receptive aphasia
language (association).
Occipitalis Posterior occipital Primary visual area that serves to receive
information from the retina of the eye.
Visual association areas that serve to
interpret the visual experience.

Disorders of the frontal lobes can cause symptoms:

• Monoplegi or hemiplegi

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• Motor dysphasia (expressive dysphasia)
• Personality changes with antisocial behavior, loss of initiative, akinetic
mutism urine incontinence et alvi.
Disorders of the parietal lobe may cause:
• Position disturbance
• Sensory impairment of passive movement
• Subtle flavor disorders
• Two point discrimination disturbance
• Astereognosia (disorder recognizes form through palpability)
• Receptive or sensory aphasia
• Abnormalities on the dominant side will be obtained Gerstmann Syndrome
with symptoms: can not distinguish between left and right extremities,
difficulty recognizing fingers (finger agnosia), counting disorders
(akalkuli), writing disorders (agrafia).
• Disorders of the non-dominant side will be symptomatic: anosognosia (no
recognition of the contralateral extremity and not recognizing its paralysis),
apraxia (difficulty performing complex actions, such as wearing shirts,
tacking shoes), geographical agnosia (no location locale), constructive
apraxia unable to mimic geometric images).
Disorders of the temporal lobes may cause:
• Sensory deafness
• Hearing loss of rhythm (amusia)
• Learning and memory disorders
• Abnormalities in the limbic system: olfaktorik hallucinations, aggressive
and antisocial behavior, short-term memory disorders
• Abnormalities in the dominant hemisphere will result in Wernicke
dysphasia or receptive dysphasia.
Disorders of the occipital lobe may cause:
• Field disturbance
• cortical blind if abnormalities in the striata cortex (area17)

7
• Interference visual interpretation if damage in the cortex striata and
parastriata

Brain layer
The brain is wrapped by 3 membranes (meninges), namely:
Duramater:
The endosteal layer  periosteum which covers the inner surface of the skull
bone.
The meningeal layer  (true duramater) is a solid and powerful fibrous
membrane that encloses the brain.
Arachnoideamater  fine impermeable membrane covering the brain
Piamater  vascular membrane tightly wrapped around the brain, covering
gyri and entering into the deepest sulci.

The brain nerve

1) N.olfactorius (sensory)
2) N.opticus (sensory)
3) N.oculomotorius (motor)
4) N.trochlearis (motor)
5) N.trigemenus (motor and sensory)
6) N.abducens (motor)

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 7) N.facialis (motor and sensory)
8) N.vestibulcochlearis (sensory)
9) N.glossopharyngeus (motor and sensory)
10) N.vagus (motor and sensory)
11) N.acessorius (motorist)
12) N.hypoglossus (motorist)

Tractus Pyramidalis
Skeletal muscles and neuron neurons make up the neuromuscular
volunteer arrangement, the system that takes care of it as well as exercises a
voluntary movement. The anatomic system consists of upper motoneuron,
lower motoneuron, the link between nerve elements and muscle elements, and
skeletal muscle.

9
 Muscle movements throughout the body parts can be mapped to the entire
motor cortex region of the contralateral contralateral precentral gyrus, the map
known as the motor homunculus. Through the axon motor neuron cortex
contacts the neurons that form the motor nucleus of the cranial nerve and
motoneuron in the anterior horn of the spinal cord. These axons constitute the
corticobulal and corticospinal pathways. As their compact nerve bundles
descend from the motoric cortex and at the thalamus level and their basal
ganglia lie between the two buildings, this is known as the internal capsula.
Somatotropic arrangement that has been found in the motor cortex
(homunculus), rediscovered in the internal capsule region. At the mesensefalon
level, the fibers gather in the middle of the cerebral peduncle, then continue
into the pons, after passing through the pontices of corticobulbal-corticospinal
fibers passing through the pyramic building (the ventral medulla oblongata),
along the brain stem, the corticobulal fibers leave their territory. Furthermore

10
 on the boundary between the medulla oblongata and the spinal cord, most
corticospinal fibers crosses on the decussatio pyramidalis.

Then the corticospinal fibers leave the spinal cord at the anterior horn,
synchronized with the lower motoneuron until it reaches the neuromuscular
junction and provides innervation to the skeletal muscle. (Snell, 2012)

b. What is the meaning sudden onset of weekness of right side since 3 hours ago ?
Answer :
It’s mean damaged cortex motoric primer which one side cerebri. In this
case hemisfer sinistra. 3 hours ago means the complain was acute

c. How is the pathophysiology of weekness of right side ?

11
 Answer :
Atherosclerotic plaque in one more arterie

Activating blood clooting mechanism

Produce clot and inhibiting blood flow in artery

Loss of brain function acutely in a localized area

Obstruction at a cerebri media in the left side of the brain

Loss of function of the motor reguler area

Spastic paralysis in all/half apposite side of body

Weakness of the half right side of body

(Robbins, 2015)

d. What is the meaning he had a slurred speeach, right facial drop, aphasia, right
hemiplegy and right homonous hemianopsia ?
Answer :
The meaning a slurred speach,right facial drop,aphasia, right hemiplegy,
and right homonous hemianopksi characteristic is of stroke

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e. How is the pathophysiology of slurred speech slurred speeach and right facial
drop ?
Answer :
The presence of cerebral infarction causes media cerebral artery dysfunction
in upper motor neurons resulting in lesions in the cerebral sinistra in the
pyramidal tracts located in the frontal lobes and towards the corticobulary tract
and on the seven nerves located in the pons resulting in facial drop and twelve
nerves in the medulla oblongata causing tongue deviation resulting in slurred
speech (Bruno, 2010).
Dysfunction of cerebri media artery  Damage jaras motoric (UMN) 
The interruption of cortex piramidalis  Lession at brain stem  Pons 
Damage nervus VII  Right facial drop (Price and Wilson, 2015).

f. What is the relation between age and gender with the main problem?
Answer :
 Being age 55 or older.
 Gender — Men have a higher risk of stroke than women. Women are
usually older when they have strokes, and they’re more likely to die of
strokes than are men.
(Fitriyani, 2012)

g. How is the pathophysiology of aphasia and kind of aphasia ?

Answer :
Risk factors causing cerebral infarction such as smoking and hypertension
cause endothelial dysfunction resulting in atherosclerosis where blood clot
formation occurs (thrombus) then thrombus loosens in the blood vessels and
clogs the brain causing the supply of nutrients and oxygen to decrease causing
cerebral infarction, in cerebral infarction medial cerebral artery dysfunction of
the upper motor neurons causes lesions in the cerebral sinistra in the pyramidal
tract and on the brocca area resulting in aphasia (Hinkle, 2010).

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Type of aphasia
A stroke that affects the left side of the brain may lead to aphasia, a
language impairment that makes it difficult to use language in those ways.
Aphasia can have tragic consequences:
People with aphasia:
 May be disrupted in their ability to use language in ordinary
circumstances.
 May have difficulty communicating in daily activities.
 May have difficulty communicating at home, in social situations, or at
work.
 May feel isolated.
Scientists and clinicians who study how language is stored in the brain
have learned that different aspects of language are located in different parts of
the left hemisphere. For example, areas in the back portions allow us to
understand words. When a stroke affects this posterior or back part of the left
hemisphere, people can have great difficulty understanding what they hear or
read.
1) Wernicke's Aphasia (receptive
People with serious comprehension difficulties have what is called
Wernicke’s aphasia and:
 Often say many words that don’t make sense.
 May fail to realize they are saying the wrong words; for instance, they
might call a fork a “gleeble.”
 May string together a series of meaningless words that sound like a
sentence but don’t make sense.
 Have challenges because our dictionary of words is shelved in a
similar region of the left hemisphere, near the area used for
understanding words.

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 2) Broca's Aphasia (expressive)
When a stroke injures the frontal regions of the left hemisphere, different
kinds of language problems can occur. This part of the brain is important
for putting words together to form complete sentences. Injury to the left
frontal area can lead to what is called Broca’s aphasia. Survivors with
Broca's aphasia:
 Can have great difficulty forming complete sentences.
 May get out some basic words to get their message across, but leave
out words like “is” or “the.”
 Often say something that doesn’t resemble a sentence.
 Can have trouble understanding sentences.
 Can make mistakes in following directions like “left, right, under, and
after.”
3) Global Aphasia
When a stroke affects an e xtensive portion of the front and back regions of
the left hemisphere, the result may be global aphasia. Survivors with
global aphasia:
 May have great difficulty in understanding words and sentences.
 May have great difficulty in forming words and sentences.
 May understand some words.
 Get out a few words at a time.
 Have severe difficulties that prevent them from effectively
communicating.
(Edward, 2017)

h. How is the pathophysiology of right hemiplegy and right homonous

hemianopsia ?
Answer :
Right hemiplegy
Risk factors (smoker, hypertension)AtheroscleroticThrombosis of
cerebral blood vesselOcclusion of cerebral blood vesselCerebral
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 ischemicInfract of cerebralLession on left corticospinal tractRight
hemiplegy
Hemianopsia
Risk factors (smoker, hypertension)AtheroscleroticThrombosis of
cerebral blood vesselOcclusion of cerebral blood vesselCerebral
ischemicInfract of cerebralLession on the left optics tractRight
homonous hemianopsia
(Price, 2015)

i. What is the possibility etiology in this case ?

Answer :
The most common cause of stroke is the sudden occlusion of a blood vessel by
a thrombus or embolism, resulting in an almost immediate loss of oxygen and
glucose to the cerebral tissue.
 Cerebral thrombosis refers to a thrombus (blood clot) that develops at the
clogged part of the vessel.
A thrombotic stroke occurs when a blood clot (thrombus) forms in one of
the arteries that supply blood to your brain. A clot may be caused by fatty
deposits (plaque) that build up in arteries and cause reduced blood flow
(atherosclerosis) or other artery conditions.
• Cerebral embolism refers generally to a blood clot that forms at another
location in the circulatory system, usually the heart and large arteries of the
upper chest and neck. A portion of the blood clot breaks loose, enters the
bloodstream and travels through the brain's blood vessels until it reaches
vessels too small to let it pass. A second important cause of embolism is an
irregular heartbeat, known as atrial fibrillation. It creates conditions where
clots can form in the heart, dislodge and travel to the brain.
In an embolic stroke, a blood clot or plaque fragment forms somewhere in
the body (usually the heart) and travels to the brain. Once in the brain, the
clot travels to a blood vessel small enough to block its passage. The clot

16
 lodges there, blocking the blood vessel and causing a stroke. (Isselbacher
dkk. 2012)

2. Mr. R is known as heavy smoker and has history of hypertention and

cardiac disease since 10 years ago. There is no family history of this complain and
this is first time for him.
a. What is the relation between heavy smoker and has history of hypertention and
cardiac disease and the complain this case ?
Answer :
Smoking harms almost every tissue and organ in the body, including your
heart and blood vessels. Smoking also harms nonsmokers who are exposed to
second-hand smoke .If you smoke, you have good reason to worry about its
effect on your health, your loved ones and others. Deciding to quit is a big step,
and following through is just as important. Quitting smoking isn’t easy, but
others have done it, and you can too. Recent studies confirm that cigarette
smoking is another crucial risk factor for R’s symptoms. The nicotine and
carbon monoxide in cigarette smoking can greatly increase the risk of stroke.
Smoking can lead to increased levels of nicotine in the blood resulting in lesions
in the blood vessel endothelial and cause blood clotting and then formed platelet
factors to form thrombus and then the proliferation of smooth muscle and fat
accumulation in blood vessel walls. If the mechanism occurs continuously it
will form abnormal thrombus that trigger the occurrence of atherosclerosis so
that blood vessels will narrow (Maas, 2011).
Hypertension will make the cerebral blood vessels contribute. When blood
pressure rises high enough and occurs over the years it will cause hyalinization
of the cerebral blood vessel lining that causes blood flow to the brain to
decrease so that the supply of oxygen and nutrients is also automatically
reduced. High blood pressure (Hypertension) is a symptomless “silent killer”
that quietly damage blood vessels and lead to serious health threats.
Hypertension is the leading cause of stroke and the most significant controllable
risk factor for stroke (Maas, 2011).
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 R also has history of cardiac disease. If you have cardiac disease manage
related conditions and work with your healthcare provider. People who have
cardiac disease are at high risk of stroke than people who have healthy hearts.
Dilated cardiomyopathy (an enlarged heart), heart valve disease and some types
of congenital heart defects can also raise the risk of stroke. Cardiac disease that
is possible in this case is Heart Disease Hypertension is a term used to describe
overall heart disease caused by increased blood pressure either directly or
indirectly from left ventricular hypertrophy, arrhythmia, coronary heart, coronis
heart. For the third connection the above problem is a risk factor for the
occurrence of symptoms of stroke that can be controlled (Maas, 2011).

b. What isi the meaning of known as heavy smoker and has history of hypertention
and cardiac disease since 10 years ago ?
Answer :
The major or more common risk factors for cerebral ischemia and
infraction include family history, hypertension, smoking to bacco, DM, higher
body mass index, an other risk factors for the development of atherosclerosis
such as hypercholseterolemia. Cardiac disease include atrial fibrillation and
myocardial infraction risk factor of stroke too. (Bathala, 2013)

c. What are risk factors of this case ?

Answer :
Lifestyle risk factors
 Being overweight or obese
 Physical inactivity
 Heavy or binge drinking
 Use of illicit drugs such as cocaine and methamphetamines
Medical risk factors
 High blood pressure — the risk of stroke begins to increase at blood
pressure readings higher than 120/80 millimeters of mercury (mm Hg). Your

18
 doctor will help you decide on a target blood pressure based on your age,
whether you have diabetes and other factors.
 Cigarette smoking or exposure to secondhand smoke.
 High cholesterol.
 Diabetes.
 Obstructive sleep apnea — a sleep disorder in which the oxygen level
intermittently drops during the night.
 Cardiovascular disease, including heart failure, heart defects, heart infection
or abnormal heart rhythm.
Other factors associated with a higher risk of stroke include:
 Personal or family history of stroke, heart attack or transient ischemic
attack.
 Being age 55 or older.
 Race — African-Americans have a higher risk of stroke than do people of
other races.
 Gender — Men have a higher risk of stroke than women. Women are
usually older when they have strokes, and they're more likely to die of
strokes than are men. Also, they may have some risk from some birth
control pills or hormone therapies that include estrogen, as well as from
pregnancy and childbirth.
(Kanyal, 2015)

d. What is the meaning no familly history of this complain and this is first time for
him ?
Answer :
It’s mean the complaint is not because genetic and this is not a recurring
attack and ease the diagnosis of the complaint

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e. What is the possibility disease in this case ?
1) Hemorrhagic Stroke
This type of stroke takes place when a weakened blood vessel in the
brain ruptures. A hemorrhage, or bleeding from the blood vessel, occurs
suddenly. The force of blood that escapes from the blood vessel can also
damage surrounding brain tissue. Hemorrhagic stroke is the most serious kind
of stroke. About 13% of all strokes are hemorrhagic. There are two types of
hemorrhagic strokes: intracerebral and subarachnoid. Intracerebral
hemorrhages are more common and occur when a blood vessel in the deep
tissue of the brain ruptures. Subarachnoid hemorrhages usually occur when
an aneurysm (a blood-filled pouch ballooned out from an artery) ruptures and
bleeds into the space between the brain and the skull. This type of
hemorrhagic stroke is most often caused by high blood pressure.

2) Non Hemorrhagic Stroke / Ischemic strokes

This type of stroke occurs when a blood vessel in the brain develops a
clot and cuts off the blood supply to the brain. A blood clot that forms in a
blood vessel in the brain is called a “thrombus.” A blood clot that forms in
another part of the body, such as the neck or lining of the heart, and travels to
the brain is called an “embolus.” Blood clots often result from a condition
called “atherosclerosis,” the build-up of plaque with fatty deposits within
blood vessel walls. About 87% of all strokes are ischemic. Treatment for

20
ischemic strokes depends on how quickly after the symptoms start the stroke
victim arrives at the hospital. In eligible patients, a medication called tPA
(tissue plasminogen activator) may be given. This medication works to
dissolve the clot and help restore blood flow. In other patients, a stroke
specialist may recommend a mechanical thrombectomy. This is where a
specialized doctor threads a catheter through an artery in the groin up through
the body to the brain and uses a clot retrieval device to grab the clot and pull
it out.
There are two main types of ischemic stroke:
 Thrombotic: This is the most common type.

Over time, fatty deposits (plaque) attach inside the artery walls. The
plaque may narrow or close the artery, preventing normal blood to flow
to the brain. Another type of thrombotic stroke occurs deep in the brain.
It involves smaller vessels and causes damage to small areas of brain
tissue. This type is called lacunar. The location of the lacunar stroke
determines how extensive the stroke symptoms will be.
 Embolic:
This occurs when a small blood clot breaks off from a blood vessel in the
heart or one of the larger blood vessels leading to the brain. This clot
travels in the bloodstream to the brain until it becomes stuck and blocks a
blood vessel. In more severe strokes, the large cerebral blood vessels, the
21
 carotid arteries or the vertebral arteries can be blocked. This blockage
may result in permanent injury to the large area of the brain. This type of
stroke often causes more serious problems due to widespread brain
damage. This damage can cause swelling in the brain, which may lead to
more injury and, sometimes, death.

3) Transient ischemic attack (TIA)

A TIA should be treated as seriously as a stroke. A TIA has the same
symptoms as a stroke, but they only last several minutes, or up to 24 hours.
Unlike a stroke, a TIA does not kill the brain cells, so there is no lasting
damage to the brain. A TIA is considered a serious warning sign of stroke.
About 1 in 3 people who have a TIA will go on to have a stroke.

22
 f. How is the patophysiology hypertension ?
Answer :
Various factors causing hypertension → blood vessel response to
vasoconstriction stimulation → improve the sympathetic nervous system →
vasoconstriction of blood vessels → decreased blood flow to the kidney →
renin release → renin stimulates formation of angiotensin I → then converted
to angiotensin II (assisted by enzyme ACE) → stimulates aldosterone secretion
→ aldosterone reduces NaCl excretion by reabsorption → NaCl increases →
exacellular fluid volume → increased blood volume → blood pressure
increases (Price and Wilson, 2015).

3. Physical examination :
Vital sign : BP 170/90 mmHg, HR 112x/minutes, irregular; RR 24x/minutes; T
37,2o C.
- Head : Conjunctiva anemis (-), icteria sclera (-), pupils isokor, flat right
plicanasolabialis, right tongue devition.
- Thorax ; symmetrial, retraction (-)
- Cor : left cor enlargement, HR 112 x/minutes, irreguler
- Pulmo : normal
- Abdomen : normal
- Superior extremity:
Right : limited movement, muscle strength 2, physiology reflex increase,
pathology reflex (+)
Left : normal
- Inferior extremity
Right : limited movement, muscle strength 2, physiology reflex increase,
Babinsky
Reflex (+)
Left : normal

23
a. How is the interpretation of physical examination?
Answer :
In physiological state Interpretation
Verbal (can not be
GCS: E4 M6 Vx GCS : E4 M6 V5
assessed)
Systolic pressure 100-
BP 170/90 mmHg 120 mmHg and diastolic Hypertension stage II
pressure 60-80 mmHg
HR 112x/minutes, Pulse palpable 60-100 x /
Tachycardia
irreguler minutes

Head : flat right There are not

plicanasolabialis, right plicanasolabialis and Abnormal
tongue deviation tongue deviation

Cor : left cor Nothing enlargment in

Abnormal
enlargment organ

b. How is the abnormal mechanism of physical examination ?

Answer :
Various factors causing hypertension → blood vessel response to
vasoconstriction stimulation → improve the sympathetic nervous system →
vasoconstriction of blood vessels → decreased blood flow to the kidney →
renin release → renin stimulates formation of angiotensin I → then converted to
angiotensin II (assisted by enzyme ACE) → stimulates aldosterone secretion →
aldosterone reduces NaCl excretion by reabsorption → NaCl increases →
exacellular fluid volume → increased blood volume → blood pressure increases
(Makino, 2011).

Hypertension → increased pressure → the heart compensates by strengthening

the pump (left ventricle) in order to supply enough blood → increase in heart
wall cells → left ventricular hypertrophy (Price and Wilson, 2015).

24
 Risk Factors (heavy smoker and has history of hypertension and cardiac disease)
→ constriction of blood vessels constriction of blood vessels heart → work
increases → blood pressure and heart rate increases → endothelial dysfunction
→ atherosclerosis → the formation of blood clots (thrombus) → thrombus loose
in the blood vessel into an embolus → the supply of nutrients and oxygen is
reduced in neuron cells → cerebral infarction → dysfunction of cerebry
anterior artery cause hemiplegy contralateral. (Price and Wilson, 2015).

Risk Factors (heavy smoker and has history of hypertension and cardiac disease)
→ constriction of blood vessels constriction of blood vessels heart → work
increases → blood pressure and heart rate increases → endothelial dysfunction
→ atherosclerosis → the formation of blood clots (thrombus) → thrombus loose
in the blood vessel into an embolus → the supply of nutrients and oxygen is
reduced in neuron cells → cerebral infarction → dysfunction of carotis interna
artery cause homonous hemianopsia → dysfunction of cerebri media artery
cause afasia → dysfunction of cerebry anterior artery cause hemiplegy
contralateral → dysfunction of vertebrobasillaris system cause pathology
reflex, Babinsky (+) (Corwin, 2010).

The presence of cerebral infarction causes media cerebral artery dysfunction in

upper motor neurons resulting in lesions in the cerebral sinistra in the pyramidal
tracts located in the frontal lobes and towards the corticobulary tract and on the
seven nerves located in the pons resulting in facial drop and twelve nerves in the
medulla oblongata causing tongue deviation resulting in slurred speech (Bruno,
2010).

c. How to measure of the muscle strength ?

Answer :
Muscle strength is often rated on a scale of 0/5 to 5/5 as follows:
 0/5: no contraction
 1/5: muscle flicker, but no movement
25
  2/5: movement possible, but not against gravity (test the joint in its
horizontal plane)
 3/5: movement possible against gravity, but not against resistance by the
examiner
 4/5: movement possible against some resistance by the examiner (sometimes
this category is subdivided further into 4–/5, 4/5, and 4+/5)
 5/5: normal strength
(Bickley, 2015)

d. What kinds of physiology reflex ?

Answer :
1) Biceps reflex
2) Triceps reflex
3) Brachioradialis reflex
4) Knee reflex
5) Ankle reflex
(Bickley, 2015)

e. What kinds of pathology reflex ?

Answer
1) Hoffman tromer reflex
2) Babinsky reflex
3) Oppenheim reflex
4) Gordon reflex
5) Schaefer reflex
6) Chaddock reflex
7) Rossolimo reflex
(Bickley, 2015)

4. If all complaints are collected then :

26
a. How to diagnose this case ?
Answer :
SIRIRAJ STROKE SCORE
Variables Clinical Features (n) Score Case
Alert 0 
Level of consciousness (n x 2,5) Drowsy/stupor 1
Coma 2
No 0 
Vomiting (n x 2)
Yes 1
No 0 
Headache (n x 2)
Yes 1
Atheroma Markers (DM, angina, None 0
One or more 1 
intermittent claudication) (- (n x -3))
Diastole BP (n x 0,1) mmHg - 90 mmHg

Constant -12
Interpretation :
1. SSS ≥ 1 = Hemorrhagic stroke
2. SSS 0 = Do CT Scan
3. SSS ≤ -1 = Non Hemorrhagic stroke

Case :
SSS = (0 x 2,5) + (0 x 2) + (0 x 2) + (90 x 0,1) – (1 x 3) – 12
= 9 – 3 – 12
= –6
= Non Hemorrhagic stroke
(Fitriyani, 2012)

Gajah Mada Score

Sufferers of acute stroke

With or without

Decreased consciousness, headache, reflex babinski

27
 No
All or two of them Hemorrhagic Stroke
Yes

No
Decreased consciousness (+)
Headache (-) Yes Hemorrhagic Stroke
Babinski reflex (-)

No

Decreased consciousness (-)

Headache (+) Yes Hemorrhagic Stroke
Babinski reflex (-)

No

Decreased consciousness (-)

Headache (-) Non Hemorrhagic
Yes
Babinski reflex (+) Stroke

No

Decreased consciousness (-)

Headache (-) Non Hemorrhagic
Yes
Babinski reflex (-) Stroke

(Fitriyani, 2012)

28
b. What is the differential dignose on this case ?
Answer :
Cerebral Infraction
Cerebral Hemorraghe

c. What is the supporting examination on this case ?

Answer :
Emergent brain imaging is essential for evaluation of acute ischemic
stroke. Noncontrast computed tomography (CT) scanning is the most commonly
used form of neuroimaging in the acute evaluation of patients with apparent
acute stroke. The following neuroimaging techniques may also be used
emergently:
 CT angiography and CT perfusion scanning
 Magnetic resonance imaging (MRI)
 Carotid duplex scanning
 Digital subtraction angiography
Lumbar punctureA lumbar puncture is required to rule out meningitis or
subarachnoid hemorrhage when the CT scan is negative but the clinical suspicion
remains high
Laboratory studies
Laboratory tests performed in the diagnosis and evaluation of ischemic stroke
include the following:
 Complete blood count (CBC): A baseline study that may reveal a cause for the
stroke (eg, polycythemia, thrombocytosis, leukemia), provide evidence of
concurrent illness, and ensure absence of thrombocytopenia when considering
fibrinolytic therapy
 Basic chemistry panel: A baseline study that may reveal a stroke mimic (eg,
hypoglycemia, hyponatremia) or provide evidence of concurrent illness (eg,
diabetes, renal insufficiency)

29
  Coagulation studies: May reveal a coagulopathy and are useful when
fibrinolytics or anticoagulants are to be used
 Cardiac biomarkers: Important because of the association of cerebral vascular
disease and coronary artery disease
 Toxicology screening: May assist in identifying intoxicated patients with
symptoms/behavior mimicking stroke syndromes or the use of
sympathomimetics, which can cause hemorrhagic and ischemic strokes
(Kemenkes, 2014)

d. What is the working diagnose on this case ?

Answer :
Cerebral Infraction

e. What is the governance on this case ?

Answer :
Prevention
Knowing your stroke risk factors, following your doctor's recommendations
and adopting a healthy lifestyle are the best steps you can take to prevent a
stroke. If you've had a stroke or a transient ischemic attack (TIA), these measures
may help you avoid having another stroke. The follow-up care you receive in the
hospital and afterward may play a role as well.
Many stroke prevention strategies are the same as strategies to prevent heart
disease. In general, healthy lifestyle recommendations include:
 Controlling high blood pressure (hypertension). One of the most important
things you can do to reduce your stroke risk is to keep your blood pressure
under control. If you've had a stroke, lowering your blood pressure can help
prevent a subsequent transient ischemic attack or stroke.
Exercising, managing stress, maintaining a healthy weight, and limiting the
amount of sodium and alcohol you eat and drink are all ways to keep high

30
 blood pressure in check.. In addition to recommending lifestyle changes, your
doctor may prescribe medications to treat high blood pressure.
 Lowering the amount of cholesterol and saturated fat in your diet. Eating
less cholesterol and fat, especially saturated fat and trans fats, may reduce the
fatty deposits (plaques) in your arteries. If you can't control your cholesterol
through dietary changes alone, your doctor may prescribe a cholesterol-
lowering medication.
 Quitting tobacco use. Smoking raises the risk of stroke for smokers and
nonsmokers exposed to secondhand smoke. Quitting tobacco use reduces your
risk of stroke.
 Controlling diabetes. You can manage diabetes with diet, exercise, weight
control and medication.
 Maintaining a healthy weight. Being overweight contributes to other stroke
risk factors, such as high blood pressure, cardiovascular disease and diabetes.
Weight loss of as little as 10 pounds may lower your blood pressure and
improve your cholesterol levels.
 Eating a diet rich in fruits and vegetables. A diet containing five or more
daily servings of fruits or vegetables may reduce your risk of stroke.
Following the Mediterranean diet, which emphasizes olive oil, fruit, nuts,
vegetables and whole grains, may be helpful.
 Exercising regularly. Aerobic or "cardio" exercise reduces your risk of stroke
in many ways. Exercise can lower your blood pressure, increase your level of
high-density lipoprotein cholesterol, and improve the overall health of your
blood vessels and heart. It also helps you lose weight, control diabetes and
reduce stress. Gradually work up to 30 minutes of activity — such as walking,
jogging, swimming or bicycling — on most, if not all, days of the week.
 Drinking alcohol in moderation, if at all. Alcohol can be both a risk factor
and a protective measure for stroke. Heavy alcohol consumption increases
your risk of high blood pressure, ischemic strokes and hemorrhagic strokes.
However, drinking small to moderate amounts of alcohol, such as one drink a

31
 day, may help prevent ischemic stroke and decrease your blood's clotting
tendency. Alcohol may also interact with other drugs you're taking. Talk to
your doctor about what's appropriate for you.
 Treating obstructive sleep apnea, if present. Your doctor may recommend
an overnight oxygen assessment to screen for obstructive sleep apnea (OSA).
If OSA is detected, it may be treated by giving you oxygen at night or having
you wear a small device in your mouth.
 Avoiding illicit drugs. Certain street drugs, such as cocaine and
methamphetamines, are established risk factors for a TIA or a stroke. Cocaine
reduces blood flow and can cause narrowing of arteries.
(Maas, 2011)
Pharmacology
1) Thrombolytics: Thrombolytic drugs dissolve blood clot by activating
plasminogen,which form plasmin . Plasmin is a proteolytic enzyme that break
cross-links between fibrin molecules and restricts the damage caused by the
blockage in the blood vessel.Because of this action it is also known as
“plasminogen activator” and “fibrinolytic drugs”. The primary aim of
thrombolysis in acute ischemic stroke is recanalization of an occluded
intracranial artery. Recanalization is an important predictor of stroke outcome
as timely restoration of regional cerebral perfusion helps salvage threatened
ischemic tissue (Kanyal, 2015).
2) Antiplatelet drugs: Early antiplatelet treatment is recommended to treat most
patients with acute ischemic stroke because few patients can be treated with
thrombolysis due to the limit of strict indications, such as a time window
• Aspirin 81 or 325 mg once/day
• Clopidogrel 75 mg once/day
• The combination product aspirin 25 mg/extended-release dipyridamole 200
mg bid
(Kanyal, 2015).

32
3) Anticoagulants: Routine anticoagulation with unfractionated or low-
molecular-weight heparin is not recommended in acute ischemic stroke,
particularly for patients with moderate to extensive cerebral infraction due to
increased risk of severe intracranial hemorrhagic complications. The use of
fixed dose subcutaneous unfractionated heparin is not recommended for
decreasing the risk of death or stroke-related morbidity or for preventing early
stroke recurrence because of concomitant increase in the occurrence of
haemorrhage (Kanyal, 2015).
• Dabigatran (a direct thrombin inhibitor) 150 mg bid in patients without
severe renal failure (creatinine clearance < 15 mL/min) and/or liver
failure (elevated INR)
• Apixaban (a direct factor Xa inhibitor) 5 mg bid in patients ≥ 80 yr, in
patients with serum creatinine ≥ 1.5 mg/dL and creatinine clearance ≥
25 mL/min, or as an alternative to aspirin in patients who cannot take
warfarin
• Rivaroxaban (a direct factor Xa inhibitor) 20 mg once/day for patients
without severe renal failure (creatinine clearance < 15 mL/min)
4) Antihypertensive drugs- Elevated systolic pressure, with or without an
accompanying elevation in diastolic pressure, has been shown to increase
stroke risk. BP reduction was associated with a 32% risk reduction in stroke
incidence[111]. In case of arterial hypertention the target for systolic blood
pressure is under140mmHg, except for older patients (>160-150 mmHg). In
the PROGRESS study, active treatment with perindopril, with or without the
diuretic indapamide, reduced the risk of recurrent stroke by 28%. The
PROGRESS and ACCESS trials suggest that ACE inhibitors or angiotensin II
receptor blockers (ARBs) may be especially effective in secondary stroke
prevention. The HOPE trial also confirmed a benefit of the ACE inhibitor
ramipril in preventing strokes. The LIFE trial suggested that an ARB
(losartan) was superior to a β-blocker (atenolol) for prevention of stroke. The
angiotensin converting enzyme (ACE) inhibitor ramipril significantly reduces

33
the risk of stroke and acute coronary syndromes in patients with vascular
disease and at least one recognised risk factor, irrespective of blood pressure
and other treatments. Data suggests that a diuretic or the combination of a
diuretic and an ACEI are useful . On the basis of PROGRESS study thiazide
diuretic with or without an angiotensin-converting enzyme inhibitor is
recommended. Other-CCBs or B-blokers.Drug selection should be based on
patient specific factors and comorbities (Kanyal, 2015).
To lower BP, clinicians can give nicardipine 2.5 mg/h IV initially; dose is
increased by 2.5 mg/h q 5 min to a maximum of 15 mg/h as needed to
decrease systolic BP by 10 to 15%. Alternatively, IV labetalol 20 mg IV can
be given over 2 min; if response is inadequate, 40 to 80 mg can be given every
10 min up to a total dose of 300 mg.

Supportive care
When cerebral infarction occurs, the immediate goal is to optimize cerebral
perfusion of the ischaemic area, monitor potential stroke-related complications
(cerebral oedema, seizures, haemorrhagic transformation, cardiovascular and
pulmonary problems, fever and malignant hypertension) and to prevent the
common complications of bedridden patients, such as malnutrition, infections,
pressure sores, aspiration pneumonia, deep venous thrombosis and pulmonary
embolism. Early mobilisation is very useful in preventing these complications.
Early involvement of physical therapists may reduce the rate of long term
stroke complications and may speed up the recovery process.
Good nutrition, support of paralyzed limbs, and general positioning of the
patient may also minimize complications immediately following stroke. There
are also on going trials evaluating the effectiveness of active cooling in the
period following a stroke.
The provision of airway support and ventilatory assistance for patients with
acute stroke who have depressed levels of consciousness or airway obstruction
may be necessary. A further recommendation is to provide supplementary

34
oxygen only to hypoxic patients. Fever is associated with poor outcomes and
should be treated with antipyretics with no antiplatelet effect. There is general
agreement to recommend control of hypoglycaemia or hyperglycaemia
following stroke. A reasonable goal would be to lower markedly elevated
glucose levels to <300 mg/dL (<16.63 mmol/L). Swallowing function should
also be monitored and treated if necessary with dietary modifications or a
nasogastric feeding tube. These strategies were found to be effective in a trial
that implemented protocols for monitoring for hyperglycaemia, fever and
swallowing dysfunction. These patients showed reduced death and dependency
at 90 days following the incidence of a stroke.
As cardiovascular diseases (mainly myocardial infarction and arrhythmias)
are risk factors and complications of an acute stroke, they should be carefully
evaluated and treated using established protocols in stroke patients. Use of
anticoagulants during the first 14 days should be avoided. Controversy exists
within the research community regarding whether or not hypertension should
be actively treated during the acute phase of the stroke. Studies have been done
confirming both arguments, thus more research is urgently needed in this area.
Hypotension may also be a complication and should be carefully monitored.
Once the patient has been stabilized, patient and family education,
screening and treatment of depression, and physical and functional
rehabilitation should be started as soon as possible. Finally, the patient should
have further evaluation to determine the cause of the stroke, and medical or
surgical therapies should be administered to prevent recurrent ischaemic
events.
In patients with malignant middle-cerebral-artery-territory infarction and
space-occupying brain oedema, hemispheric decompression preformed within
48 hours of infarction has been shown to be beneficial. A combined analysis of
three clinical trials found that 75% of patients who received the surgery had an
mRS≤4 at 12 months compared to 24% of controls (pooled absolute risk
reduction 51% [95% CI 34 to 69]). Though only a small group of patients will

35
 benefit from this surgery, it has been shown to be effective and should become
part of protocol for patients who qualify for it (Kanyal, 2015).

f. What is the complication from this case ?

Answer :
A stroke can sometimes cause temporary or permanent disabilities,
depending on how long the brain lacks blood flow and which part was affected.
Complications may include:
 Paralysis or loss of muscle movement. You may become paralyzed on one
side of your body, or lose control of certain muscles, such as those on one side
of your face or one arm. Physical therapy may help you return to activities
hampered by paralysis, such as walking, eating and dressing.
 Difficulty talking or swallowing. A stroke may cause you to have less
control over the way the muscles in your mouth and throat move, making it
difficult for you to talk clearly (dysarthria), swallow or eat (dysphagia). You
also may have difficulty with language (aphasia), including speaking or
understanding speech, reading or writing. Therapy with a speech and language
pathologist may help.
 Memory loss or thinking difficulties. Many people who have had strokes
experience some memory loss. Others may have difficulty thinking, making
judgments, reasoning and understanding concepts.
 Emotional problems. People who have had strokes may have more difficulty
controlling their emotions, or they may develop depression.
 Pain. People who have had strokes may have pain, numbness or other strange
sensations in parts of their bodies affected by stroke. For example, if a stroke
causes you to lose feeling in your left arm, you may develop an uncomfortable
tingling sensation in that arm.
People also may be sensitive to temperature changes, especially extreme cold
after a stroke. This complication is known as central stroke pain or central
pain syndrome. This condition generally develops several weeks after a

36
 stroke, and it may improve over time. But because the pain is caused by a
problem in your brain, rather than a physical injury, there are few treatments.
 Changes in behavior and self-care ability. People who have had strokes
may become more withdrawn and less social or more impulsive. They may
need help with grooming and daily chores.
(Isselbacher dkk. 2012)

g. What is the prognoctic on this case ?

Answer :
About 10% of people who have an ischemic stroke recover almost all
normal function, and about 25% recover most of it. About 40% of people have
moderate to severe impairments requiring special care, and about 10% require
care in a nursing home or other long-term care facility. Some people are
physically and mentally devastated and unable to move, speak, or eat normally.
About 20% of people who have a stroke die in the hospital. The proportion is
higher among older people. About 25% of people who recover from a stroke
have another stroke within 5 years. Subsequent strokes impair function further.
(Hinkle JL, Guanci M. 2010)

Quo Ad Vitam : Dubia Ad Bonam

Quo Ad Fungsional : DubiaAd Bonam

h. What is the general practitioner’s competence in this case ?

Answer :
Level 3B (Emergency Cases)
Doctor graduates are able to make clinical diagnoses and provide preliminary
therapy in emergency situations to save lives or prevent the severity and / or
disability of the patient. Doctor graduates are able to determine the most
appropriate referral for the next patient's treatment. Doctor graduates are also
able to follow up after returning from referral.

37
5. What is the Islamic view on this case ?
Answer :
Ash-Shura 42:30

Whatever misfortune happens to you, is because on the things your hands have
wrought, and for many (of them) He grants forgiveness.

38
1.7. Conclusion
Mr R, A 60 years old complain sudden onset of weekness of right side, slurred
speech, right facial drop, aphasia, right hemiplegy, and right homonous hemianopsia caused
by Cerebral Infraction

1.8. Frame Work

Risk factor (heavy smoker,

hypertension and cardiac disease)

Atherosclerotic

Oclussion blood vessel

(Midle Cerebral Artery)

Iscemic cerebral

Cerebral infraction

Broca Area Lession on Lession on tractus N. Cranialis

optic tract pyramidalis VIII & XII
sinistra Sinistra

Slurred Homonous Hemiplegy Right facial drop,

Speech, hemianopsia on right side tongue deviation,
aphasia plicanasolabialis

39
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