CASE REPORT

DECREASE OF CONSCIOUSNESS

By :
Nuraidah, S.Ked
Muchtar Luthfi, S.Ked
Advisor :
dr. H. A. Rachman Toyo, Sp.S(K)
NEUROLOGY DEPARTMENT
MEDICAL FACULTY OF SRIWIJAYA UNIVERSITY
MOHAMMAD HOESIN GENERAL HOSPITAL
PALEMBANG 2016

OUTLINE

Case
Analysis
Resume

Patients
status

Literatur
e
Review

Decrease
of
Conscious
ness

Referenc
es
2

PATIENTS STATUS
IDENTIFICATION
Name
:Mrs. T
Age
:56 years old
Sex
:Female
Occupation : Housewife
Address
: Pipa Reja
Kemuning
Palembang
Religion
: Moslem
Admitted
: 29th May 2016
3

ANAMNESIS

(Autoanamnesis, 19th December 2015)

1st paragraph
Patient was admitted to
Neurologic Department of
Mohammad Hoesin
General Hospital due to
suddenly getting loss of
consciousness.

2nd paragraph
Since 4 hours before
admission, patients
experienced sudden onset
loss of consciousness.
Headache (+). Vomitting
(+),projectile, the content
is what is eaten.
Weakness in half of the
body(+), equal both the
arm and leg.The
sensibility disturbance
couldnt be assessed The
patient work using the
right hand daily.
Seizure(-), asymmetric
mouth can not be
assessed. Patient can not
express good
thoughts,
4
oral language, writting

Cont..
3rd paragraph
History of
shortness of
breath and
palpitation
(-),History of
headache in the
back of the head
(-), hypertension
(+)since 5 years
ago, taking
medication
irregularly,

4th paragraph
This disease
occurs for the 1st
time

PHYSICAL EXAMINATION

Internal State

Conciousness : GCS 9 E2M5V2

Nutrition : Sufficient
Temperature
: 36,8oC
Pulse : 104 beats/min
Respiratory rate : 24 times/min
Blood pressure
: 130/80 mmHg
Heart
: No abnormality
Lungs : No abnormality
Liver : No abnormality
Spleen : No abnormality
Extremities : See neurological state
Genital
: not be assessed
6

Cont..
Psychiatric state

Attitude
:can not be assessed
Attention
: can not be assessed
Facial Expression : can not be assessed
Psychological contact :can not be assessed

Neurological state
Head
Shape : Normocephali
Size : Normal
Symetric : Yes
Hematome : No
Tumor : No
Deformity
: No

Cont..

Fracture
: No
Fracture pain : No
Vessel
: No widening
Pulsation
: No

Neck
Position
: Normal
Torticolis
: No
Nuchal Rigidity : No
Deformity
: No
Tumor
: No
Vessels
: No widening
8

N.I: Olfactory Nerves

Right

CRANIAL
NERVES
can not be assessed
Smelling

Left
can not be assessed

Anosmia

can not be assessed

can not be assessed

Hyposmia

can not be assessed

can not be assessed

Parosmia

can not be assessed

can not be assessed

Visual acuity

can not be assessed

can not be assessed

Visual field

can not be assessed

can not be assessed

Anopsia

can not be assessed

can not be assessed

Hemianopsia

can not be assessed

can not be assessed

Papil edema

can not be interpreted

can not be interpreted

Papil atrophy

can not be interpreted

can not be interpreted

Retinal bleeding

can not be interpreted

9 be interpreted
can not

N.II: Optical Nerves

Oculi fundus

N.III: Occulomotorius
N.IV: Trochlearis
N.VI: Abducens

Right

Left

Cont..

Diplopia

can not be assessed

can not be assessed

Eyes gap

can not be assessed

can not be assessed

Ptosis

can not be assessed

can not be assessed

can not be assessed

can not be assessed

Eyes position
-Strabismus
-Exophtalmus
-Enophtalmus
-Deviation conjugae
Eyes movement

Pupil
-Shape
-Size
-Isochor/anisochor
-Midriasis/miosis

Round
d=2 mm
isochor
+/+ Normal

Round
d=3 mm
isochor
+/+ Normal
10

Cont..
N.III: Occulomotorius
N.IV: Trochlearis
N.VI: Abducens

Right

Left

Light reflex
-Direct
-Consensuil
-Accomodation

Positive
Positive
Positive

Positive
Positive
Positive

Argyl Robertson

No

No

Motoric:
-Biting
-Trismus
-Corneal reflex

can not be assessed

can not be assessed

Sensory:
-Forehead
-Cheek
-Chin

can not be assessed

can not be assessed

N.V: Trigeminus nerve

11

Cont..
N.VII: Facialis nerve

Right

Left

Frowning

can not be assessed

can not be assessed

Eyes closing

can not be assessed

can not be assessed

Normal

Normal

Flat

Normal

Facial shape
-Rest
-Speaking/whistling

can not be assessed

can not be assessed

Sensory
- 2/3 anterior tongue

can not be assessed

can not be assessed

can not be assessed

can not be assessed

Giggling
Nasolabial fold

Autonomy
-Salivation
-Lacrimation
-Chovsteks sign

12

Cont..
N.VIII: Statoacusticus
nerve

Right

Left

Whispering

can not be assessed

can not be assessed

Hour ticking

can not be assessed

can not be assessed

Weber test

can not be assessed

can not be assessed

Rinne test

can not be assessed

can not be assessed

Nystagmus

can not be assessed

can not be assessed

Vertigo

can not be assessed

can not be assessed

Symmetrical

Symmetrical

At the center, no
disorder

At the center, no
disorder

No

No

Cochlearis nerve

Vestibularis nerve

N. IX:
Glossopharingeus
N.X: Vagus nerve
Pharyngeal arch
Uvula
Swallowing disorder

13

Cont..
N. IX:
Glossopharingeus
N.X: Vagus nerve

Right

Left

Hoaring/nasalising

No

No

Heart beat

No

No

positive

positive

can not be assessed

can not be assessed

Shoulder raising

can not be assessed

can not be assessed

Head twisting

can not be assessed

can not be assessed

Reflex
-Vomiting
-Coughing
-Occulocardiac
-Caroticus sinus
Sensory
- 1/3 posterior tongue
N.XI: Accessorius
nerve

14

Cont..
N.XII: Hypoglossus
nerve

Right

Left

Tongue showing

can not be assessed

can not be assessed

Fasciculation

can not be assessed

can not be assessed

Papil atrophy

can not be assessed

can not be assessed

Dysarthria

can not be assessed

can not be assessed

MOTORIC
Arms
Motion

Lateralization to the right side

Power
Tones

Normal

Physiological Reflex
-Biceps
-Triceps
-Radius
-Ulna

Normal
Normal
Normal
Normal

15

Cont..
MOTORIC

Right

Left

Hoffman Tromner

No

No

Leri

No

No

Meyer

No

No

Trofik

No

No

Pathological Reflex

Legs
Motion

Lateralization to the right side

Power
Tones

Normal

Clonus
-Thigh
-Foot

Negative
Negative

Negative
Negative

Normal
Normal

Physiological Reflex
-KPR
-APR

16

Cont..
MOTORIC

Right

Left

- Babinsky

Positive

Negative

- Chaddock

Positive

Negative

-Oppenheim

Negative

Negative

- Gordon

Negative

Negative

-Schaeffer

Negative

Negative

-Rossolimo

Negative

Negative

- Mendel Bechterew

Negative

Negative

Negative
Negative
Negative
Negative

Negative
Negative
Negative
Negative

Pathological Reflex

Abnormal skin reflex

-Upper
-Middle
-Lower
-Tropik
SENSORY
Can not be assessed

17

Cont..
VEGETATIVE
FUNCTION

Right

Left

Micturition

Can not be assessed

Defecation

Can not be assessed

VERTEBRAL
COLUMN
- Kyphosis

No

-Lordosis

No

-Gibbus

No

-Deformity

No

-Tumor

No

-Meningocele

No

-Hematome

No

-Tenderness

No
18

Cont..

MENINGEAL
REFLEX

Right

Left

Nuchal rigidity

No

No

Kerniq

No

No

Laseque

No

No

-Neck

No

No

-Cheek

No

No

-Symphisis

No

No

- Leg I

No

No

- Leg II

No

No

Brudzinsky

19

GAIT AND BALANCE

Gait: can not be assessed
Balance and Coordination:
can not be assessed
Ataxia :
Romberg :
Hemiplegic
:
Dysmetri :
Scissor:
finger finger :
Propulsion :
finger nose
:
Histeric
:
heel - heel :
Limping :
Rebound phenomenon:
Steppage :
Dysdiadochokinesis:
Astasia-Abasia:
Trunk Ataxia :
Limb Ataxia :

20

ABNORMAL

LIMBIC FUNCTION

MOVEMENTS

Can not be assessed

Can not be assessed

Motoric aphasia :

Tremor

Sensoric aphasia

Chorea

Apraksia

Agraphia

Athetosis

Ballismus

Dystoni

Myoclonus

Alexia

Nominal aphasia
:
21

Laboratory Findings
BLOOD
Hematology
Hemoglobin 12,5 g/dl
Erythrocyte 3,88 x 106/mm3
Leukocyte 17,500/mm3
Hematocrite 36%
Thrombocyte
212,000/microlitre
Diff. Count 0/0/89/6/5

Blood Chemist
INR 1,13
PT 14,3
APTT29,3
Renal
Ureum 26 mg/dl
Creatinin 0,79 mg/dl
Electrolyte
Ca 8,4 mg/dl
Na 140 mEq/L
K 3,37 mEq/L
Cl 110 mmol/L

22

Rontgen Thorax AP

In rontgen thorax PA, it is found that:

Bones/soft tissues: no abnormality
Cor: seems bigger (inspiration is not
enough)
Pulmo: no abnormality
Trachea: position, borders and
diameter normal; no thickenning of
paratracheal line
Mediastinum: located in the center and
not widened
Diaphragm: normal position or shape;
right and left costophrenicus angle are
sharp
Result: heart enlargement, aorta
elongation
23

Head CT-Scan
(14th December 2015)

In non contrast head CT-Scan, it is found

that:
There is hiperdens lesion in left, corona
radiata and nukleus lentiformis with
perifocal oedema
Gray/white matter differentiation is clear
No midline structure deviation
Ventricle system is normal, sulci/gyri are
Pons/cerebellum/CPA are normal
Paranasal sinus/cavum nasi and orbita
are normal
No fracture in the cranium/bones are
good
Result: ICH, IVH

24

25

Intracranial hemorrhage
Intraventricular hemorrhage

capsula interna, Hemispherium

sinistra cerebri, ventrikel

Loss of consciousness
Right hemiparesespastic type
N.VII dextra paralysis central type

Topical
Diagnosi
s
Etiologic
al
Diagnosi
s
Clinical
Diagnosi
s

DIAGNOSIS

MANAGEMENT
Non-pharmacology :

Head up 30
Liquid diet 1800
kkal (low salt)
O2 8 L/m
o

Nasogastric Tube

Pharmacology :

IVFD NaCl 0,9% gtt xx/m

Inj. Tranexamic Acid 3 x
500 mg (i.v)
Inj. Citicholin 2 x 250 mg
(i.v)
Neurobion
Drip Manitol 4 x 125 cc
(i.v)
Amlodipine 1x10mg (po)

26

 PROGNOSIS:
Quo ad vitam
: dubia ad
malam
Quo ad functionam : dubia ad
malam

27

CASE ANALYSIS
No.
1

Symptoms of Lesion in Cortical Cerebri

The patient

Motoric deficit that is hemiparesis/ hemiplegia at contralateral Right hemiparese spastic type
lesion

Topical
DD

Irritable symptom that is seizures at the weak side of the body

Focal symptoms that is unequal paralyzed of the arms and the Equal paralyzed of the arms and
leg

legs

Sensoric deficit that is disturbance at the weak side of the Cant be assessed
body

No.
1

Symptoms of lesion in Subcortical Cerebri

The patient
Motoric deficit that is hemiparesis/ hemiplegia at contralateral Right hemiparese spastic type
lesion

2
No.
1

Pure motoric afasia

Symptoms of lesion in capsula interna

Cant be assessed
The Patient

Motoric deficit that is hemiparesis/ hemiplegia at contralateral Right hemiparese spastic type
lesion

Parese N. VII central

Left N.VII parese central type

Parese N. XII central

cant be assessed

28

No. Symptoms of lesion in mesencephalon

1

The patient

Motoric deficit that is hemiparesis/ hemiplegia at Right hemiparese spastic type

contralateral lesion (alternant hemiparese)

Parese N. III ipsilateral lesion

No. Symptoms of lesion in pons

1

The patient

Motoric deficit that is hemiparesis/ hemiplegia at Right hemiparese spastic type

contralateral lesion (alternant hemiparese)

Parese N. IV, V, VI, VII, VIII

No. Symptoms of lesion in medula oblongata

1

Left N.VII parese central type

The patient

Motoric deficit that is hemiparesis/ hemiplegia at Right hemiparese spastic type

contralateral lesion (alternant hemiparese)

Parese N. IX, X, XI, XII

cant be assessed

29

Cont..
Etiol
ogic
al
DD

A.
.
.
.
A.
.
.
A.
.
.

LEVEL OF CONSCIOUSNESS
Coma : 2
Apatis : 1
Conscious : 0
VOMIT
(+) : 1
(-) : 0
HEADACHE
(+) : 1
(-) : 0

A.
1.
.
.
1.
.
.
1.
.
.

ATEROMA SIGNS
Angina Pectoris
(+) : 1
(-) : 0
Claudicatio Intermitten
(+) : 1
(-) : 0
DIABTES MELLITUS
(+) : 1
(-) : 0

SSS = (2,5 CONSCIOUSNESS) + (2 VOMIT) + (2 HEADACHE) + (0,1 DIASTOLE) (3

ATEROMA) 12
Interpretation:
0
: See the CT Scan result
- 1 : Infark / Iskemi / Non hemorrhagic
1 : Hemorrhage

SSS = (2,5 2) + (2 1) + (2 1) + (0,1

80) (3 0) 12
=2
Conclusion: Hemorrhagic Stroke (CT scan
result)
30

Gadjah Mada Algorithm

Cont..
At the patient, there are:
Loss of consciousness
(+)
Severe headache (+)
Babinski reflex (+)
Conclusion:
Intracerebral
Hemorrhage

Etiological Diagnose:
Intracerebral
Hemorrhage
31

Non-pharmacology :
Head up 30o
Liquid diet 1800 kkal (low salt)
O2 8 L/m
Nasogastric Tube
Pharmacology :
IVFD NaCl 0,9% gtt xx/m
Inj. Tranexamic Acid 3 x 500 mg (i.v)
Inj. Citicholin 2 x 250 mg (i.v)
Neurobion
Drip Manitol 4 x 125 cc (i.v)
Amlodipine 1x10mg (po)
32

THANK YOU

33