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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 paien

• Nama Paien : -n.

• Um/r : $! -ah/n

• 0eni Kelamin : Laki1Laki

• Alamat : Ran+egan 

•

Peker2aan: 3ira4ata • Stat/ Perka4inan : 5enikah

• Agama: lam

• S/k/ : S/n+a

• -anggal 5a/k :  0an/ari !"6

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Anamnei

Kel/han /tama •

 Lemah angg'ta gerak kiri e2ak2am S5RS

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R3A8A- P9N8AK- S9KARAN  

6hari SMRS

O mengel/hkan nyeri pa+a kepala

kiri e2ak 6 hari

S5RS. Nyeri +iraakan 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 ' meraa

akit kepala ebelah kiri. aat ke2a+ian ' mengak/

ti+ak e+ang men2alani akti;ita apap/n. O

hanya e+ang +/+/k beritirahat ep/lang +ari

kant'r5/ntah (1&, ke2ang

(1&, rer' (1&

SMRS

P/k/l "#:!! ' +atang

ke UD RSUD

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• Ri4ayat Str'ke (1&

• Ri4ayat iperteni (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/mi peng'bpan2ang

Riwayat Psikososial

OS e'rang per'k'k, min/m alk'h'l

Riwayat Alergi

Ri4ayat Alergi +iangkal

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Pemerikaan )iik

Kea+aan Um/m : -ampak akit e+ang

Kea+aran : *'mp' menti, *S "7 (9%>756&

-an+a1tan+a ;ital

•

-ekanan Darah : "%[email protected]! mmg • Na+i : #7 kali?menit (terat/r, k/at, pen/h&

• La2/ Pernapaan : ! 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'nai, De;iai ept/m (1&, ekret 1?1

• 5/l/t : 5/k'a 'ral baah, ian'i (1&, li+ah k't'r (1&

• Leher : Pembearah K< (1&, pembearan tir'i+ (1&

Thorax

• Paru

 npeki : imetri, retraki +in+ing +a+a (1?1&

Palpai : ;'kal )remit/ kiri  kanan

Perk/i : 'n'r pa+a ke+/a lapang par/

A/k/ltai : ;eik/ler (=?=&, rh'nki (1?1&, 4heeBing (1?1&

•  

Stat/ enerali

• Jantung

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• Abdomen

npeki :

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Pemerikaan ne/r'l'gi

• Tanda Rangsang Meningeal • Kak/ k/+/k : 1

• Kernig : 1

•

LaeE/e : 1 •

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PEMERKSAA! SARA" KRA!A#

!ER$%S "AKT&R%S

Detra Sinitra

Daya pemba/ N'rm'mia N'rm'mia

!ER$%S &PTK%S

Detra Sinitra

>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 Reeks

!aha"a

#an$sun$

% %

Reeks

!aha"a &idak

#an$sun$

% %

!ER$%S &K%#&M&T&R%S

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!ER$%S TR&K'#EARS

(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 "A0A#S

Kean : Paree N > initra entral

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Kanan Kiri

-e biik N'rmal

-i+ak +ilak/kan-e Rinne

-e 3eber

-e SGh4abaGh

!ER$%S $EST/%#&0'&0#EARS

!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 %

PEMERKSAA! M&T&RK

Kek/atan 't't

-'n/ 't't : N'rmal

Atr')i : -i+ak a+a

"%!)S $E)ETAT" 5iki : baik

De)ekai : baik

Keringat : baik

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"#

PEMERKSAA! SE!S&RK

Detra Sinitra

Raa Raba

-9ktremita Ata

-9ktremita

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"@

RE"#EKS "S&)S

(extra Sinistra

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"I

RE"#EKS PAT&)S

Detra Sinitra

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SKOR A0A 5ADA

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Sk'r Sirira2:

 (,7  kea+aran& = (  ;'mit/& = (  hea+aGhe& = (!

+iat'le& J ($  penan+a ater'ma& J "

 (,7  !& = (  !& = (  "& = (!,"  @!& J ($  !& J "

 (! = !=  = @ J !& J "

 1

 1  n)ark *erebri

SCORE SIR

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DFF9R9N-AL DANOSS

• Str'ke n)ark Kar+i' 9mb'li

• D+? Str'ke Per+arahan ntraerebri

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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'leter'l t'tal, LDL, DL

• *'n/l Speiali 0ant/ng

RE!0A!A PEMERKSAA! PE!%!JA!)

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Pemerikaan Lab'rat'ri/m (?!"?!"6&

JE!S PEMERKSAA! '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 PEMERKSAA! '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 +etra

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3ORKN DANOSS

• Str'ke n)ark Kar+i'emb'li item *ar'ti Detra +engan )akt'r reik' *AD kemik

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-atalakana

 n)/ Aering = -rama+'l  Amp !tpm

 *itiG'lin 7!mg >

 OmepraB'l " >

 5PS $" >

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R9SU59

-n.  $! tah/n +atang ke UD +engan kel/han 7 2am S5RS tiba1tiba ' mengel/hkan lemah angg'ta gerak kiri. Sebel/mnya ' meraa akit kepala ebelah