Patient: Mrs. S/63 y.

o/11491400/Housewife/Pasuruan
Referred from: Internal medicine outpatient clinic (CVA thrombosis + polisitemia vera + HT + DM)
Resident: NAN
Positive Findings Problem List Diagnose Planning
Anamnesis: Medical: left hemiparesis + Right Clinical diagnoses: PDx : -
• Weakness of the left side of the body since homonymus upper left hemiparesis + Right homonymus PTx:
12 days ago, suddenly in the morning after quadrantanopia + cognitive upper quadrantanopia + cognitive Continue medication
woke up and now has improved. The patient impairment e.c CVA thrombosis + impairment e.c CVA thrombosis + Exercise
developed a slurred speech but now has polisitemia vera + HT + DM polisitemia vera + HT + DM • Active ROM of right UE&LE
improved. She also complained vision Surgical: - • strengthening exercise of right
disturbance since 12 days ago. Functional diagnoses: UE & LE
• She had headache, the characteristic is R1 (M): limitation in changing Impairment: • Breathing exercise
sharp, the pain is intermitent. VAS 4-5 basic body (sitting and standing) left hemiparesis, Right homonymus OT : Memory therapy
• There is no lost of consciousness, headache, R2 (A): limitation in doing ADL upper quadrantanopia, hypertension, cognitive therapy
seizure or vomitting (dressing) diabetes mellitus. cognitive PMo:
• She was treated at RSSA 2 weeks ago and R3 (C): impairment MMT, ADL, ROM, and speech
was diagnosed with CVA infarction + R4 (P): - function
polisitemia vera R5 (S): limitation to social activity Disability:
• Now patient can walk independently. Patient R6 (V): - limitation in changing basic body
can do all the ADL, but needs to be helped R7 (O): left hemiparesis, Right (sitting and standing)
when transfers from lying to sitting, or homonymus upper limitation in doing ADL (dressing)
sitting to standing. quadrantanopia, hypertension,
• Numbness (-) tingling sensation (-) diabetes mellitus, cognitive Handicap:
• No difficulty to swallow. No bladder/ bowel impairment limitation to social activity
problem
• History : HT (+), DM (+) stroke (-) trauma (-)
• Medication: anti HT drug, insulin
• BI: 80 (mild dependency)

1
 Patient: Mrs. S/63 y.o/11491400/Housewife/Pasuruan
Referred from: Internal medicine outpatient clinic (CVA thrombosis + polisitemia vera + HT + DM)
Resident: NAN
Positive Findings Planning
Physical Examination: • Coordination: Finger to nose PEd :
• GCS 456 (able), disdiadokinesia (able) • Explain the condition.
• BP 170/120 mmHg • Aphasia: fluency (good), • Purpose & effect of PMR
• independent ambulation (sit to stand by help) comprehension (good), repetition therapy.
• Lying to sitting (+), sitting balance (+), sitting to (poor), naming (good) • Continue exercise & training at
standing (+), standing balance (+) • Attention good, orientation (time, home.
• Sensory : Sensory (light touch): 100% / 100% place, people, situation) good, • Routine control.
• 100% / 100% memory (short term: poor, long • Continue medication from
• Propioceptive (joint position): normal term: poor). Neurology and internal
• MMT: UE 4-5/5 • Dysarthria (-) medicine department.
LE 4-5/4 • Attention good, orientation (time, • Control risk factor
• ROM: Full / Full place, people, situation) good, • Family support.
• Full / Full memory (short term: fair, long
• BPR: +3/+3, TPR/: +2/+3, KPR: +3/+2, APR: +2/+2, term: fair).
• clonus ankle -/- • MMSE: 15 (cognitive impairment)
• Spasticity -/- • Moca: 12
• Babinski: -/-, Chaddock -/-, Oppenheim -/-, Hoffman
-/-, Tromner -/- • Hand function : F/F
• Chest expansion 2 cm
• Breath count test 10-10-14

2
• Cranial nerve:
I
II blindness in quarter upper right of the visual field ODS, visus >
5/60 ODS
III Eye movement (+), pupillary reflex (+)
IV Eye movement (+)
V Mastication muscle (+), midface sensory (+)
VI Eye movement (+)
VII Weakness of left face (-)
VIII Hearing (+)
IX Difficulty to swallow (-)
X Difficulty to swallow (-),
XI Head & neck movement (+)
XII Disartria (-), Tongue movement (+)
SHOULDER ROM MMT
Flexion F/F (0-1800) 4-5 / 5
Extension F/F (0-600) 4-5 / 5
Abduction F/F (0-1800) 4-5 / 5
Adduction F/F (0-450) 4-5 / 5
Internal rotation F/F (0-700) 4-5 / 5
External rotation F/F (0-900) 4-5 / 5

ELBOW ROM MMT

Flexion F/F (0-1500) 4-5 / 5
Extension F/F (1500-0) 4-5 / 5
Supination F/F (0-900) 4-5 / 5
Pronation F/F (0-900) 4-5 / 5

WRIST ROM MMT

Flexion F/F (0-800) 4-5 / 5
Extension F/F (0-700) 4-5 / 5
Ulnar deviation F/F (0-300) 4-5 / 5
Radial deviation F/F (0-200) 4-5 / 5
Barthel Index

80
MMSE
4
3
2

2
1
3
0
0
0

15

6
MOCA

0 0 1 0 0 1

1 0 1 2
   
0
1
0
1 1
0
1 1
0

1 1 1 1 1 5
12
 CT SCAN (2/9/2020)

Kesimpulan:
- Infark subakut pada lobus occipital kiri
- Infark lacunar kronis pada capsula interna kanan limb antero-posterior,
thalamus kiri, capsulla interna kiri limb anterior, nukelus lentiformis kiri
- Senile brain atrophy
- arteriosklerosis a. vertebralis bilateral, a. basillaris, a. Cerebri media
bilateral, a. carotis bilateral
- Sinusitis etmoidalis, sphenoidalis bilateral, sinus maksilaris billateral
Homonymous Superior Quadrantanopia Andres E. Monserrate; Orlando De Jesus. (Last Update: June 23, 2020)
Systemic diseases associated with
hypercoagulable states:
Systemic diseases associated with hypercoagulable states:
– Elevated RBC count, hematocrit, fibrinogen
– Protein S and C deficiencies
– Sickle-cell anemia

Cucurullo