Case Saraf Stroke Infark MM

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  • 7/24/2019 Case Saraf Stroke Infark MM

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    Laporan Kasus

    STROKE INFARK

    Oleh

    Muhammad Maliki

    1308468769

    Pembimbi!"

    d#$ A!u% T#i &'k'( S)$S

    KEPANITERAAN K*INIK

    +A,IAN I*M- PEN.AKIT SARAF

    RS-/ ARIFIN AMA/

    FAK-*TAS KE/OKTERAN

    -NI2ERSITAS RIA-

    PEKAN+AR-

    01

    1

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    RS-/ ARIFIN AMA/

    Fakul5a% Ked'k5e#a -R

    SMF/ BAGIAN SARAFSek#e5a#ia5 " SMF Sa#a I#a Medikal *a5ai 4

    Jl. Diponegoro No. 2 Telp. (0761 702622!

    P E K A N + A R -

    STAT-S PASIEN

    Nama K'a%% " Muhammad Maliki

    N I M N - K " 1308468769

    Ta!!al " 0 Ok5'be# 01

    Pembimbi! d#$ A!u% T#i &'k'( S)$S

    I$ I/ENTITAS PASIEN

    N"#" N$. S

    %#&r '1 T"h&n

    Jeni )el"#in *ere#p&"n

    Al"#"+ *e)"n,"r&

    Ag"#" Il"#

    S+"+& per)"-in"n "-in

    *e)er""n I,& R"h T"ngg"

    T"ngg"l M"&) RS 1 O)+o,er 201!

    Mei"l Reor 0 '7 '

    II$ ANAMNESIS("&+o"n"#nei "n "llo"n"#nei eng"n "n") "n &"#i

    p"ien

    Keluha -5ama

    ele#"h"n p"" "nggo+" ger") e,el"h )"n"n

    Ria:a5 Pe:aki5 Seka#a!

    Se") 1 h"ri SMRS p"ien #engel&h)"n )ele#"h"n p"" "nggo+"

    ger") e,el"h )"n"n. le#"h ir"")"n #en"") ""+ p"ien &&) i

    2

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    r"hn$" e+el"h ,"ng&n +i&r3 p"gi e)i+"r p&)&l 06.'0 4IB. S""+ )e"i"n3

    #&l&+ p"ien #enong )e )iri. *"ien +i") #eng"l"#i pen&r&n"n )e""r"n3

    n$eri )ep"l" +i") ""3 #&"l "n #&n+"h +i") "". *"ien ,er"l"n eng"n

    ip"p"h oleh )el&"rg" p"ien. *"ien ,er,i"r" pelo. *"ien #enger+i

    pe#,i"r""n or"ng l"in3 n"#&n l"#,"+ #ereponn$". *"ien l"l& i ,"-" )e

    R"h S")i+ *e+"l" Bi. D"ri R"h ")i+ *e+"l" Bi p"ien )e#&i"n

    ir&&) eng"n "l""n +i") +erei" Spei"li S"r"5 "n 5"ili+" TS"n.

    Se") 1 #ingg& SMRS p"ien #engel&h)"n ,eng)") p"" )e&"

    leng"n "n +&ng)"i. Se") n"5" +i") "".

    Ria:a5 Pe:aki5 /ahulu

    Ri-"$"+ DM (8 i)e+"h&i e") 12 +"h&n +er")hir3 p"ien ,ero,"+ r&+in eng"n

    #eng)oni #e+5or#in

    Ri-"$"+ +ro)e e,eln$" +i") i)e+"h&i

    Ri-"$"+ hiper+eni (8 i)e+"h&i e") 1 +"h&n +er")hir3 p"ien ,ero,"+ r&+in

    eng"n #eng)ono#i "p+opril

    Ri-"$"+ pen$")i+ gin"l )roni) (8 i)e+"h&i ! ,&l"n $"ng l"l&.

    Ri-"$"+ pen$")i+ "n+&ng +i") i)e+"h&i

    Ri-"$"+ +r"" )ep"l" (

    Ria:a5 Kebia%aa

    *"ien #ero)o) e") #&".

    Ria:a5 Pe:aki5 Kelua#!a

    I,& )"n&ng p"ien pern"h #eneri+" +ro)e.

    RES-ME ANAMNESIS

    Tn.S3 !! +"h&n3 )ele#"h"n p"" "nggo+" ger") e,el"h )"n"n3 #en"") ""+

    p"ien &&) e+el"h ,"ng&n +i&r3 p"gi. *"ien ""r. S""+ )e"i"n3 #&l&+ p"ien

    #enong )e )iri. *"ien ,er"l"n eng"n i,"n+& ip"p"h oleh )el&"rg" p"ien. *"ien

    ,er,i"r" pelo. *"ien #enger+i pe#,i"r""n or"ng l"in3 n"#&n l"#,"+ #ereponn$"..

    *"ien i)e+"h&i #e#ili)i ri-"$"+ DM "n hiper+eni. *"ien #e#p&n$"i )e,i"""n

    9

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    #ero)o). I,& )"n&ng p"ien pern"h #eneri+" +ro)e.

    III$ PEMERIKSAAN ;10 Mei 014 ;2a!u%II ;i)'!l'%%u%ole +",le+ 9 = 1

    Ter"pi o)&p"i

    Ta!!al 17 Mei 014

    S: T"ng"n )"n"n "n )")i )"n"n ,i" iger"))"n +e+"pi #"ih le#"h3 ,eng)")

    p"" )")i3 ,""n le#"3 #&"l (8 hil"ng +i#,&l

    O: e""r"n )o#po#en+i3 GS : @'M6 !

    TD :170/100 ##

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    oorin"i : &li+ inil"i

    O+ono# : nor#"l

    Re5le) Fiiologi : nor#"l3 *"+ologi : (/

    i#i" "r"h:

    Gl&)o" D"r"h *&"" : 22; #g/l

    %re : 196 #g/l

    re"+inin: 63'' #g/l

    AST: 120 I%/

    AST: 70; %/

    A: S+ro)e in5"r) e. +ro#,o+i) 8 D +"ge 8 hiper+eni gr"e II8DM +ipe II

    *: In i+iolin 2!0 #g/;"#

    Ine)i F&roe#i 1=1 "#p

    Apile+ ;0 #g 2=1

    A"# 5ol"+ 2=1

    "l"r+"n ;0 #g 1=1

    ole +",le+ 9 = 1

    In.Noer"pi 9=6 &ni+

    Ter"pi o)&p"i

    Ta!!al 18 Mei 014

    S: T"ng"n )"n"n "n )")i )"n"n ,i" iger"))"n +e+"pi #"ih le#"h3 ,eng)")

    p"" )")i3 ,""n le#".

    O: e""r"n )o#po#en+i3 GS : @'M6 !

    TD :160/0 ##

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    *ro)i#"l

    Ton&

    Tro5i

    Ger.inol&n+er

    '

    N

    @&+ro5i

    !

    N

    @&+ro5i

    ing/

    1

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    F&ngi l&h&r: nor#"l

    R"ng"ng #eninge"l: (

    S"r"5 )r"ni"l: ,n

    Mo+ori)

    "n"n iri e+er"ng"n

    @)+re#i+" "+"

    e)&"+"n

    Di+"l

    *ro)i#"l

    Ton&

    Tro5i

    Ger.inol&n+er

    '

    '

    N

    @&+ro5i

    !

    !

    N

    @&+ro5i

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    PEM+AASAN

    I$ /eii%i

    De5inii +ro)e #en&r&+ 4

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    9. S+ro)e progrei5 "+"& stroke in evolution $"i+& +ro)e $"ng ge"l"

    )linin$" e"r" ,er+"h"p ,er)e#,"ng "ri $"ng ring"n "#p"i e#")in

    ,er"+.

    '. S+ro)e )o#pli+ "+"& completed stroke3 $"i+& +ro)e eng"n e5ii+

    ne&rologi $"ng #ene+"p "n &"h +i") ,er)e#,"ng l"gi.

    . Ber""r)"n lo)"i lei ")&ler

    1. Si+e# )"ro+i1. Mo+ori): he#ip"ree )on+r"l"+er"l3 i"r+ri"

    2. Senori): he#ihipe+ei )on+r"l"+er"l3 p"re+ei"

    9. G"ngg&"n i&"l: he#i"nopi" ho#on$# )on+r"l"+er"l

    '. G"ngg&"n 5&ngi l&h&r: "5"i"3 "gnoi"

    2. Si+e# er+e,ro,"iler

    1. Mo+ori): he#ip"ree "l+ern"n3 i"r+ri"

    2. Senori): he#ihipe+ei" "l+ern"n3 p"re+ei"

    9. G"ngg&"n i&"l : he#i"nopi" ho#ini#3 or+i"l ,linne3 TIA

    '. G"ngg&"n l"in: g"ngg&"n )eei#,"ng"n3 er+igo3 iplopi"

    I2$ ,e@ala S5#'ke

    Se"r" ge"l" +ro)e ,er&p" er"ng"n #en"")3 ,er&p" :139

    1. ee#&+"n "n )ele#"h"n p"" -""h3 leng"n "+"& +&ng)"i3+er&+"#" p""

    "+& ii +&,&h

    2. Confuse3 g"ngg&"n ,i"r" "+"& #enger+i pe#,i"r""n

    9. G"ngg&"n penglih"+"n "+& "+"& )e&" #"+"

    '. e&li+"n ,er"l"n3 p&ing3 g"ngg&"n )eei#,"ng"n "n )oorin"i

    !. N$eri )ep"l" he,"+ $"ng ,el el" pen$e,",n$"

    S5#'ke em'#a!ik

    *e"hn$" pe#,&l&h "r"h o+") #en$e,",)"n )el&"rn$" "r"h )e "ring"n

    p"ren)i# o+")3 r&"ng "ir"n ere,ropin"li ie)i+"r o+") "+"& )o#,in"i )e&"n$".

    *er"r"h"n +ere,&+ #en$e,",)"n g"ngg&"n er",&+ "r"5 o+") #el"l&i pene)"n"n

    +r&)+&r o+") "n &g" oleh he#"+o# $"ng #en$e,",)"n i)e#i" p"" "ring"n

    e)i+"rn$". *ening)"+"n +e)"n"n in+r")r"ni"l p"" gilir"nn$" ")"n #eni#,&l)"n

    herni"i "ring"n o+") "n #ene)"n ,"+"ng o+").!

    E5i'l'!i da#i S5#'ke em'#a!ik "

    1< Pe#da#aha i5#a%e#eb#al

    22

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    *er"r"h"n in+r"ere,r"l i+e#&)"n p"" 10 "ri el&r&h )"& +ro)e3 +eriri "ri

    ;0 i he#i5er o+") "n i"n$" i ,"+"ng o+") "n ere,el. 6

    Ge"l" )lini :

    One+ per"r"h"n ,eri5"+ #en"")3 +er&+"#" e-")+& #el")&)"n ")+ii+" "n

    "p"+ i"h&l&i oleh ge"l" proro#"l ,er&p" pening)"+"n +e)"n"n "r"h $"i+&

    n$eri )ep"l"3 #&"l3 #&n+"h3 g"ngg&"n #e#ori3 ,ing&ng3 per"rh"n re+in"3 "n

    epi+")i.

    *en&r&n"n )e""r"n $"ng ,er"+ "#p"i )o#" ier+"i he#iplegi"/he#ip"ree

    "n "p"+ ier+"i )e"ng 5o)"l / .

    T"n"+"n" pene)"n"n ,"+"ng o+")3 ge"l" p&pil &nil"+er"l3 re5le) perger")"n

    ,ol" #"+" #enghil"ng "n eere,r"i

    D"p"+ ip"i +"n"+"n" +e)"n"n +inggi in+r")r"ni"l (TTI3 #i"ln$"

    p"pilee#" "n per"r"h"n &,hi"loi.

    < Pe#da#aha %uba#akh'id

    *er"r"h"n &,"r")hnoi ""l"h &"+& )e"""n i#"n" +er"i per"r"h"n i r&"ng

    &,"r")hnoi $"ng +i#,&l e"r" pri#er.6

    Ge"l" )lini :

    One+ pen$")i+ ,er&p" n$eri )ep"l" #en"") eper+i #ele")3 r"#"+i3

    ,erl"ng&ng "l"# 1 H 2 e+i) "#p"i 1 #eni+. er+igo3 #&"l3 #&n+"h3 ,"n$") )ering"+3 #engigil3 #&"h +er"ng"ng3 geli"h

    "n )e"ng.

    D"p"+ i+e#&)"n pen&r&n"n )e""r"n "n )e#&i"n ""r "l"# ,e,er"p"

    #eni+ "#p"i ,e,er"p" "#.

    Dip"i ge"l"ge"l" r"ng"ng #eningen

    *er"r"h"n re+in" ,er&p" per"r"h"n &,hi"li #er&p")"n ge"l" )"r")+eri+i)

    per"r"h"n &,"r")hnoi.

    G"ngg&"n 5&ngi o+ono# ,er&p" ,r"i)"ri "+"& +")i)"ri3 hipo+eni "+"&

    hiper+eni3 ,"n$") )ering"+3 &h& ,""n #ening)"+3 "+"& g"ngg&"n

    pern"5""n.!

    S5#'ke N'em'#a!ik

    *er,e""n per"r"h"n in+r"ere,r"l3 in5"r) +ro#,oi "n e#,oli7

    29

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    *er"r"h"n

    in+r"ere,ri

    In5"r) +hro#,oi @#,oli

    One+ %#n$" +er"i

    ""+ ,er")+ii+"

    S""+ i+ir"h"+3

    Bi""n$" i"-"li

    ge"l" proor#"l

    p&ing (TIA

    eng"n e5ii+

    ne&rologi

    Ter"i ""+

    ,er")+ii+"3

    ge"l" #&n&l

    "l"#

    -")+& ,e,er"p"

    e+i)

    "+"& #eni+

    Ge"l"

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    B"+""n pen$")i+ gin"l )roni)

    1. er&")"n gin"l 9 ,&l"n3 $"i+& )el"in"n +r&)+&r "+"& 5&ngi gin"l3 eng"n "+"& +"np"

    pen&r&n"n l"& 5il+r"i glo#er&l& ,er""r)"n:

    el"in"n p"+ologi)

    *e+"n" )er&")"n gin"l eper+i pro+ein&ri" "+"& )el"in"n p"" pe#eri)""n peni+r""n

    2. "& 5il+r"i glo#er&l& K 60 #l/#eni+/1379# el"#" 9 ,&l"n eng"n "+"& +"np" )er&")"n

    gin"l

    "& 5il+r"i glo#er&l& (FG "n +"i pen$")i+ gin"l )roni) ""l"h:

    S5adium /e%k#i)%i *F, ;m*mei51$73 mB