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 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