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    MR Jaga 27-9-2016

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    Dhani
    1) Tn. S, a 65-year-old male farmer, experienced sudden weakness on the left half of his body while pulling weeds. On examination, he had acute hemiparesis on the left side and facial palsy. 2) His medical history included uncontrolled hypertension since 2011. Imaging showed recent and old infarcts in the right anterior capsule and basal ganglia regions. 3) He was diagnosed with an acute cerebral infarction in the right middle cerebral artery territory, likely due to thrombotic occlusion, as a complication of his hypertension. Treatment included antihypertensives, anticoagulants, and supportive care.

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    MR Jaga 27-9-2016

    Uploaded by

    Dhani
    6 views13 pages
    1) Tn. S, a 65-year-old male farmer, experienced sudden weakness on the left half of his body while pulling weeds. On examination, he had acute hemiparesis on the left side and facial palsy. 2) His medical history included uncontrolled hypertension since 2011. Imaging showed recent and old infarcts in the right anterior capsule and basal ganglia regions. 3) He was diagnosed with an acute cerebral infarction in the right middle cerebral artery territory, likely due to thrombotic occlusion, as a complication of his hypertension. Treatment included antihypertensives, anticoagulants, and supportive care.

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    morning report

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    MR JAGA 27-9-2016

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    1) Tn. S, a 65-year-old male farmer, experienced sudden weakness on the left half of his body while pulling weeds. On examination, he had acute hemiparesis on the left side and facial palsy. 2) His medical history included uncontrolled hypertension since 2011. Imaging showed recent and old infarcts in the right anterior capsule and basal ganglia regions. 3) He was diagnosed with an acute cerebral infarction in the right middle cerebral artery territory, likely due to thrombotic occlusion, as a complication of his hypertension. Treatment included antihypertensives, anticoagulants, and supportive care.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    6 views13 pages

    MR Jaga 27-9-2016

    Uploaded by

    Dhani
    1) Tn. S, a 65-year-old male farmer, experienced sudden weakness on the left half of his body while pulling weeds. On examination, he had acute hemiparesis on the left side and facial palsy. 2) His medical history included uncontrolled hypertension since 2011. Imaging showed recent and old infarcts in the right anterior capsule and basal ganglia regions. 3) He was diagnosed with an acute cerebral infarction in the right middle cerebral artery territory, likely due to thrombotic occlusion, as a complication of his hypertension. Treatment included antihypertensives, anticoagulants, and supportive care.

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    © All Rights Reserved
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    of 13

    MORNING

    REPORT JAGA
    27 SEPTEMBER 2016

    DM Jaga :
    Nathalia Chrisanty
    Akbar Fitrahadi
    Hamdhani W.S
    IDENTITAS PASIEN

    NAMA : Tn. S
    USIA : 65 th
    ALAMAT : Malang
    PEKERJAAN: Petani
    STATUS : Menikah
    ANAMNESIS (AUTOANAMNESA)

    Keluhan utama : lemah badan kiri.


    Pasien mengeluh lemah setengah badan kanan
    dengan mendadak saat pulang dari mencabut
    rumput pukul 11.00 (5 jam SMRS). Pasien merasakan
    tebal pada badan kiri (+), bicara pelo (-), merot
    (-), nyeri kepala (-), muntah (-), pusing (-), kejang (-)
    Tebal / kesemutan badan (-), ngompol (-), ngebrok
    (-).
    Riwayat penyakit dahulu :
    Pasien memiliki HT sejak 2011 Uncontrolled.
    DM (-), stroke sebelumnya (-), penyakit jantung (-),
    penyakit kolesterol (-), Penyakit kronis lain (-)
    Riwayat Soial :
    Makan makanan asin (+), santan (+), Merokok (-),
    Alkohol (-).
    PEMERIKSAAN FISIK
    Status Interna
    KU : pasien tampak sakit ringan
    TTV
    TD : 200/70 mmHg
    Nadi : 75x/menit
    RR : 20x/ menit
    Tax : 36,50 C
    K/L : anemis -/- ikterik -/- pembesaran KGB -/-
    Thoraks
    C/ S1S2 single, murmur (-), gallop (-)
    P/ SN v/v, Wh -/-, Rh -/-
    Abdomen : soefl, BU (+) normal
    Ekstremitas : akral hangat (+) edema (-)
    Status Neurologis
    GCS : 456, Fungsi Luhur : sde
    Meningeal sign : Kaku kuduk(-), Burdzinski I-IV (-),
    kernig (-)
    PBI 3 mm/3 mm, RC +/+, RK +/+
    N. I : dbn
    N. II : dbn
    N. III,IV,VI : dbn
    N. VII : parese S tipe UMN
    N. IX, X, XI
    N. XII : parese S UMN
    Motorik : Power 5 4 Tonus N N
    5 4 N N
    Reflek fisiologi : B +2/+2, T +2/+2, K +2/+3, A
    +2/+2
    Reflek patologis : H -/-
    T -/-
    B -/+
    C -/+
    O -/-
    G -/-
    S -/-
    Sensorik : sde
    ANS : cath (+)
    DIAGNOSIS
    Diagnosis Klinis :
    - Acute hemiparese S
    - Acute parese N. VII S UMN
    - Acute parese N VII S UMN
    - Riwayat HT (+)
    Diagnosis Topis :
    - Arteri Cerebri Media Dextra
    Diagnosis Etiologi :
    CVA Thrombosis
    Diagnosis Banding :
    CVA Emboli
    Diagnosis Sekunder :
    Hipertensi Emergensi
    PLANNING Planning Tx :
    Head up 30 derajat
    02 2-4 lpm NC
    IVFD NS 0.9% 20 Planning Mo :
    Planning Dx :
    tpm Subjektif
    CT scan Inj. Antrain
    CXR Vital sign
    3x1gram (k/p)
    EKG Inj. Ranitidin 2x50 GCS
    Lab. DL, GD I/II, mg TIK
    lipid profile, Inj. Citicolin 3x500
    albumin, FH, BGA, mg
    SE Drip Nicardipin 0,5-
    6 mcg/kgBB, jika
    TD >220/120,
    target MAP turun
    20-25%
    P/NGT :
    CT Scan Kepala
    Infark sub akut di limb
    anterior kapsula interna
    kanan
    Infark kronis di nukleus
    lentiformis kanan dan nukleus
    caudatus kanan, kapsula
    externa kiri
    Senile Brain atrophy
    Sinusitis ethmoidalis kanan
    kiri
    HASIL FOTO POLOS
    THORAX

    Cardiomegali
    LABORATORY RESULT NORMAL VALUE UNIT

    Hb 13,80 13,4-17,7 g/dL


    Leucocyte 7,09 4.700-11.300 /L
    Hematocrit 40,40 40-47 %
    Thrombocyte 298.000 142.000-420.000 /L
    Differential count 1,3/0,6/62,5/30,7/4,9 0-4/0-1/51-67/25-33/2-5 %
    SGOT 21 0-40 U/L
    SGPT 14 0-41 U/L
    GDS 93 <200 mg/dl
    Ureum 22,40 16,6-48,5 mg/dL
    Creatinine 0,90 <1,2 mg/dL
    Na 136 136-145 mmol/L
    K 4,75 3,5-5,0 mmol/L
    Cl 110 98-106 mmol/L
    Thank
    You

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