Case Report

Rizkha Meilia Tanika

INFARCTION STROKE 1808436186
Supervisor
dr. Riki Sukiandra, SpS
CASE REPORT
PATIENT’S IDENTITY
Name Mr.H
Age 69 years old
Gender Male
Address Rumbai
Religion Moeslim
Marital’s Status Married
Occupation Unemployment
Day of admission July, 22th 2019
Medical Record 22988
ANAMNESIS

Main Complaint

Weakness on right extremities since one day before

admission to hospital.
PRESENT ILLNESS STORY

Weakness Sudden Must be Loss

on right while patient helped to speaking
extremities woke up in walk ability
the morning .

• He is not headache, decreased consciousness, seizures,

vomiting spraying, visual disturbances or had a history
of trauma.
 Past illness Socioeconomic The family
history history disease history
• Uncontrolled • History of
Hypertension, hypertension,
• Smoker
• Uncontrolled DM, stroke in
diabetes mellitus
patient’s
• Tuberculosis
droup out family (-)
SUMMARY

Mr.H, 69 years old, was admitted to Arifin Achmad’s General

Hospital with weakness on right extremities and lose speaking
ability one day ago and There is history of uncontrolled
hypertension, diabetes melitus and tuberculosis drop out. There
are no history of headache, decreased consciousness, seizures,
vomiting spraying, visual disturbances and trauma.
PHYSICAL EXAMINATION
(JULY, 25 TH 2019 ON 07.00 PM)

Blood Pressure :160/90 mmHg

Heart Rate : 90 dpm
Respiratory rate : 25 dpm
Temperature : 37°C
NEUROLOGICAL STATUS
Consciousness : Composmentis Cooperative
GCS : E(4)V(6)M(5)
Cognitive Function : Normal
Meningeal Sign : Neck stiffness (-)
Brudzinki I, II (-)
NEUROLOGICAL STATUS - CRANIAL NERVES
N. I ( Olfactory )

Right Left Interpretation

Sense of Smell Normal Normal Normal

N. II ( Opticus )
Right Left Interpretation

Visual Acuity Normal Normal

Visual Fields Normal Normal Normal
Colour Recognition Normal Normal
NEUROLOGICAL STATUS - CRANIAL NERVES
N. III ( Oculomotorius )

Right Left Interpretation

Ptosis
Pupil (-) (-)
Shape Isochoric Isochoric
Size 2 mm 2 mm Normal
Pupillary Reaction to light Normal Normal
Direct (+) (+)
Indirect (+) (+)
NEUROLOGICAL STATUS - CRANIAL NERVES
N. IV ( Trochlear )

Right Left Interpretation

Extraocular movement Normal Normal Normal

N. V ( Trigeminal )
Right Left Interpretation

Motoric Normal Normal

Sensoric Normal Normal Normal
Corneal reflex (+) (+)
NEUROLOGICAL STATUS - CRANIAL NERVES
N. VI ( Abduscens )

Right Left Interpretation

Eyes movement Normal Normal

Strabismus (-) (-) Normal
Deviation (-) (-)
NEUROLOGICAL STATUS - CRANIAL NERVES
N. VII ( Facial)

Right Left Interpretation

Tic (-) (-)

Motoric
frowning Normal Normal
raised eye brow Normal Normal central right facialis
closed eye Normal Normal nerve parese
corners of the mounth Flat when patient smile Upward
nasolabial fold Flatter Normal
Sanse of Taste Normal Normal
Chvostek Sign (-) (-)
NEUROLOGICAL STATUS - CRANIAL NERVES
N. VIII ( Acustic )

Left Right Interpretation

Hearing Sense Normal Normal Normal

N. IX (Glossopharyngeal)
Left Right Interpretation

Pharyngeal arch Normal Normal

Sense of taste Normal Normal Normal
Gag reflex (+) (+)
NEUROLOGICAL STATUS - CRANIAL NERVES
N. X ( Vagus )

Right Left Interpretation

Pharyngeal arch Normal Normal

Normal
Dysphonia (-) (-)

N. XI ( Accesory )
Right Left Interpretation

Motoric Normal Normal

Normal
Trophy Eutrophy Eutrophy
NEUROLOGICAL STATUS - CRANIAL NERVES
N. XII ( Hypoglosals )

Right Left Interpretation

Motoric Deviation to the left side Normal

Paresis of right N.
Trophy Eutrophy Eutrophy
XII, central type
Tremor (-) (-)
Disartria (-) (-)
NEUROLOGICAL STATUS – MOTORIC SYSTEM
 Right Left Interpretation

Upper Extremity
Strength
Distal 3 5
Medial 3 5
Proximal 3 5
Tone Normal Normal
Trophy Eutrophy Eutrophy
Involuntar movements - -
Clonus - - Hemiparesis
Lower Extremity dextra
Strength
Distal 1 5
Medial 1 5
Proximal 1 5
Tone Normal Normal
Trophy Eutrophy Eutrophy
Involuntarymovements - -
-
Clonus -
Body
Trophy Eutrophy Eutrophy
Normal
Involuntary movements (-) (-)
 NEUROLOGICAL STATUS – SENSORY SYSTEM

Right Left Interpretation

Touch Normal Normal

Pain Normal Normal
Normal
Temperature Normal Normal
Propioseptive Normal Normal
 NEUROLOGICAL STATUS - REFLEX
Right Left Interpretation

Physiologic
Biceps (+) (+)
Triceps (+) (+) Normal

Knee (+) (+)

Ankle (+) (+)

Pathologic
Babinsky (-) (-)
Chaddock (-) (-)
Normal
HoffmanTromer (-) (-)

Openheim (-) (-)

(-) (-)
Schaefer
 NEUROLOGICAL STATUS- COORDINATION FUNCTION

Right Left Interpretation

Point to point
movement
Walk heel to toe
Difficult to asses Difficult to asses Difficult to asses
Gait
Tandem
Romberg
NEUROLOGICAL STATUS
AUTONOM

Urination : Using Catheter

Defecation : Normal

OTHERS EXAMINATION

 Laseque : Unlimited (>70)

 Kernig : Unlimited (>130)

 Patrick : -/-

 Kontrapatrick : -/-

 Valsava test : -

 Brudzinski : -
 GADJAH MADA STROKE ALGORITHM

Loss Phatology Reflex

Headache (-)
consciousness (-) (-)

Infarction Stroke
SIRIRAJ STROKE SCORE
Consciousness (C) : CM (0)
Vomitting (V) : No (0)
Headache within 2 hours (H) : No (0)
Atheroma (A) : No (0)
Diastolic blood pressure (DBP) : 90 mmHg (90)

SSS = 2,5 C + 2 V + 2 H + 0,1 DBP - 3 A - 12

= 2,5 (0) + 2 (0) + 2 (0) + 0,1 (90) - 3 (1) – 12
= - 6 (infarction)
EXAMINATION RESUME
Generalized condition
Consciousness : Composmentis (GCS : E(4)V(6)M(5) )
Blood Pressure : 160/90 mmHg
Heart Rate : 90 bpm
Respiratory Rate : 25 bpm
Temperature : 37,0°C
Cognitive Function : Normal
Meningeal sign : Neck stiffness (-), Brudzinski I-IV (-)
Cranial Nerves : N.VII: Right paresis central type
N. XII: Right paresis central type
Motoric : Right hemiparesis (UMN lesion)
Sensory : Normal
EXAMINATION RESUME
Coordination : Difficult to interpretable
Autonomy : Normal
Reflex : Physiology (+), Pathology (-)
Gajah Mada Score: Infarction stroke
Siriraj score : Infarction stroke
WORKING DIAGNOSE
Clinical Diagnose : Right hemiparesis (UMN), central
right facialis nerve parese, central right hypoglossus nerve
parese, motoric aphasia

Topical Diagnose : frontal lobe innerverted by medial

cerebral artery

Etiological Diagnose : Stroke Thrombolic

Differential Diagnose : Stroke Embolic

MANAGEMENT
A. General
Vital sign monitoring
IVFD Ringer Lactate 20 dpm
Consult the patient to physical medicine and rehabilitation (PM&R)
B. Specific
 Aspilet 500 mg/8 h PO
 Citicolin 500 mg/8 h IV
 Piracetam 300mg/8h IV
 Ranitidin 50 mg/12 h IV
LABOURATURIUM FINDING
Blood Routine (July, 22th 2019) Blood Chemistry (July,22th 2019)
Hemoglobin :14,6gr/dl Glucose : 219 mg/dl (<200 mg/dl)
Hematocrit : 45,5 % Uremic Acid : 6,8 mg/dl

Leucocytes: 16.020 /mm3 Total Cholesterol : 177 mg/dl

Platelets : 238/mm3 HDL/LDL : 42/114 mg/dl

Trigleserida : 108 mg/dl
HEAD CT-SCAN

Interpretation : hypodense
view at left frontal lobe
Conclusion : infarction stroke
FINAL DIAGNOSE

Infarction stroke
DISSCUSSION
 STROKE

DEFINITION
Rapidly developing clinical signs of focal (or global) disturbance of cerebral
function, with symptoms lasting 24 hours or longer or leading to death, with no
apparent cause other than of vascular origin
 RISK FACTORS
Not Modifable Modifable

1. Age 1. Stroke history 10. Smoking

2. Gender 2. Hypertension
3. Genetik 3. Heart disease
4. Ras 4. Diabetes melitus
5. Carotic stenosis
6. TIA
7. Hypercholesterolemia
8. Oral contraception
9. Obesity
11. Alcohol
12. Drug abuse
13. Hyperhomosisteinemia
14. Antibody anti fosfolipid
15. Hyperurisemia
16. Elevation of hematocrit
17. Elevation of fibrinogen
Embolic • Embolic: blood clot from another part
of body not from a cerebral blood
vessel
Infarction • Heart: the most common source

• The artery blocked by blood clot from

Thrombotic cerebral blood vessel

Infarction
 Stroke trombus Stroke Emboli
Slower and usually passed by Transient Ischemic Attack Suddenly, it can be accompanied by headache a few
hours before
There are found sources of emboli such as the heart
there is no source of embolism or bleeding and A. carotis

Blockages originate from other places such as thrombus

Blockage due to the process of thrombus formation in that escapes from the heart or carotid artery
the blood vessels of the brain itself

Less often at a young age More often at a young age

occurs at rest Occurs at activity
Not accompanied by a decrease in consciousness Decreased consciousness can occurs

prevalent distribution
Often into the cerebral arteries because the media is
bigger and straight
 DIAGNOSE
Anamnesis Physical examination Neurological examination and scale of
stroke

Initial symptomps Vital sign and general examination FAST, LAPSS

Onset Infark/hemoragik: Algoritma gajah

mada, Sriraj skor

Patient activity during an attack

Other symptoms; headache, nausea,

vomiting, convulsions, hiccups, visual
disturbances, decreased consciousness
 FACE ARM SPEECH TEST (FAST)
Criteria Note
F Facial palsy One side of the face falls and does not mov

A Arm weakness
One side of the arm can’t move or is lower than the other
side of the arm

S Speech impairment Lack of speech or loss speaking ability

Note :
The diagnosis of stroke if found ≥ 1 of the criteria
GADJAH MADA SCORE

Lost of
Headache Pathology reflex
consciousness

All criteria or two of the three  hemorrhage

Lost of consciousness (+), headache (-), pathology reflex (-)  hemorrhage
Lost of consciousness (-), headache (+), pathology reflex (-)  hemorrhage
Lost of consciousness (-), headache (-), pathology reflex (+)  infarction
Lost of consciousness (-), headache (-), pathology reflex (-)  infarction
SIRIRAJ STROKE SCORE (SSS)
C = Consciousness
Alert : 0
Drowsy & stupor : 1
Semicoma & coma : 2
V = Vomitting
No : 0
Yes : 1
H = Headache within 2 hours
No : 0
Yes : 1
A = Atheroma (Diabetic history, angina, claudication)
No : 0
One or more : 1
DBP = Diastolic Blood Pressure
SSS DIAGNOSIS
>1 Cerebral haemorhage
<-1 Cerebral infarction
-1 to 1 Uncertained diagnosis, use probability curve and/or CT Scan
SUGGESTIVE EXAMINATION
Labouraturoim examination

• Blood Routine
• Glucouse
• Profil lipid

Radiology Examination

• Chest photo
• Head-CT scan
• Head MRI
 THERAPY
General Underlying rehabilitation
treatment treatment

• Hypertension
• Hemodynamic • Hyper/hypoglycemia
• Speech and
stabilization • Anticoagulant motoric therapy
• TIA Control • Antiplatelet
• Neuroprotectan
BACIS CLINICAL DIAGNOSE

Anamnesis
Weakness on right extremities Onset one day before Loss speech ability
admission

Physical examination
Parasise N.VII dextra central Hemiparese detxtra Parasise n. ix detra central
type type
BASIC TOPIC DIAGNOSE
Anamnesis
Weakness on right extremities and loss speech ability

Physical Examination
Parasise N.VII dextra central type Hemiparese detxtra Parasise n. ix detra

Frontal lobus innerverted by media artery cerebral

BASIC ETILOGY DIAGNOSE
weakness on right extremities
Loss of speech ability
One day before admission
Composmentis
cooperative
Anamnesis
History of DM and hypertension One day before admission when
patient woke up in the morning
Physical Examination
Parasise N.VII dextra Hemiparese detxtra Parasise n. ix detra
central type
Stroke Thrombolic
BASIC ETIOLOGY DIAGNOSE
Gadjah Mada Stroke Algorythm (ASGM)

Decrease Headchace Reflex pathology

consciousness (-) (-) (-)

Stroke infarction

Siriraj Stroke Score

Consciousness (C) : Alert (0)
Vomitting (V) : No (0)
Headache within 2 hours (H) : No (0)
Diastolic blood pressure (DBP): 90 mmHg (90)
Atheroma (A) : Yes (0)
SSS = 2,5 C + 2 V + 2 H + 0,1 DBP - 3 A - 12
= 2,5 (0) + 2 (0) + 2 (0) + 0,1 (90) - 3 (1) – 12
= - 6 (infark serebral)
 BASIC DIFFERENTIAL DIAGNOSES
Thrombolic Emboli To The Patient
Less often at a young age More often at a young age Old age (69 yo)

Occurs at rest Occurs at activity Occurs at rest

hypertension Relative normal blood preassure hypertension

There is no source of embolism or bleeding Sources of emboli such as the heart or a. There is no source of embolism or
carotis bleeding
Blockage due to the process of thrombus
formation in the blood vessels of the brain
BASIC PLAN THERAPHY – GENERAL THERAPHY
Observation VT and Neurogical Status

• Observing progressing of dissease

Fisiothreaphy

• Prevent disability and complications from prolonged

immobilization
BASIC PLAN THERAPHY - SPESIFIC

Citicoline
• Neuroprotector : stabilizes cell membranes by increasing
phosphatidylcholine and sphingomyelin synthesis

Aspilet
• Anti aggregation trombocyte
DASAR RENCANA TERAPI - SPESIFIC

Piracetam
• Improve neuron fuction
• Improve microcirculation

Ranitidine
• Gastric protector
THANK YOU