2. Identify
● Name : Mr. S
● Age : 92 Years
● Gender : Man
● Address : Batu
● Arrival Date : 29-06-2023
● Patient Type : non-Trauma
3. ANAMNESIS
Main Complaint
Left weak of half body
Riwayat Penyakit Sekarang
At 8 am, the patient experienced sudden lips drooping and weakness in the left side of the body while eating. Previously the
patient went to pray Eid at the mosque and did not complain of any complaints. While eating, the patient suddenly leaned
against the wall due to weakness. History of trauma (-) nausea (+) vomiting (+) 2 times while in ER, seizure (-) cough (-),
dizziness (-), fever (-), History of pelo (-), History of stroke (-)
RPD: HT (-), DM (-)
RPK: -
RPO: -
4. GENERALIST STATUS
Consciousness : Composmentis
GCS : 456
BP : 244/129 mmHg
HR : 64 x/minute
RR : 20 x/minute
SpO2 : 95% on RA
Tax : 36.5 °C
5. PHYSICAL
EXAMINATION
HEAD/NECK:
Head
Eyes: Anemic conjunctiva (-/-), icteric sclera (-), Isochor pupil
diameter 3mm/3mm, Light reflex direct and indirect +/+
Ears : bloody Otorea (-/-)
Nose : epistaksis (-/-)
Neck :
Inspection: tracheal deviation (-)
Palpation: enlarged lymph nodes (-)
Auscultation : Bruits (-)
THORAX :
Cor:
Inspection: ictus cordis invisible
Palpation: ictus cordis palpable at ICS 5 MCL S
Percussion: D heart border at ICS 4 PSL D, heart border S at ICS 5
MCL S
Auscultation: S1 S2 single, regular, murmur (-), gallop (-)
Pulmo:
Inspection: normal chest wall shape, retraction (-)
Palpation: symmetrical D/S chest wall movement
Percussion: sonor
Auscultation:
R
h
-
-
-
-
-
-
Wh -
-
-
-
-
-
Ves +
+
+
+
+
+
6. PHYSICAL EXAMINATION
Abdomen
Inspection: Normal
Auscultation : Bowel Sounds (+) 10x/minute
Abdominal percussion: Timpany
Abdominal Palpation:
Defans (-) Superficial and profundus pain (-)
Extremity:
Dry red warm akral +/+/+/+, CRT< 2, pitting oedem (-)
Neurologis Status
GCS: 456
Pupil anisokor 3 mm/3 mm RCL/RCTL +/+
n kranialis: parese n VII S
Motorik 5/4
Sensorik dbn
Physiological Reflexes
Biceps +1 / +2
Triceps +1 / +2
Patella +1 / +2
Achilles +1 / +2
Reflek patologis
Babinski -/+
Chaddock -/-
Hoffman -/-
Tromner -/-
9. PROBLEM LIST & PLANNING
Problem list Definitive Diagnosis Planning
Diagnosis
Planning Therapy &
Monitoring
Main Complaint:
• Left Weak half body
• sudden lips drooping and weakness in the left side of the body while eating
• Nausea (+) Vomiting (+) 2x, convulsions (-)
• BP: 244/129 mmHg
CT Scan
Terdapat gambaran hiperdens pada ventrikel kiri dengan perkiraan Volume = (8 x 4 x 4)/ 4
= 32 cc
CVA ICH - - IVFD NS Maintanance
IVFD Ringer Lactate Maintain
DoseHolliday-segar formula
(Weight=55 Kg)=10 (Kg) x 100
ml + 10 (Kg) x 50 ml + (55-20
Kg) x 20 ml = 1000 ml + 500
ml + 700 ml= 2200 ml/24
Hours
- Inj. Ranitidin 50 mg
- Inj. Metamizol 500 mg
- Inj. Sitikolin 250 mg
- Inj. Piracetam 3 gram
- Drip Nicardipin 15 mg per
jam target tensi <160/90
