Seorang wanita 60 tahun dengan mitral regrgitasi moderate, decomp cordis nyha iii, penyakit jantung rematik

SEORANG PEREMPUAN USIA 57 TAHUNDENGAN HEMIPARESE TIPIKA SINISTRA ET CAUSA SUSPEK STROKE NON HEMORAGIK

Oleh:Tri Adinda G M G99122108

KEPANITERAAN KLINIK BAGIAN REHABILITASI MEDIKFAKULTAS KEDOKTERAN UNS/RSUD DR MOEWARDIS U R A K A R T A2013Presentasi KasusPembimbing:dr. Hj. Tri Lastiti Widowati, Sp. KFR, M. Kes

Status PasienNama:Ny. YUmur: 57 tahunJenis Kelamin: PerempuanAgama: IslamPekerjaan : Ibu rumah tanggaAlamat: Banjarsari, surakartaNo. RM: 01225386Tanggal Masuk: 25 Oktober 2013Tanggal periksa: 29 Oktober 2013

IDENTITAS PENDERITA ANAMNESISKelemahan anggota gerak kiri

KELUHAN UTAMA1 hari sebelum masuk rumah sakit Kurang lebih 1 hari sebelum masuk rumah sakit, pasien mengalami kelemahan anggota gerak kiri saat sedang istirahat di rumahnya. Keluhan dirasakan semakin memberat. Menurut keluarga pasien, sejak 1 hari sebelum masuk rumah sakit, pasien bicara pelo. Pasien sadar dan dapat berkomunikasi, pasien juga tidak mengeluh pusing, namun tidak mual atau muntah, merot (+), kejang (-), wajah tampak merot ke kanan.RIWAYAT PENYAKIT SEKARANG RIWAYAT PENYAKIT DAHULURIWAYAT PENYAKIT KELUARGASt. Generalis

Keadaa Umum : sakit berat, gizi kesan cukup Vital Sign : TD: 140/90 mmHgNadi: 88 x/menitRR: 18 x/menitSuhu: 36.5 C

PEMERIKSAAN FISIK

Pemeriksaan fisik

KulitKepalaMataHidungTelingaMulutLeherThoraksJantung jantung kesan melebarParuAbdomenekstremitas

St. Neurologis

Kesadaran: GCS E4V5M6Fungsi luhur: disartriaFungsi vegetatif: dbnFungsi sensorik: N/N N/N

St. Neurologis

Fungsi motorik dan reflek:AtasTengahBawahKa/kika/kika/ki1. LenganKekuatan5/15/15/1 Tonusn/ n/ n/Reflek Biseps+2/+3Reflek Triseps+2/+3Reflek Hoffman- / +Reflek Tromner- / +AtasTengahBawahKa/kika/kika/ki2. TungkaiKekuatan5/1 5/1 5/1Tonusn/ n/ n/Reflek Patella+2/+3Reflek Achilles+2/+3Reflek Babinsky - / +Reflek Gonda stranski- / +

Nervus CranialisN.VII: kesan parese sinistraN. XII: kesan parese sinistra

Status Ambulasi : Fully dependent

ROM

MMT

PEMERIKSAAN PENUNJANGLAB DARAH29/10/2013SatuanRujukanHb12.4g/dl11.7-16.2Hct3633-45AE4.75106/l4.6-6.2AL6.5103/l4,5-11AT238103/l150-440Gol DarahBGDS117mg/dL80-140Ureum17mg/dL10-50Kreatinin0,8mg/dL0,7-1,3Na142mmol/ L136-146K3.1mmol/ L3,5-5,1Cl109mmol/ L98-106Foto Thorax PA26 oktober 2013Cor : ukuran membesar dengan CTR > 50%, tampak dilatasi aortaPulmo : tak tampak infiltrate di kedua lapang paru, corakan bronkovaskular normalSinus phrenicocostalis kanan kiri tajamHemidiafragma kanan kiri normalTrakea di tengahSistema tulang baikKesimpulan : Cardiomegaly Hypertension heart disease

DIAGNOSISDaftar MasalahMedis : - suspek stroke infark- Hipertensi stage I

Problem rehab medik :FT: kelemahan ekstremitas atas dan bawah sebelah kiriST: ggn artikulasiOT: ggn aktivitas fisikSM: butuh bantuan untuk aktivitas sehari-hariOP: keterbatasaan saat ambulasi

PenatalaksanaanHead up 30O2 3 liter/menitInfus NaCl 0.9% 20 tpmInjeksi Sohobion amp/24 jam DRIPInjeksi Citicolin 250 mg/ 12 jamInjeksi Ranitidin 50 mg/12 jamCaptopril 2x25 mg

Penatalaksanaan rehab medikEdukasi pasien dan keluarganya tentang penyakit pasienFisioterapi : Positioning dan turning setiap 2 jamGeneral passive ROM exerciseTerapi wicara: latihan terapi wicara dan terapi bahasaSosiomedik: motivasi dan konseling keluarga pasien untuk selalu berusaha menjalankan home program maupun program di RS.Psikologi : memberikan motivasi kepada keluarga pasien agar selalu melaksanakan program rehabilitasi.IMPAIRMENT, DISSABILITY DAN HANDICAPImpairment: lateralisasi sinistra, parese N. VII UMN, disartriaDisability: penurunan fungsi tungkai dan lengan kiri, artikulasi tidak jelasHandicap: keterbatasan melakukan aktivitas sehari-hari, keterbatasan melakukan komunikasi dan sosialisasi.PlanningTujuanMengurangi impairment, disabilitas, dan handicap yang dialami.Mencegah komplikasi yang lebih buruk.Mengatasi masalah psikososial yang timbul akibat penyakit yang diderita pasienPrognosisTINJAUAN PUSTAKAGangguan fungsional otak yang terjadi secara mendadak dengan tanda dan gejala klinis (fokal & global), berlangsung lebih dari 24 jam atau menyebabkan kematian, tanpa adanya penyebab lain yang jelas selain vaskuler (WHO, 2005)DEFINISIKLASIFIKASISTROKEHEMORAGIKNON -HEMORAGIKINTRASEREBRALSUBARACHNOIDTROMBOTIKEMBOLIK

31 Penyebab Kematian No.3 & penyebab kecacatan No.1 di dunia Tingkat Insidensi : 10 20 kasus/ 100.000 populasiEPIDEMIOLOGISTROKEDAPAT DIMODIFIKASI RIWAYAT STROKEHIPERTENSI PENYAKIT JANTUNG DIEBETES MELITUS TIA (Transient Ischemic Attack) HIPERKOLESTEROL OBESITAS MEROKOK

FAKTOR RESIKOTIDAK DAPAT DIMODIFIKASI USIA JENIS KELAMIN GENETIKEtiologiPatofisiologiGangguan pasokan darahAliran darah ke otak terputusInfark / Kematian jaringanProses patologik yang mendasari :

Keadaan penyakit pada pembuluh darah itu sendiriBerkurangnya perfusi akibat gangguan status aliran darahAkibat bekuan atau embolus infeksi yang berasal dari jantung atau pembuluh ekstrakraniumManifestasi KlinisBergantung pada berat ringannya gangguan pembuluh darah dan lokasi tempat gangguan peredaran darah terjadi. DIAGNOSIS & PEMERIKSAANCustom animation effects: faded zoom text, collapse, and stretch(Intermediate)

Tip: This effect can be applied to a series of names, award recipients, team members, etc.

To reproduce the text effects on this slide, do the following:On the Home tab, in the Slides group, click Layout, and then click Blank.On the Insert tab, in the Text group, click Text Box, and then on the slide, drag to draw the text box.Enter text in the text box, select the text, and then on the Home tab, in the Font group, select Franklin Gothic Heavy from the Font list, enter 56 in the Font Size box, and then click Bold.On the Home tab, in the Paragraph group, click Center to center the text in the text box.With the text box still selected, under Drawing Tools, on the Format tab, in the bottom right corner of the WordArt Styles group, click the Format Text Effects dialog box launcher. In the Format Text Effects dialog box, click Text Fill in the left pane, select Gradient fill in the Text Fill pane, and then do the following:In the Type list, select Linear.Click the button next to Direction, and then click Linear Down (first row, second option from the left). Under Gradient stops, click Add or Remove until two stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops that you added as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 25%.Click the button next to Color, and click More Colors. In the Colors dialog box, on the Custom tab enter values for Red: 219, Green: 76, and Blue: 19.Select Stop 2 from the list, and then do the following: In the Stop position box, enter 100%.Click the button next to Color, and click More Colors, and then in the Colors dialog box, on the Custom tab enter values for Red: 245, Green: 174, and Blue: 135.On the slice, select the text box. On the Home tab, in the Clipboard group, click the arrow under Paste, and then click Duplicate. Right-click the second text box, and then click Edit Text. Enter new text.On the slide, press and hold CTRL, and then select both text boxes.On the Home tab, in the Drawing group, click Arrange, point to Align, and then do the following:Click Align to Slide.Click Align Middle.Click Align Center.

To reproduce the animation effects for the first text box on this slide, do the following:On the Animations tab, in the Animations group, click Custom Animation.On the slide, select the text box. In the Custom Animation task pane, do the following:Click Add Effect, point to Entrance, and then click More Effects. In the Add Entrance Effect dialog box, under Subtle, click Faded Zoom.Select the animation effect (faded zoom effect for the first text box). Under Modify: Faded Zoom, do the following: In the Start list, select With Previous.In the Speed list, select Medium.On the slide, select the first text box. In the Custom Animation task pane, do the following:Click Add Effect, point to Entrance, and then click More Effects. In the Add Entrance Effect dialog box, under Basic, click Fly-In.Select the second animation effect (fly-in effect for the first text box). Under Modify: Fly In, do the following: In the Start list, select With Previous.In the Direction list, select From Top.In the Speed list, select Medium.On the slide, select the first text box. In the Custom Animation task pane, do the following:Click Add Effect, point to Exit, and then click More Effects. In the Add Exit Effect dialog box, under Moderate, click Collapse.Select the third animation effect (collapse effect for the first text box). Click the arrow next to the selected effect, and then click Effect Options. In the Collapse dialog box, do the following: On the Effect tab, in the Direction list, select Across.On the Timing tab, do the following:In the Start list, select After Previous.In the Delay box, enter 0.5.In the Speed list, select 1 seconds (Fast).

To reproduce the animation effects for the second text box on this slide, do the following:On the Animations tab, in the Animations group, click Custom Animation.On the slide, select the second text box. In the Custom Animation task pane, do the following:Click Add Effect, point to Entrance, and then click More Effects. In the Add Exit Effect dialog box, under Moderate, click Stretch. Select the fourth animation effect (stretch effect for the second text box). Click the arrow next to the stretch effect, and then select Effect Options. In the Stretch dialog box, do the following:On the Effect tab, in the Direction list, select Across.On the Timing tab, do the following:In the Start list, select With Previous.In the Delay box, enter 1.In the Speed list, select 1 seconds (Fast).On the slide, select the second text box. In the Custom Animation task pane, do the following:Click Add Effect, point to Exit, and then click More Effects. In the Add Exit Effect dialog box, under Basic, click Fly Out.Select the fifth animation effect (fly-out effect for the second text box). Click the arrow next to the fly-out effect, and then select Effect Options. In the Fly Out dialog box, do the following:On the Effect tab, in the Direction list, select To Bottom.On the Timing tab, do the following:In the Start list, select After Previous.In the Delay box, enter 0.5.In the Speed list, select 2 seconds (Medium).On the slide, select the second text box. In the Custom Animation task pane, do the following:Click Add Effect, point to Exit, and then click More Effects. In the Add Exit Effect dialog box, under Subtle, click Faded Zoom. Select the sixth animation effect (faded zoom effect for the second text box). Under Modify: Faded Zoom, do the following:In the Start list, select With Previous.In the Speed list, select Medium.

To reproduce the background effects on this slide, do the following: Right-click the slide background area, and then click Format Background. In the Format Background dialog box, click Fill in the left pane, select Gradient fill in the Fill pane, and then do the following:In the Type list, select Radial.Click the button next to Direction, and then click From Center (third option from the left).Under Gradient stops, click Add or Remove until two stops appear in the drop-down list.Also under Gradient stops, customize the gradient stops that you added as follows:Select Stop 1 from the list, and then do the following:In the Stop position box, enter 25%.Click the button next to Color, and then click White, Background 1 (first row, first option from the left).Select Stop 2 from the list, and then do the following: In the Stop position box, enter 100%.Click the button next to Color, and then click Olive Green, Accent 3, Lighter 60% (third row, seventh option from the left). Pemeriksaan FisikDiagnosis dan Pemeriksaan TambahanPenatalaksanaanMedikamentosaobat yang memperbaiki perfusi ke daerah penumbra, yaitu golongan trombolitik (streptokinase, urokinase, aktivator plasminogen)

obat yang melindungi daerah penumbra agar tidak mengalami kematian sel, yaitu golongan neuroprotektan (citikolin, piracetam, nimodipin)

Rehabilitasi MedikFisio terapiTerapi wicaraPetugas sosiomedik, memotivasi dan melakukan konseling keluarga pasien untuk selalu menjalankan home program atau pun program di RS.Ortesa protesaPsikoterapiPenatalaksanaanIntervensi rehabilitasi pada stroke secara khusus, ditujukan untuk:

Mencegah timbulnya komplikasi akibat tirah baringMenyiapkan/mempertahankan kondisi yang memungkinkan pemulihan fungsional yang paling optimalMengembalikan kemandirian dalam melakukan aktivitas sehari-hariMengembalikan kebugaran fisik dan mental

Pedoman Rehabilitasi Medik pada StrokeHari 1-3 (di sisi tempat tidur)Kurangi penekanan pada daerah yang sering tertekan (sakrum, tumit)Modifikasi diet, bed side, positioningMulai PROM dan AROMHari 3-5Evaluasi ambulasiBeri sling bila terjadi subluksasi bahuHari 7-10Aktifitas berpindahLatihan ADL: perawatan pagi hariKomunikasi, menelan2-3 mingguTeam/family planingTherapeuthic home evaluation3-6 mingguHome programIndependent ADL, tranfer, mobility10-12 mingguFollow upReview functional abilitiesPrognosis10% penderita stroke mengalami pemulihan hampir sempurna25% pulih dengan kelemahan minimum40% mengalami pemulihan sedang sampai berat tidak membutuhkan perawatan khusus.10% membutuhkan perawatan oleh perawat pribadi di rumah atau fasilitas perawatan jangka panjang lainnya.15% langsung meninggal setelah serangan stroke.TERIMA KASIH