NEUROLOGY ROTATION

ROYAL TARUMA HOSPITAL

FACULTY OF MEDICINE
TARUMANAGARA UNIVERSITY
NONHEMORRHAGIC CEREBROVASCULAR DISEASE
IN BRAINSTEM
Identity
 Name = Mr. R A H
 Age = 64 y.o
 Address = Keagungan, West Jakarta
Current Medical History
Nov 11st 2019

 A 64-year-old man was brought by his family in a state of

unconsciousness and general weakness since half an hour
before being hospitalized. Before fainting, the patient did not
complain about headaches or vomiting. History of head
trauma (-). Since a few days ago, the patient has experienced
unstoppable hiccups. He always measured his own blood
pressure at home and in recent days his blood pressure was
quite high around 170 even though he had antihypertensive
medication.
 Past medical history : Hypertension (+)
Physical Examination
Vital Sign

 Awareness = Delirium
 GCS = E3M6V4
 Blood Pressure = 190/100
 Heart Rates = 58 bpm
 Respiratory Rates = 18 bpm
 Temperature = 36,6°C
 Weight = 75 kg
 Height = 170cm
PHYSICAL EXAMINATION

Head Normochepali, hair: black, even distribution

Pupil: round, equal, Ø 3mm/3mm, palpebral edema (-/-), anemic

Eyes
conjunctiva (-/-), Icteric sclera (-/-), lagophthalmus (-/-), ptosis (-/-)

Ears Normal shape, battle’s sign (-/-), otorrhea (-/-), blood (-/-)

Nose Septum deviation (-), secrete (-/-), blood (-/-)

Mouth Mucose: wet, hyperemic (-), teeth in normal range

Neck Tracheal deviation (-), no lymph node enlargement

 PHYSICAL EXAMINATION

Inspection Simetrical, both sides are even in static and dynamic state,

Thorax – Palpation No palpable mass, no crepitation

Pulmo Percussion Sonor on both lungs

Auscultation Vesicullar (+/+), rales (-/-), wheezing (-/-)

Inspection Ictus cordis pulsation not seen

Palpation Ictus cordis pulsation palpable on ICS V MCLS

• Right heart margin : ICS III - V linea parasternalis

Cor dextra
Percussion • Left heart margin : ICS V, 1 cm at medial line MCLS
• Upper heart margin : ICS III linea parasternalis sinistra

Auscultation S1 and S2 heart sound in normal range, murmur (-), gallop (-)
 PHYSICAL EXAMINATION

Inspection Flat on inspection, wound (-), mass (-)

Auscultation Rigid (-), bowel sounds (+) 5x/minute

Abdomen Muscular defence (-), no pain response, no liver or

Palpation
spleen enlargement palpated

Percussion Tympanic on all abdomen region

Extremities All extremities warm, CRT < 2sec, edema (-/-)

Skin Skin turgor in normal range, cyanosis (-)

 NEUROLOGICAL EXAMINATION

MENINGEAL SIGNS

Neck stifness (-)

Brudzinsky I (-)

Brudzinsky II (-)

Brudzinsky III (-)

Brudzinsky IV (-)

Laseq (-)

Kernig (-)
 NEUROLOGICAL EXAMINATION

CRANIAL NERVE

N. I No examinations was performed

N. II No examinations was performed

No examinations was No examinations was

Ocular movements
performed performed

Ptosis - -
N. III
N. IV Pupil size 2mm 2mm
N. VI Pupil shape Round, equal Round, equal

Direct Light Reflex + +

Indirect Light Reflex + +

NEUROLOGICAL EXAMINATION

Right Left

Ophthalmic sensibility Normal Normal

Maxillar sensibility Normal Normal
N. V
Mandibular sensibility Symmetric Symmetric
Masseter and temporal
+ +
muscle contraction
Corneal reflex + +
Palpebral fissure ±2 mm ±2 mm
Frontal contraction Round, equal Round, equal

N. VII Lagophthalmus - -
Grinning Normal Normal
Cheek inflation - -
NEUROLOGICAL EXAMINATION

Opening mouth +
N. V Moving the jaw +
Biting +
Facial Expression Symmetric
Palpebrae Fissure Symmetric
N. VII Raised Eyebrows Symmetric
Wrink Forehead Symmetric
Lagophtalmus - -
Grinning Symmetric
Puff Cheeks Symmetric
NEUROLOGICAL EXAMINATION

N. VIII Ability of hearing +/+

Sound Quality Dysarthria

N. IX
Swallowing Dysphagia
N. X
Pharynx, Uvula +

M.Sternocleidomastoideus +
N. XI
M. Trapezius +

N. XII Tounge Tremor -

NEUROLOGICAL EXAMINATION

PHYSIOLOGIC REFLEX
Right Left
Biceps ++ ++
Triceps ++ ++
Patella ++ ++
Achilles ++ ++
PATHOLOGICAL REFLEX
Hoffman - tromner - -
Babinski - -
Chaddock - -
Schaefer - -
Gordon - -
Oppenheim - -
Klonus paha - -
Klonus kaki - -
Diagnosa : susp CVD Hemorrhage
 DD/
 CVD Nonhemorrhage
Planning
 Lab test
 MRI brain
LABORATORIUM Nov 11rst 2019 UNIT NORMAL RANGE
Hemoglobin 15,6 g/dl 12.0-16.0
LED 6 mm/jam 2-30
Leukocyte 10,8 103/uL 5.0-10.0
Basophils 0 % 0-1
Eosinophils 0 % 1-3
Segmen 81 % 50-70
Lymphocytes 11 % 21-40
Monocytes 8 % 2-8
MCV 88 u3 82 – 92
MCH 32 pg 26 – 32
MCHC 36 g/dl 31 – 36
Hematocrit 43,2 Vol % 37.0-47.0
Erythrocytes 4,94 106/uL 4.00-5.00
Platelets 355 103/uL 150.0-450.0
LABORATORIUM Nov 11st 2019 UNIT NORMAL RANGE
SGOT 21 u/l 15 – 37
SGPT 30 u/l 12 – 78
Ureum 26 mg/dl 15-39
Nov 13rd 2019
Hemoglobin 14,8 g/dl 12.0-16.0
Leukocyte 9,7 103/Ul 5.0-10.0
Hematocrit 43,3 Vol % 37.0-47.0
Platelets 358 103/uL 150.0-450.0
GDS 111 mg/dl 70=180
Kalium 3,11 mmol/l 3.50 – 5.10
Natrium 121 mmol/l 137 – 145
MSCT Brain
 Infarct in pons and Cerebellopontine angle
 Septum nasi deviation to the left
Working diagnosis
BRAINSTEM ISCHEMIC STROKE
Treatments
 Brainact (citicoline) 3x500mg
 Ezomeb (esomeprazole) 1x1 IV
 Amlodipine 1x10mg (1-0-0)
 Nicardipne (if needed)
 Truvaz (atorvastatin) 1x40mg
 Tomit (metoclopramide) 10 mg if needed
 Clogin (clopidogrel) 2x75mg
 Entramix 6x200cc via NGT
Thank you