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8/20/2019 Lapkas Fitriya Stroke Infark
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LAPORAN KASUS
Pembimbing: Dr. Zaki, Sp.S
Oleh : Fitriya(!""#$!"$%&
Kepaniteraan Klinik Ilmu Neurologi Rumah Sakit Umum Daerah Banjar Universitas Muhammadiyah Jakarta
2!"
Str'ke n)ark *erebri
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+entita paien
• Nama Paien : -n.
• Um/r : $! -ah/n
• 0eni Kelamin : Laki1Laki
• Alamat : Ran+egan
•
Peker2aan: 3ira4ata • Stat/ Perka4inan : 5enikah
• Agama: lam
• S/k/ : S/n+a
• -anggal 5a/k : 0an/ari !"6
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Anamnei
Kel/han /tama •
Lemah angg'ta gerak kiri e2ak2am S5RS
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R3A8A- P9N8AK- S9KARAN
6hari SMRS
O mengel/hkan nyeri pa+a kepala
kiri e2ak 6 hari
S5RS. Nyeri +iraakan hilang timb/l. ilang 2ika
min/m 'bat akit kepala. 5/ntah (1&,
kelemahan agg'ta gerak (1&, ke2ang(1&
5Jam SMRS
-iba1tiba ' mengel/hkan
lemah angg'ta gerak kiri. Sebel/mnya ' meraa
akit kepala ebelah kiri. aat ke2a+ian ' mengak/
ti+ak e+ang men2alani akti;ita apap/n. O
hanya e+ang +/+/k beritirahat ep/lang +ari
kant'r5/ntah (1&, ke2ang
(1&, rer' (1&
SMRS
P/k/l "#:!! ' +atang
ke UD RSUD
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• Ri4ayat Str'ke (1&
• Ri4ayat iperteni (1&
• Ri4ayat Penyakit D5 (1&
• Ri4ayat Penyakit 0ant/ng (1&
• Ri4ayat Ke2ang (1& • Ri4ayat -ra/ma (1&
Ri4ayat Penyakit Dah/l/
Riwayat Penyakit Keluarga
Str'ke (1&, D5(1&, Penyakit 0ant/ng
(1&
Riwayat Pengobatan
-i+ak e+ang mengk'n/mi peng'bpan2ang
Riwayat Psikososial
OS e'rang per'k'k, min/m alk'h'l
Riwayat Alergi
Ri4ayat Alergi +iangkal
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Pemerikaan )iik
Kea+aan Um/m : -ampak akit e+ang
Kea+aran : *'mp' menti, *S "7 (9%>756&
-an+a1tan+a ;ital
•
-ekanan Darah : "%[email protected]! mmg • Na+i : #7 kali?menit (terat/r, k/at, pen/h&
• La2/ Pernapaan : ! kali?menit (terat/r&
• S/h/ : $6,#'*
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• Kepala : N'rm'e)ali, +e)'rmita (1&.
• 5ata : K'n2/ngti;a anemi 1?1, klera ikterik 1?1
• -elinga : N'rm'tia, Ser/men 1?1
• i+/ng : N'rm'nai, De;iai ept/m (1&, ekret 1?1
• 5/l/t : 5/k'a 'ral baah, ian'i (1&, li+ah k't'r (1&
• Leher : Pembearah K< (1&, pembearan tir'i+ (1&
Thorax
• Paru
npeki : imetri, retraki +in+ing +a+a (1?1&
Palpai : ;'kal )remit/ kiri kanan
Perk/i : 'n'r pa+a ke+/a lapang par/
A/k/ltai : ;eik/ler (=?=&, rh'nki (1?1&, 4heeBing (1?1&
•
Stat/ enerali
• Jantung
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• Abdomen
npeki :
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Pemerikaan ne/r'l'gi
• Tanda Rangsang Meningeal • Kak/ k/+/k : 1
• Kernig : 1
•
LaeE/e : 1 •
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PEMERKSAA! SARA" KRA!A#
!ER$%S "AKT&R%S
Detra Sinitra
Daya pemba/ N'rm'mia N'rm'mia
!ER$%S &PTK%S
Detra Sinitra
>i/ N'rmal N'rmal
Lapang Pan+ang N'rmal N'rmal
F/n+/k'pi
-i+ak +ilak/kanPapil e+ema
Arteri:>ena
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Dextra Sinistra
Ptosis - -
Gerakan Bola Mata
•Medial
•Atas
•Bawah
Baik
Baik
Baik
Baik
Baik
Baik Ukuran Pupil Pupil bulat isokor Ø ODS 3 mm Reeks
!aha"a
#an$sun$
% %
Reeks
!aha"a &idak
#an$sun$
% %
!ER$%S &K%#&M&T&R%S
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!ER$%S TR&K'#EARS
(extra Sinistra
erakan 5ata
5e+ial
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Kanan Kiri
erakan mata ke lateral
= =
Kanan K
5engangkat Ali =
5en/t/p 5ata =
5enyeringai N'rmal -erti
(aya ke*a+ lidah ,-. de+an -i+ak +ilak/kan -i+ak +
!ER$%S A/(%SE!S
!ER$%S "A0A#S
Kean : Paree N > initra entral
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Kanan Kiri
-e biik N'rmal
-i+ak +ilak/kan-e Rinne
-e 3eber
-e SGh4abaGh
!ER$%S $EST/%#&0'&0#EARS
!ER$%S )#&S&"AR!)E%S dan !ER$%S $A)%
(aya Ke*a+ #idah 1-. belakang Tidak dilakukan
U;/la Letak +itengah, gerak imetri
5enelan N'rmal
Re)lek m/ntah -i+ak +ilak/kan
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7 !
7 %
PEMERKSAA! M&T&RK
Kek/atan 't't
-'n/ 't't : N'rmal
Atr')i : -i+ak a+a
"%!)S $E)ETAT" 5iki : baik
De)ekai : baik
Keringat : baik
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"#
PEMERKSAA! SE!S&RK
Detra Sinitra
Raa Raba
-9ktremita Ata
-9ktremita
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"@
RE"#EKS "S&)S
(extra Sinistra
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"I
RE"#EKS PAT&)S
Detra Sinitra
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SKOR A0A 5ADA
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Sk'r Sirira2:
(,7 kea+aran& = ( ;'mit/& = ( hea+aGhe& = (!
+iat'le& J ($ penan+a ater'ma& J "
(,7 !& = ( !& = ( "& = (!," @!& J ($ !& J "
(! = != = @ J !& J "
1
1 n)ark *erebri
SCORE SIR
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DFF9R9N-AL DANOSS
• Str'ke n)ark Kar+i' 9mb'li
• D+? Str'ke Per+arahan ntraerebri
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• *-1SGan Kepala
• 9K
• R' -h'ra
• Lab'rat'ri/m : b, t, Le/k'it, -r'mb'it, P-, A
DS, DP, Pr')il lipi+: k'leter'l t'tal, LDL, DL
• *'n/l Speiali 0ant/ng
RE!0A!A PEMERKSAA! PE!%!JA!)
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Pemerikaan Lab'rat'ri/m (?!"?!"6&
JE!S PEMERKSAA! 'AS# !#A !&RMA# (A!
Elektrolit
Natri/m (Na& "$I.% "$7 J "%@ m
Kali/m (K& [email protected] $.7 J 7.$ m
Kl'ri+a (*l& [email protected]# I7 J "[email protected] m
Kimia Klinik
Kretainin [email protected]# [email protected] J ".7 m
Ure/m $!.I "! J 7! m
/la Darah Se4akt/ [email protected] @!1"7! mg
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0a4aban *'n/l 0ant/ng :
Diagn'i : *AD kemik
JE!S PEMERKSAA! 'AS# !#A !&RMA# (
'ematologi Anali3er
em'gl'bin "@. "!1"@
-r'mb'it $$" "7!1%7!
emat'krit 77.6 $"1
Le/k'it ". %.! J "".!
9ritr'it 6.!I %.#6 J 6.
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ambaran hip'+en pa+a
+aerah temp'ral +etra
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3ORKN DANOSS
• Str'ke n)ark Kar+i'emb'li item *ar'ti Detra +engan )akt'r reik' *AD kemik
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-atalakana
n)/ Aering = -rama+'l Amp !tpm
*itiG'lin 7!mg >
OmepraB'l " >
5PS $" >
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R9SU59
-n. $! tah/n +atang ke UD +engan kel/han 7 2am S5RS tiba1tiba ' mengel/hkan lemah angg'ta gerak kiri. Sebel/mnya ' meraa akit kepala ebelah