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ENDORSEMENT PAGE

Case Report

Non-Haemorrhagic Stroke

Presented by:

Agus Salim

04101401015

Ardiyanto

04101401032

Has been accepted as one of requirements in undergoing senior clinical clerkship period of

April 21 th May 28 st 2014 in Department of Neurology Faculty of Medicine Sriwijaya

University Mohammad Hoesin General Hospital Palembang.

Palembang, 10 th May 2014

Advisor

Dr. H. A. Rachman Toyo, Sp.S(K)

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CHAPTER I

NEUROLOGY MEDICAL RECORDS

IDENTIFICATION

Name : Mr. HD

Age : 67 years

Sex : Laki-laki

Occupation : -

Address : Perum Azhar Blok AX 06 No 17 Rt/Rw: 27/03 Kel.Kenten Laut,

Kab. Banyuasin.

Date of Admission : 07 Mei 2014Registry Number : RI14012432

ANAMNESIS

Patient was admitted to Neurology Department of RSMH due to sudden loss of

consciousness.

+ 12 hours before admission, patient was found unconscious by his neighbours inside

of his house, nothings certain about the process, but they said to seeing him doing someworks outside before the incident. On the onset, whether there is or not headache was

unkown, nauseas (-), vomitting (-), generalized tonic-clonic seizures (-), weakness on right

side of the body (+), drooping mouth (+), slurred speech (could not be assessed), sensibility

(could not be assesed).

History of hypertension (-), history of stroke (-), history of heart diseases (-), history

of head trauma (-), history of fever of unkown origin (-), history of a long time cough (-),

history of previous loss of consciousness (-).

This is the first time patient suffered these conditions and no family history of the same

loss of consciousness.

PHYSICAL EXAMINATION

PRESENT STATEInternal State

Conciousness : E 4M6Vglobal aphasia Nutrition : Overweight Temperature : 37 oC

Heart : No abnormalityLungs : No abnormalityLiver : No abnormality

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Pulse : 56 beats/minRespiratory rate : 16 times/minBlood pressure : 140/80 mmHg

Psychiatric state

Attitude : uncooperativeAttention : unattended

Neurological stateHeadShape : Brachiocephali Size : Normocephalic Symmetric : SymmetricHematome : NoTumor : No

NeckPosition : Straight Torticolis : No

Nape of neck stiffness : yes

Spleen : No abnormality Extremities : see neurological state Genital : Not examined

Facial Expression : FlatPsychological contact : None

Deformity : NoFracture : NoFracture pain : NoVessel : No wideningPulsation : No disorder

Deformity : NoTumor : NoVessels : No widening

CRANIAL NERVES N.I: Olfaktorius nerveSmellingAnosmiaHyposmiaParosmia

N.II: Opticus nerveVisual acuityCampus visi

Anopsia

HemianopsiaOculi fundus Edema papil Atrophy papil Retina bleeding

N.III: Occulomotorius, N.IV: Trochlearis, and N.VI: Abducens nervesDiplopiaEyes gap

PtosisEyes position

Right Not examined Not examined Not examined Not examined

Right6/6

V.O.D

No

No

No No No

Right No

Symmetric

No

Left Not examined Not examined Not examined Not examined

Left6/6

V.O.S

No

No

No No No

Left No

Symmetric

No

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Strabismus Exophtalmus Enophtalmus Deviation conjugae

Eyes movement

Pupil Shape Size Isochor/anisochor Midriasis/miosis

Light reflex direct consensuil accommodation

N.V: Trigeminus nerveMotoric

Biting Trismus Corneal reflex

Sensory Forehead Cheek Chin

N.VII: Facialis nerveMotoricFrowningEyes closingGiggling

Nasolabial foldFacial shape

rest Speaking/whistling

Sensory 2/3 anterior tounge

Autonomy Salivation Lacrimation Chvosteks sign

N.VIII: Statoacusticus nerveCochlearis nerveWhisperingHour tickingWeber test

Rinne testVestibularis nerve

No No No No

No abnormality

Round 3 mmIsochor

No

Positive, NormalPositivePositive

Right No disorder

NoYes

Not examined Not examined Not examined

Right Normal Normal

Not examinedFlat

Drooping mouth No disorder

Not examined

No disorder No disorder No disorder

Right Not examined Not examined Not examined

Not examined

No No No No

No abnormality

Round 3 mmIsochor

No

Positive, NormalPositivePositive

Left No disorder

NoYes

Not examined Not examined Not examined

Left Normal Normal

Not examined Normal

No disorder No disorder

Not examined

No disorder No disorder No disorder

Left Not examined Not examined Not examined

Not examined

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NystagmusVertigo

N.IX: Glossopharingeus, and N.X: Vagus nerves

Pharyngeal archUvulaSwallowing disorderHoarsing/nasalisingHeart beatReflex

Vomiting Coughing Occulocardiac Caroticus sinus

Sensory 1/3 posterior tounge

No No

Right

SymmetricSymmetric

No No

Normal

YesYes

No disorder No disorder

Not examined

No No

Left

SymmetricSymmetric

No No

Normal

YesYes

No disorder No disorder

Not examined

N.XI: Accessorius NerveShoulder RaisingHead Twisting

N.XII: Hypoglossus NerveTounge ShowingFasciculationPapil AthrophyDysarthria

MOTORICArmsMotionStrengthTonesPhysiological Reflex

Biceps Triceps

Radius UlnaPathological Reflex

Hoffman Trommer Leri Meyer

LEGMotionPowerTones

Clonus Thigh

Right No disorder No disorder

Right Not examined Not examined Not examined Not examined

Right

Decreased

DecreasedDecreased

DecreasedDecreased

Negative Negative Negative

Right

Decreased

Negative

Left No disorder No disorder

Left Not examined Not examined Not examined Not examined

Left

Normal

Normal Normal

Normal Normal

Negative Negative Negative

Left

Normal

Negative

Lateralisation to the right

Lateralisation to the right

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FootPhysiological reflex

K P R A P R

Pathological reflex

Babinsky Chaddock Oppenheim Gordon Schaeffer Rossolimo Mendel Bechterew

Abdominal skin reflex Upper Middle Lower

Tropik

Negative

DecreasedDecreased

YesYes

Negative Negative Negative Negative Negative

Negative Negative Negative Negative

Negative

Normal Normal

Negative Negative Negative Negative Negative Negative Negative

Negative Negative Negative Negative

SENSORY Not Examined

PICTURE

VERTEBRAL COLUMN

Kyphosis : No Tumor : NoLordosis : No Meningocele : NoGibbus : No Hematome : NoDeformity : No Tenderness : No

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SYMPTOMS OF MENINGEAL IRRITATION

Nuchal rigidityKerniq

LassequeBrudzinsky

Neck Cheek Symphisis Leg I Leg II

Right No No

No

No No No No No

Left No No

No

No No No No No

GAIT AND BALANCE Not examined

ABNORMAL MOVEMENTSTremor : NoChorea : NoAthetosis : NoBallismus : NoDystoni : NoMyoclonus : No

VEGETATIVE FUNCTIONMicturition : CatheterizedDefecation : No abnormality

LIMBIC FUNCTIONGlobal aphasia

SPECIFIC EXAMINATIONCranium X- Ray : Not performedVertebral column X- Ray : Not PerformedThorax X-Ray : PerformedElectroencephalography : Not performed

Electroneuromyography : Not performedElectrocardiography : Not performedArteriography : Not performedPneumography : Not performedHead CT-Scan : PerformedHead MRI : Not PerformedLumbal Puncture : Not Performed

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Thorax Rontgen Mr.

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Laboratory Findings07 t May 2014 09 t May 2014 Normal value

Haemoglobin - 13,3 12,6-17,4 mg/dLRBCs - 4,21 4,20-4,87 x 10 /mm

WBCs - 8,7 4,5-11,0 x 103

/mm3

Haematocrits - 37 43-49 %

CT Scan Mr HD

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PLT - 260 150-450 x 10 /uLBasophils - 0 0-1 %Eosinophil - 1 1-6 %Rod Neutrophils - 0 2-6 %Segment Neutrophils - 63 50-70 %Lymphocytes - 30 25-40 %Monocytes - 6 2-8 %Prothrombin Time 11.7 - 12-18 detikINR 0.89 -APTT 27,7 - 27-42 detikFibrinogen 362 - 200-400 mg/dLTotal Protein 7,5 6,9 6,4 8,3 g/dLAlbumin 4,1 3,7 3,5 5,0 g/dLGlobulin - 3,2 2,6-3,6 mg/dLTotal Cholesterol 174 177 65 mg/dLLDL 115 120

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CHAPTER II

CASE ANALYSIS

RESUME

IDENTIFICATION:

Name : Mr. Hayun Darwis

Age : 67 years

Sex : Laki-laki

Nationality : Indonesia

Occupation : -Address : Perum Azhar Blok AX 06 No 17 Rt/Rw: 27/03 Kel.Kenten

Laut, Kab. Banyuasin.

Date of Admission : 07 Mei 2014

Registry Number : RI14012432

ANAMNESISPatient was admitted to Neurology Department of RSMH due to sudden loss of

consciousness.+ 12 hours before admission, patient was found unconscious by his neighbours inside

of his house, nothings certain about the process, but they said to seeing him doing some

works outside before the incident. During the onset, the presence of headache was unkown,

nauseas (-), vomitting (-), generalized tonic-clonic seizures (-), weakness on right side of the

body (+), drooping mouth (+), slurred