Friday, July 3nd 2015

 Name : Mr. Kosim

 Age : 51 yo
 Religion : Moslem
 Occupation : government employees
 Residence : Tulung RT 10 RW 3 Karangan
Kepohbaru Bojonegoro
 Observe : July 3nd 2015
1.mr.saimvertigoRJ
2.mr.soetarjovertigoRJ

3.mr.dodotcva
blledingmultazam 7
4mr.suharmadjiDM tipe 2 and ICH in
hemyspher subcorticalmarwah 3
 Chief complaint :
Loss of consciousness
 Present illness history :
since 3 hours SMRs, patients discharged wash
motor. Suddenly complained of headache and
dizziness spinning, pasien jatuh, pasien tidak
nyambung saat diajak bicara,muntah (-),kejang
(-),demam (-).
Previous Illness History :
HT (+), does not control routine
 Family History of Disease
 HT (-)
 DM (-)
 Sociality History
 farmer
Vital sign:
 BP: 204/121 mmHg
 HR: 138 x/mnt
 RR: 24 x/mnt
 Temp: 38,90C
Primary survey:
 A : clear, gargling (-), snoring (+), speak
frequently (-), potential obstruction (-)
 B : spontaneous, RR 24x/mnt, ves/ves, rh -
, wh -/-, O2 saturation 94% with O2 NRM 8
lpm support
 C : acral dry red warm, CRT < 2’, N 138
x/mnt, BP 204/121 mmHg
 D : GCS 115, lateralisation sinistra, PBI 1
mm/1 mm, LR +/+ slow
 E : Temp 38,9 0C
Secondary survey:
 GCS 115
 H/N : a -/ I -/ c -/d-;Enlargement of Lymph
node -
 Tho : simestris, ret -/-
 P : ves/ves, rh -/-, wh -/-
 C : S1S2 single, murmur (-), gallop (-)
 Abd : Soepel, met -, bowel loudness (+) N, H/L
unpalpable,
 Extr: aie -, acral dry red warm
 SIRIRAJ SCORE :
(2,5x2)+(2x1)+(2x0)+(0,1x121)-(3x0)-12 = 7,1
 CVA Bleeding
1. Head : Position : Normal, middle
Mass :-
Shape | size : normal | normal
Auskultation : bruit a. carotis(-)

2. Nervus Cranialis :
 N.I (Olfaktorius)
Penghidu : hard to evaluated
 N.II (Optikus)
Visual acuity : hard to evaluated
Field of vision : hard to evaluated
Funduscopy : not evaluated
 N. III (Okulomotorius)
slit eye: Ptosis : -| -

Exoftalmus : -| -
Movement of eye ball : hard to evaluated
Pupil : Pupil round isokor 1 mm / 1 mm
Light Reflek : direct :-|-
non-direct :-|-
nistagmus : -|-

 N.IV (Troklearis)
Position of eye ball : normal | normal
movement of eye ball : hard to evaluated
 N.VI (Abdusen)
movement of eye ball : hard to evaluated
 N.V (Trigeminus)
Sensibility : N. V I : hard to evaluated
N. V II : hard to evaluated
N. V III : hard to evaluated
Motorik :
Inspeksi : symmetris
Palpasi : hard to evaluated
chewing : hard to evaluated
Bitting : hard to evaluated
Reflek masseter: hard to evaluated
Reflek cornea : + / +
 N.VII (Fasialis)
Motorik: facial palsy
m. frontalis : hard to evaluated
m. oblik okuli : hard to evaluated
m. oblik oris : hard to evaluated
taster of 2/3 front tongue : not evaluated

 N.VIII (Vestibulokoklearis)
wrist watch : hard to evaluated
whispered voice: hard to evaluated
Tes weber : not evaluated
Tes Rinne : not evaluated
  N.IX (Glossofaringeus)
taster 1/3 (back side): not evaluated
sensibilitas faring : hard to evaluated
 N.X (Vagus)
the arc of arcus faring : hard to evaluated
(rest |AAH) : hard to evaluated
Reflek swallow/vomit : not evaluated
 N.XI (Acsessorius)
Shruging : hard to evaluated
Looked away : hard to evaluated
 N.XII (Hipoglossus)
Tongue deviation : hard to evaluated
Fasiculation, Tremor, Atrofi, Ataxia: hard to
evaluated
 Neck

 Sign of Menigeal infection :

 Kaku kuduk : not evaluated
 Brudzinski I dan II : negatif
 Kernig : negatif
 Kelenjar lymphe : bulge (-)
 Arteri karotis :
 Palpasi : strong, regular
 Auskultasi : bruit (–)
 Kelenjar gondok : bulge (-)
Kolumna Vertebralis
 Inspeksi : not to evaluated
 Palpasi : not to evaluated
 Movement : not to evaluated
 Perkusi : not to evaluated
Ekstremitas
 Motorik
 Movement : hard to evaluated
 Strength : lateralisasi sinistra
 Tonus : normal

Reflek fisiologis :
 BPR : +2 | +2
 TPR : +2 | +2
 KPR : +2 | +2
 APR : +2 | +2
Reflek patologis :
 Hoffman-tromner : -|-
 Babinski : -| -
 Chaddock : -|-
 Gordon : -|-
 Schaefer : - |-
 Oppenheim : -|-
 Mendel B : -|-
 Rossolimo : -|-

Trofi : -|-
Sensibilitas
Eksteroseptif
 Pain : hard to evaluated
 Temperature : not evaluated
 Rasa raba halus : hard to evaluated
Proprioseptif
 Rasa sikap : hard to evaluated
 Rasa nyeri dalam : hard to evaluated
Fungsi kortikol
 Discrimination function : hard to evaluated
 Stereognosis : hard to evaluated
 Barognosis : hard to evaluated
 Abnormal spontan movement : -

Impaired coordination
 Tes finger nose : hard to evaluated
 Tes pronasi supinasi : hard to evaluated
 Tes knee to toe : hard to evaluated
 Diffcount  GDA 127
1,8/2,1/84/9/3.1  Kalium 3.4
 Hct 41,3  Natrium 142
 Hb 13,1  Clorida 104
 LED 1 83 ↑  SGOT 25
 LED 2 93 ↑  SGPT 22
 Leukosit 17.000 ↑  Cholesterol 215
 Trombosit 240.000  HDL 42,9
 Urea 61 ↑  LDL 153,7 ↑
 Creatinin 2.7 ↑  TG 178
 MCV 90.20
 MCH 28.60
 MCHC 31.70
 RDW 12
 Male, 51 yo
 Loss of consciousness
 Nausea (+)
 Vomit (+)
 Takipneu
 Takikardi
 Hipertension
 Febris
 Laterasisasi sinistra
 Leukositosis
 Siriraj score +7,1
 • Loss of • pons • CVA Bleeding

Diagnosis Topis
Clinical Diagnosis

Etiological Diagnosis
consciousness ICH at Pons
• Nausea (+)
• Vomit (+)
• Hipertension
• Takikardi
• takipneu
• Febris
• Laterasisasi
sinistra
• Leukositosis
• Siriraj score
+7,1
General therapy :
 O2 simple mask 4 lpm
 Head up 300
 DK
 IVFD. Assering 1500cc/24jam
 Inj. Citicolin 2x250 mg
 Inj. Metamizole 3x1g
 Inj Ranitidine 2 x 50 mg
 Pump Nifedipine 3 mg/jam , target TDS < 160
 P.O Tranesamat Acid 3x 500 mg
 Loading manitol 200 cc  6x100 cc

 Consul  dr. Dhimas H, SpS.

 Vitalsign
 Subjective complaints of patients
 Neurology Examination
 Explain to the family about the disease of
the family
 Explain the patient about therapy and
intervention, -Explain the patient about its
complication and prognosis.
 dubia ad malam