Stroke Unit Duty Report 23 SEPT

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Duty Report Tuesday September

30rd, 2014

ER: dr. DewiConsult : dr. sty

Stro!e "nit : dr. #ati

$ard: dr. %andu

Tandem : dr. E&a



Patient Identity'ame : (r. )

&e : *4 years old

ddress : %eranten, Semaran&

+upation : pri-ate

Class : / %S down &rade lass

Room : Raawali 3

(RS : +t 10t 2014

R( no. : C450346



• Main Problem : Submission from Ken Saras Hospital

with aspy7iate

• Location :

• Onset : ± 6 hour before

• Quality : Asphyiate with tracheostomi

• Quantity : A!L helpe" by family#

RECENT HISTORY



$ronolo%y:

Patient referrals from Ken Saras hospital with complaints of

Asphiiate an" attache" &racheostomy' while in Ken Saras

patient treate" at ($) "urin% *+ "ays' an" *, "ays attache" a

tracheostomy' wea- of limb ./0' 1omit .20'altere" of

consciousness ./0# Accor"in% a 3amily' patient ha" eperience" asei4ure before a"mission at -en Saras Hospital' an" ha" a loss of

consciousness' but no 5omit an" a hea"ache pre5ious#

&he patient ha" a history of pre5ious stro-e' stro-e obtaine" first

years a%o' an" was "ia%nose" as S7H' then re2epose" toattac- 8 years later' when it was reco5ere" with se9uelae wea-

limbs to the ri%ht# uni 8,* patients re2a"mitte" an" "ia%nose"

with SH'



A%%ra5atin% factor : .20

;elie5in% factor : .20

Other Symptom : .20



PAST HISTORY

2 7on Haemorrha%ic stro-e ./0 in 8,*,'8,*8 se9uellae ./0 wea- limb

;i%ht si"e2 Stro-e haemorra%ic ./0 <une 8,*

2 Hea" trauma .20#

2 Hipertension ./0 since 8,,=' but not pre5iously control

2 !M .20

FAMILY HISTORY

8 Stro!e, D(, 9T 8;

SOCIAL-ECONOMY HISTORY

Class 1 %S down &rade to Class %S



%ysial E7amination

<CS E3(*=Traeostomy

=ital Si&n :

%: 140/100 mm9&9R: >07 /minute

RR: 247 / minute wit Traeostomy

T : 35,4? C



'E"R+@+<C@ STT"SHea" : Mesocephal' Simetris

>ye : Pupil roun"' iso-hor' ? 8'@mm Post operation

Li%ht refle /2 ."ecrease"0

7ec- : nuchal ri%i"ity .20

7n $raniales : "ifficult to accesse"' seeme" lateralitation to the left

Sirira sore :

270 A 172 A072A110710B8 173812 3

9aemorra&e Stro!e



Motoric Superior Inferior

(o-ement A/derease A/derease

Stren&t Seems @ateralisation tosinistra

Tonus

Tropy E/E E/E

%ysiolo&i Ree7 AA/AA AA/AA

%atolo&i Ree7 8/8 8/A ;

Clonus 8/8

Sensibility : diult to aessed

=e&etati-e state : DC A;, no blood 8;



t t



a oratory 7am nat on22/0>/2014

Examination RESULT Normal Point

Routine Hematology

Hb 11.7 13 - 16 g/dl

Ht 33.2 40 – 52 %

Eyt!o"yte 4.06 4.3 - 6.0 mil /ul

#eu$o"yte 11.700 400 - 1000/ul

&!ombo"yte 432.000 150000 - 400000/ul

'() 1. 0 – *6 +#

'(H 2. 27 - 32 ,g

'(H( 35.2 32 – 36 g/d#



JENIS PEMERIKSAAN HASIL NILAI RUJUKAN

imia $lini$

eum 12 20 - 50 mg/dl(eatinine 0.75 0.5 – 1.5 mg/dl

Random lood uga 10 140 mg/dl

atium 141.5 135 – 147 mmol/#

alium 4.2 3.5 – 5.0 mmol/#

(!loide 107.6 *5 – 105 mmol/#



(SCTSC'

uni 2014



C9 %arietal Sinistra 14 ;(ultiple inFart nul. @entiFormisde7tra, Gapsula e7terna De7tra,and Gorona Radiata De7tra



R+ tora7

Cardiome&ali @=;

Suspetronopneumonia



I. Cinica !ia"no#tic :9emiparese de7tra Spastiltered Consiousness

SeiHure 9istoryTopi# !ia"no#tic $ Parieta Sini#traEtioo"y !ia"no#tic : S9II. Cinica !ia"no#tic :9emiparese sinistra spasti%arese '. = Sinistra SentralTopic dia"no#tic $ nuleus lentiFormis, !apsula

e!sterna, orona radiataEtiolo&y Dia&nosti : S'9

III. %ronc&opneu'onia

DIAGNOSIS



Stro!e 9emmora&i



R+'C9+%'E"(+'





Documents

Stroke Unit Duty Report 23 SEPT