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Case Report-Hemorragic Stroke-Fitra Rulian
Case Report-Hemorragic Stroke-Fitra Rulian
Case Report-Hemorragic Stroke-Fitra Rulian
Hemorrhagic Stroke
By:
Fitra Rulian Anwar
1608437616
Supervisor:
dr. Enny Lestari, Sp.S
DEPARTMENT OF NEUROLOGY
MEDICAL SCHOOL RIAU UNIVERSITY
RSUD ARIFIN ACHMAD
PEKANBARU
2018
KEMENTERIAN PENDIDIKAN DAN KEBUDAYAAN
FAKULTAS KEDOKTERAN UNIVERSITAS RIAU
SMF/ BAGIAN SARAF
Sekretariat : Gedung Kelas 03, RSUD Arifin Achmad Lantai 04
Jl. Mustika, Telp. 0761-7894000
E-mail : saraffkur@gmail.com
PEKANBARU
I. Patient’s Identity
Name Mrs. LA
Age 23 years old
Gender Female
Address Indragiri Hilir
Religion Islam
Marital’s Status Married
Occupation Housewife
II. ANAMNESIS :
Alloanamnesis with patient’s husband (Aug, 2nd 2018)
Chief Complain
Weakness of right extremities
Present illness history
Patient presented with muscle weakness on the right side of her body when
she was waking up since 7 days before admitted to Arifin Achmad’s General
Hospital. The weakness equally intense in both upper and lower limbs. Few
hours after present the muscle weakness, patient directly bring by her family
to PH Hospital and treated for 6 days. Apart from that, the patient also
complained of headache 1 week before, nausea, vomiting and speech
difficulties. The patient did not present any other complaint, including loss of
consciousness, injury or seizures.
Past Illness history
History of hypertention (-)
History of brain and spine trauma (-)
History of stroke (-)
Diabetes Mellitus (-)
History of seizurres (-)
History of heart disease (-)
History Jobs
Housewife
RESUME ANAMNESIS
Patient Mrs. LA, 23 years old, was admitted to Arifin Achmad’s General
Hospital with her main complaint being muscle weakness in the right side of her
whole body since 7 days ago, speech difficulties, headache, nausea and vomit
were present. No history of seizure and loss of consciousness.
III. Physical Examination
A. Generalized Condition
Blood Presure : 120/80 mmHg
Heart Rate : 90 bpm
Respiratory : Respiratory rate : 22 x/mnt
Temperature : 36,8°C
Weight : 50 kg
Height : 155 cm IMT : 20,83 (Normoweight)
B. NEUROLOGICAL STATUS
1) Consciousness : Composmentis GCS : E4V5M6
2) Cognitive Function : Difficult to assess
3) Neck stiffness : Positive
4) Cranial Nerves
1. N. I (Olfactorius )
Right Left Interpretation
Sense of Smell Normal Normal Normal
2. N.II (Opticus)
Right Left Interpretation
Normal Normal
Visual Acuity
3. N.III (Oculomotor)
Right Left Interpretation
Ptosis - -
Pupil
Shape isochoric isochoric
Side Round Round Normal
Φ3mm Φ3mm
Pupillary reaction to light
direct + +
Indirect + +
4. N. IV (Trochlear)
Right Left Interpretation
Extraocular
(+) (+) Normal
movements
5. N. V (Trigeminal)
Right Left Interpretation
Motoric
Sensory Normal Normal Normal
Corneal reflex
6. N. VI (Abduscens)
Right Left Interpretation
Doll eyes manuver (+) (+)
Strabismus (-) (-) Normal
Deviation (-) (-)
7. N. VII (Facialis)
Interpretati
Right Left
on
Tic (-) (-)
Motor
- Frowning Normal Normal
- Raised eye Normal Normal
brow Normal Normal
- Close eyes Normal Normal
- Corners of Normal
the mouth Normal Normal
- Nasolabial
fold Normal Normal
Sense of Taste Normal Normal
Chvostek Sign (+) (+)
8. N. VIII (Acoustic)
Right Left Interpretation
Normal Normal
Hearing sense Normal
9. N. IX (Glossopharyngeal)
Right Left Interpretation
Arcus farings Normal Normal
Normal
Gag Reflex Normal Normal
10.N. X (Vagus)
Right Left Interpretation
Arcus farings Normal Normal
Normal
Dysfonia Normal Normal
11.N. XI (Accessory)
Right Left Interpretation
Motoric Normal Normal
Normal
Trophy Normal Normal
V. SENSORY
Right Left Interpretation
Touch
Pain Normal Normal
Temperature
Proprioceptive
Position
Normal
Two point
discrimination Normal Normal
Stereognosis
Graphestesia
Vibration
VI. REFLEX
Right Left Interpretation
Physiologic
Biseps + +
Physiologic reflex
Triseps + +
(+)
Patella + +
Achilles + +
Patologic
(-) (-)
Babinski
(-) (-)
Chaddock
(-) (-) Pathologic Reflex (-)
Hoffman Tromer
(-) (-)
Openheim
(-) (-)
Schaefer
VII. COORDINATION
Right Left Interpretation
Point to point movement
Walk heel to toe
Disdiadokonesia difficult difficult
difficult to assess
Gait to assess to assess
Tandem
Romberg
VIII. OTONOM
Urinate : urine catheterized
Defecate : normal
SIRIRAJ SCORE
(2.5 x level of consciousness (0)) + (2 x Vomit (1)) + (2 x headache (1)) + (0.1
x diastolic (80)) – (3x atheroma factor (0)) – 12 = 0
Interpretation : -1until 1= Confuse Suggested to CT- Scan
X. EXAMINATION RESUME
Generalized Condition
Consciousness : Composmentis (E(4)V(5)M(6))
Blood Presure : 120/80 mmHg
Heart Rate : 90 bpm
Respiratory : Respiratory rate : 22 x/mnt
Temperature : 36,8°C
Weight : 50 kg
Height : 155 cm
Cognitive Function :difficult to assess
Meningeal Sign : Neck stiffness (+),Brudzinski I-IV (-)
Cranial Nerve : Normal
Motoric : Right hemiparesis, Central lesion of Upper Motor Neuron
Sensory :Normal
Otonom : Normal
Reflex : Physiologic (+), Patologic (-)
Gajah mada score : Hemorrhagic stroke
Siriraj score : Confuse
SUGGESTION EXAMINATION
o Blood routine Hb, Ht, leucocyte, platelets
o Blood chemistryBlood glucose, ureum, creatinin, SGOT, SGPT, total
cholesterol, HDL, LDL, Trygliseride
o Electrolyte
o Head CT Scan without contrast
o Chest X-Ray AP
o ECG
MANAGEMENT
General
- Bed rest with head position elevated 300
- Control of vital sign
- Monitoring intracranial pressure
- Oxygen 2-3 L/minute (Nasal Cannula)
- IVFD Ringer Lactate (30cc/kgBW/day) 20 dpm
- Calorie needs 25-30 kkal/kgBW/day: Carbohydrate 30-40% of total
calories, fat 20-35% of total calories, protein 20-30% of total calories
- Consult the patient to physical medicine and rehabilitation (PM&R)
Special
- Anti-edema : Manitol 125 cc/8 h
- Antifibrinolytic : Tranexamic acid 3x500 mg iv
- Neuroprotector : Citicolin 3x500 mg iv
- Gastric protector : Ranitidin 2x50 mg iv
LABORATORIUM FINDING :
1. Blood Routine (July, 25th 2018)
Hemoglobin : 12,7 gr/dl
Hematocrit : 38 %
Leucocytes : 18.000 /mm3
Platelets : 223.000/mm3
Interpretation :
Sinus Tachycardial, normo axis, heart rate 107 bpm
FINAL DIAGNOSE
- Hemorrhage stroke
- Intraventricullar hemorrhage
A : Haemorrhagic stroke
P :
Head up 30o
O2 3 L/minute
IVFD RL 20drops/minute
Manitol 125 cc/8 h iv
Tranexamat acid 3x500 mg iv
Ranitidin 2 x 50 mg iv
Follow up Aug, 4th 2018
S : Weakness of right extremities (+)
O :GCS: E4V5M6
Blood Pressure :120/80 mmHg
Heart Rate : 90 bpm
Respiratory Rate : 22x/i
Temperature : 36,9 °C
Cognitive Function :Normal
Meningeal Sign :Negative
Cranial Nerves :light reflect (+/+)
Motoric :Hemiparese dextra
Sensory :Normal
Coordination :Difficult to assess
Autonomy :urinate with urine catheterized
Reflex : Pathologic (-), Physiology (+)
A : Haemorrhagic stroke
P :
Head up 30o
O2 3 L/minute
IVFD RL 20drops/minute
Manitol 125 cc/8 h iv
Tranexamat acid 3x500 mg iv
Ranitidin 2 x 50 mg iv
A : Haemorrhagic stroke
P :
Head up 30o
O2 3 L/minute
IVFD RL 20drops/minute
Manitol 125 cc/8 h iv
Tranexamat acid 3x500 mg iv
Ranitidin 2 x 50 mg iv
DISCUSSION
1. Stroke
1.1. Definitions
Stroke is a collection of symptoms characterized by the development of
clinical manifestations of cerebral function disorders either focal or global (for the
patient in a coma), which happens quickly and more than 24 hours or ended up
with death without being discovered other causes than vascular disorders. This
definition includes stroke due to cerebral infarction (ischemic stroke),
nontraumatic intracerebral hemorrhage, intraventricular hemorrhage and some
cases of subarachnoid hemorrhage.1
1.2. Epidemiology
The increasing age of life expectancy will tend to increase the risk of
vascular disease (coronary heart disease, stroke and peripheral artery disease).
Data in Indonesia showed the tendency of an increase in stroke cases both in
terms of mortality, incidence, and disability. The mortality rate based on age is:
15.9% (age 45-55 years) and 26.8% (age 55-64 years) and 23.5% (age 65 years).
The incidence of stroke amounted to 51.6 / 100,000 population. Sufferers are men
more than women and age profile under 45 years of 11.8%, 54.2% aged 45-64
years, and age over 65 years amounted to 33.5%. Stroke attacking reproductive
age and the elderly that could potentially give rise to new problems in health
development nationally at a later date.2
1. Ischemic stroke
The obstruction that occur can be a clot (thrombus) that are present in
the brain blood vessels as wll as inherited from the distal organ blood vessels
(embolism) which causes blockage in the brain vascularization. The most
common cause of thrombosis in the form of atherosclerosis that is cause
stenosis or narrowing of the blood vessels. While the most common of
embolic stroke is an embolus coming from large blood vessels or heart.5
The brain gets blood from the heart, blood containing oxygen and
nutrients to the brain. The amount of blood flow to the brain in normal
circumstances usually about 50-60 ml / 100 g of brain tissue / min, mean the
brain needs 20% of the blood pumped from the heart. If the clogged arteries,
brain cells (neurons) can not generate enough energy and the brain stops
working.7,8
When the blood flow to the brain stops within 6 seconds will occur
neuron metabolic disorders, if more than 30 seconds EEG picture will be
horizontally, within 2 minutes there will be termination of brain activity,
within 5 minutes began to brain damage and more than 9 minutes, humans
will die. Ischemic brain occurs when blood flow to the brain is reduced to 25-
30 ml / 100 grams of brain tissue permenit.1
2. Hemorrhagic stroke
1. Lost of consciousness
2. Headache
Acute stroke
3. Pathology reflex
SSS DIAGNOSE
1.6 Management
1. Ischemic stroke
General treatment:
Special treatment:
2.Hemorrhage stroke
General treatment:
Patients with hemorrhagic stroke should be treated in the ICU if the
hematoma volume> 30 mL, intraventricular hemorrhage with hydrocephalus, and
clinical situation tends to be worsen. Blood pressure should be reduced until
premorbid blood pressure or 15-20% when the systolic pressure> 180 mmHg,
diastolic> 120 mmHg, MAP> 130 mmHg, and hematoma volume increases.
When there is heart failure, blood pressure should be reduced immediately with
10 mg iv labetalol (administration within 2 minutes) to 20 mg (administration
within 10 minutes) maximum dosage is 300 mg, enalapril iv 0,625-1.25 mg per 6
hours, captopril given three times of 6.25 to 25 mg orally. If there are signs of
increased the intracranial pressure, head position elevated 30o, the position of the
head and chest in one area, mannitol (see treatment of ischemic stroke), and
hyperventilation (pCO2 20-35 mmHg). General management same with ischemic
stroke, stomach ulcers resolved with parenteral H2 antagonists, sucralfate, or
proton pump inhibitors; airway complications prevented with physiotherapy and
treated with broad spectrum antibiotics.10
Special treatment:
1.8 Prognosis
2.Hypertension
1. Basic Diagnose
1.1 Basic clinical diagnose
From the history taking, the patient had a sudden muscle weakness on the
right side of her body when she was waking up since 7 days before admitted to
Arifin Achmad’s General Hospital. The weakness equally intense in both upper
and lower limbs. The patient complained of headache 1 week before, nausea,
vomiting and speech difficulties. The right corner of patient’s mouth was flatter 4
days before admitted to Arifin Achmad Hospital. The patient did not present any
other complaint, including loss of consciousness, injury or seizures.
From physical examination we’re found hemiparesis on both right
extremities. It consistent with the WHO definition that clinical symptoms of
stroke is cerebral disorders, either focal or global attack in 24 hours.
a. Laboratory :to find the risk factor for stroke and general condition of
patient.
b. Head CT-scan :to know the final pathology diagnose from the location
and the wide of the lesion.
c. Chest X ray :to find wether the patient had cardiomegaly or not as the
result of heart disease.
2. Basic treatment
a. Bed rest with head position elevated 20-300 to maintance the adequate
circulation to the brain.
b. IVFD (30cc/kgbb/day) RL 20 gtt/i to maintance the euvolemik
condition and glucose level needed.
c. Inj tranexamic acid 3x 500 to control the bleeding
d. Inj citicoline 2 x 500 mg the neuroprotector
e. Manitol infusion 125cc/8 hours is to maintain intra cranial pressure.
f. Inj Ranitidin 2x 50 mg to protector of the gastric.
REFFERENCE
3. Ropper AH, Brown RH. Adams and Victor’s Principles of Neurology. 8th
Ed. New York: McGraw-Hill Companies, Inc. 2005. Chapter 34,
Cerebrovascular Disease; p.660-770.
11. Hoyert DL, Xu J: NVSS. Deaths: Preliminary Data for 2011. National
Vital Statistics Report. 2012;61(6):1-4.
12. James PA, Oparil S, Carter BL, Cushman WC, Dennison C, Handler J,
dkk. Evidence-Based Guideline for The Management of High Blood
Pressure in Adults: Report from the Panel Member Appointed to the Eight
Joint National Committee (JNC 8). JAMA. 2014.