cr sr hani

8/18/2019 CR SR hani

1/21

PRESENTASI KASUS

STROKE NON HEMORAGIK DENGAN DISLIPIDEMIA DAN

HIPERTENSI GRADE II

Hani ZahiyyahSuarsyaf

Pembimbing !r" H" Sim#n Tambunan"$ S%" S


2/21

I" IDENTITAS PENDERITANama Ny" SRUmur &' (h

)enis Ke*amin Perem%uan

S(a(us Meni+ahA*ama( Purb#*ingg#Pe+er,aan Ibu Rumah Tangga

N# RM -./0/'Masu+ RS 01 Mare( -102

LAPORAN KASUS


3/21

II. DATA SUBYEKTIF

1. RIWAYAT PENYAKIT SEKARANG (Alloanamnesis oleh ana!asien"

Ke*uhan U(ama Lemah angg#(a gera+ bagian +ananL#+asi In(ra3erebra*Onse( 4 - hari sebe*um masu+ RSA5

Kua*i(as angg#(a gera+ +anan masih !a%a(me*a6an (ahanan ringan

Kuan(i(as A+(i7i(as sehari8hari se%enuhnya !iban(u#*eh +e*uarga

Ge,a*a %enyer(a Su*i( bi3ara$ mu*u( mer#( +e +iri

9a+(#r yang mem%erbera( : 8 ;9a+(#r yang mem%eringan : 8 ;


4/21

Kr#n#*#gis

Pa!a hari Kamis 01 Mare( -102 %u+u* 1


5/21

%. RIWAYAT PENYAKIT KELUARGA

Ti!a+ a!a angg#(a +e*uarga yang sa+i( se%er(i ini$Ri6aya( %enya+i( !arah (inggi %a!a +e*uarga a!aKen3ing manis !an s(r#+e %a!a +e*uarga (i!a+ a!a"

&. RIWAYAT SOSIAL EKONO'I

Pasien mengguna+an =P)S +e*as >Kesan S#se+ ?u+u%


6/21

III. DATA OBEKTIF

1.STATUS PRAESENS

Kea!aan umum Tam%a+ sa+i( se!angKesa!aran ?#m%#s men(is Te+anan Darah 021@011 mmHg

Na!i .< @meni(RR -- @meni(Suhu >2$.1?

Tinggi =a!an 0&& 3m

=era( =a!an && +g=MI O7er6eigh(


7/21

#. STATUS INTERNUS

Ke%a*a Sime(ris$ n#rm#3e%ha*

Ma(a K#n,ung(i7a anemis :8;$ s+*era i+(eri+ :8;Leher Sime(ris$ !e7iasi (ra+ea :8;

Th#ra )an(ung Suara ,an(ung I$II n#rma*$ bising :8;

Paru S#n#r$ 7esi+u*er n#rma*$ r#n+hi 8@8

Ab!#men Tim%ani$ %eris(a*(i3 :B; n#rma*$ he%ar !an *ien(i!a+ (eraba

%. STATUS PSIKIKUS

?ara ber%i+ir su*i( !ini*ai

Perasaan ha(i su*i( !ini*ai

Ting+ah *a+u su*i( !ini*ai

Inga(an su*i( !ini*ai

Ke3er!asan su*i( !ini*ai


8/21


9/21

Sensibi*i(as su*i( !ini*ai

ege(a(if !bnGera+an Abn#rma* Trem#r : 8 ;

A(he(#se : 8 ;

Mi#+*#ni : 8 ;

Kh#rea : 8 ;

K##r!inasi$ Gai( !an Keseimbangan

?ara ber,a*an (i!a+ !a%a( !i*a+u+an

Tes( R#mberg (i!a+ !a%a( !i*a+u+anDis!ia!#+#+inesis (i!a+ !a%a( !i*a+u+an

A(a+sia (i!a+ !a%a( !i*a+u+an

Reb#un! Phen#men (i!a+ !a%a( !i*a+u+an

Disme(ri (i!a+ !a%a( !i*a+u+an

I). PE'ERIKSAAN TA'BA$AN

Sirira, S3#re 1B1B1B018180- C 8- S(r#+e

N#nHem#ragi+


10/21

I" RESUME

Pasien 6ani(a usia &' (ahun !a(ang !engan +e*emahan

angg#(a gera+ +anan$ #nse( 4 - hari SMRS" Pasien su*i(berbi3ara !an mu*u( mer#( +e +iri" Pasien memi*i+i ri6aya(

hi%er(ensi (i!a+ (er+#n(r#*"

Pa!a Pemeri+saan !i!a%a(+an Kesa!aran G?S C E'M2afasia m#(#ri+

Tan!a 7i(a* TD C 021@011 mmHg Na!i C .< @meni(

RR C -- @meni(

Suhu C >2$.1?

Ma(a Pu%i* bu*a($ is#+#r -"&mm@-"&mm$ ree+ 3ahaya

B@B

Nn ?rania*is Paresis N II !e(ra sen(ra*$%aresis N FII !e(ra sen(ra*

Leher Ka+u Ku!u+ :8;M#(#ri+ Kesan hemi%aresis !e(ra s%as(i+

Sensibi*i(as su*i( !ini*ai

ege(a(if !bn


11/21

I" DIAGNOSIS

0" Diagn#sis K*inis 8 Hemi%aresis !e(ra s%as(i+ 8 Paresis n" II !an FII !e(ra sen(ra* Diagn#sis T#%is In(ra3erebra* Diagn#sis E(i#*#gis S(r#+e N#n Hem#ragi+

-" Hi%er(ensi gra!e II (i!a+ (er+#n(r#*


12/21

II" REN?ANA PENGELOLAAN AAL

1. S*+oe Non $emo+a,i

D 8 Lab#ra(#rium !arah *eng+a%

8 ?T s3an

8 GDS

T 8 E*e7asi +e%a*a >1#

8 Infus RL -1 (%m 8 ?i(i3h#*in in,"-&11 mg :i7;

8 Si*#s(as#* -011mg :%#;

8 Rani(i!in -0 :i7;

M G?S$ Tan!a 7i(a*$ Desi( Neur#*#gis

E Men,e*as+an +e%a!a +e*uarga mengenai %enya+i($ren3ana %emeri+saan$ !an %eng#ba(an


13/21

#. $i!e+*ensi G+a-e II

TD 021@011 mmHg$ MAP 0-1 mmHgD Hi%er(ensi gra!e II T 8 Am*#!i%in 001mg :%#;M 8 M#ni(#ring (e+anan !arah 2 ,am se+a*i


14/21

?T S3an :00@>@-102; Tam%a+ *esi hi%#!ens+e3i* !i 3a%su*ae(erna !e(ra$gang*ia basa*is !an3#r#na ra!ia(abi*a(era*

Kesan Mu*(i%*e *a3unarinfar+ !i 3a%su*ae(erna !e(ra$gang*ia basa*is$ !an

3#r#na ra!ia(a

HARI PERAWATAN


15/21

HARI PERAWATAN

(2 ) 11/3/2016

S Kesadaran membaik, Lemah anggota gerak kanan, mulut merot ke kiri, bicara pelo

O

KU/KS Tampak sakit sedang/ ompos mentis

TD 1!0/100 mm"g

N !# $ /mnt

RR 20 $ /mnt

S 36,%&

Status

Neuro-

logis

' *#+6-.1-+ata upil bulat, isokor, 2,-mm/2,-mm, cahaa /4nKranialis . arase 455, 55 de$tra sentral

ensibilitas dbnegetati7 dbn

P

T$ *le8asi kepala 300 9 5n7us L 20 tpm

9 iticholin in:2$-00 mg (i8)

9 ilostasol 2$100mg (po) 9 anitidin 2$1 (i8) 9 ;mlodipin 1$10mg(po)

rogram ro7il lipid, ureum, kreatinin, T scan

A

5


16/21

Hasi* Lab#ra(#rium :0-@1>@-102;

Hematologi Hasil Kimia Klinik HasilHb(gr%) .! GDS "#HT(%) $$.% Ureum (mg!") 45 ↑#ritrosit($tmmk) 4."4 Kreatinin (mg!") 4.$" ↑MH(p&) "&. Asam Urat (mg!") $.5!M'(f")

'!.$Kolesterol Total

(mg!") $#4 ↑MH(g!l) $5.4 Trigliseri!a

(mg!")"

"ekosit(rbmmk) '.!4 HD" (mg!") 4!Trombosit(rbmmk) "%! "D" (mg!") "$#.&

↑D(%) "."

M*'(f") /"'

HARI PERAWATAN


17/21

HARI PERAWATAN

(3) 12/3/2016

S Lemah anggota gerak kanan, bicara pelo, mulut merot ke kiri, demam

O


TD 220/120 mm"g

N !0 $ /mnt

RR 20 $ /mnt

S 3!,3&

Status

Neuro-

logis

' E'M2& C 0&+ata upil bulat, isokor, 2,-mm/2,-mm, cahaa /4nKranialis . arase 455, 55 de$tra sentral


P


9 iticholin in:2$-00 mg (i8) 9 ilostasol 2$100 (po)

9 anitidin 2$1 (i8) 9 icnat 3$1 (po) 9 ;sam 7olat 1$1mg (po) 9 aracetamol 3$-00mg (po)

rogram =isioterapi

9


18/21

HARI PERAWATAN

(#) 13/3/2016

S Lemah anggota gerak kanan, bicara pelo, mulut merot ke kiri

O


TD 1@0/110 mm"g

N @6 $ /mnt

RR 20 $ /mnt

S 3%,3&

Status

Neuro-

logis

' E'M2& C 0&+ata upil bulat, isokor, 2,-mm/2,-mm, cahaa /4nKranialis . arase 455, 55 de$tra sentral


P



9 anitidin 2$1 (i8) 9 ;mlodipin 1$10mg (po) 9 im8astatin 1$1 (po) 9 >icnat 3$1 (po)

9 ;sam 7olat 1$1mg (po)

rogram =isioterapi 9


19/21

HARI PERAWATAN

(-) 1#/3/2016


O


TD 220/120 mm"g

N !! $ /mntRR 20 $ /mnt

S 36,1&

Status

Neuro-

logis

' E'M2& C 0&+ata upil bulat, isokor, 2,-mm/2,-mm, cahaa /

4nKranialis . arase 455, 55 de$tra sentral


P



9 anitidin 2$1 (i8) 9 icnat 3$1 (po) 9 ;sam 7olat 1$1mg (po)

rogram =isioterapi

9


20/21

HARI PERAWATAN


21/21

HARI PERAWATAN

(%) 16/3/2016


O


TD 220/120 mm"g

N !! $ /mnt

RR 20 $ /mnt

S 36,1&

Status

Neuro-

logis

' E'M2& C 0&+ata upil bulat, isokor, 2,-mm/2,-mm, cahaa /

4nKranialis . arase 455, 55 de$tra sentral


P


9 iticholin in:2$-00 mg (i8) 9 ;spilet 1$1 (po)

9 anitidin 2$1 (i8) 9 aptopril 3$12,-mg(po) 9 Tia?id 3$2-mg(po)

9 im8astatin 1$10mg (po) 9 >icnat 3$1 (po) 9 ;sam 7olat 1$1mg (po)

ulang dengan kontrol

A

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