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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