Refleksi Kasus hemiparese

8/9/2019 Refleksi Kasus hemiparese

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REFLEKSI KASUS

Iin Astria

G 501 09 080



Identitas

• Nama: Ny.S

• Umur: 60 taun

•

!enis Ke"amin: #erem$uan• A%ama: Is"am

• A"amat: La&uan

• '%" #emeri(saan: )5*09*)01+

• ,asu( RS: )5*09*)01+



Anamnesis

• Ke"uan Utama:

masu( den%an (e"uan ti&a - ti&a (a(i (iri terasa&erat

•

In/rmasi tentan% (e"uan utama:(e"uan dirasa(an sea( (emarin saat sedan%&era"an. Sa(it (e$a"a*23mua"*23munta*23$enurunan (esadaran*23demam*23 sa(it (e$a"a

(r/ni( $r/%resi*23 terseda( saat minum42. '$ertama sete"a seran%an 107100 mm%3 'rata) 1607*mm%.





#emeri(saan Fisi(

• Kesan: sa(it sedan%

• Kesadaran: /m$/s mentis

•

Gi;i: &ai(• ': )007110 mm%

• N: 9< =7menit

•

S: +63</ • R: )<=7menit

• Anemi *23 I(terus *23 Sian/sis *2



• '/ra=

Ins$e(si: Res$irasi dadasimetris7&i"atera"

#a"$asi: ,assa *23 #er%era(an dada&i"atera"

#er(usi: #aru S/n/r23 >atas antun%

n/rma"3 &unyi $e(a(Aus(u"tasi: #aru ?esi(u"er2 dan !antun%S1 dan S)3 &unyi tam&aan *2



• A&d/men

Ins$e(si: ,assa *23 da"am &atasn/rma"

Aus(u"tasi: #erista"ti( usus 42

#er(usi: >unyi tym$ani di < (uadran3#em&esaran e$ar *23 "ien *2

#a"$asi: Nyeri te(an *2



Status Neur/"/%is

• GS: E< ?5 ,6

• Ner@us (rania"

• N.I /"a(t/rius2 : #en%idu :N/rm/smia

• * N.II /$ti(us2 : S

• * Ketaaman #en%"iatan676 676

• * La$an%an #en%"iatan n/rma" n/rma"



• N.III3 I?3 ?I

• e"a (e"/$a( mata

– #t/sis : *2

– E=/ta"mus : *2

• #/sisi &/"a mata

• #u$i" : S

* U(uran7&entu( +mm7&u"at+mm7&u"at

• * Is/(/r7anis/(/r is/(/r is/(/r

• * ReBe(s Caaya "an%sun% n7n n7n

• 7ta( "an%sun%

• ReBe(s a(/m/dasi n/rma" n/rma"

• Gera(an &/"a mata :

#arese (eara * *

Nista%mus * *



• N.? 'ri%eminus2 :

DSensi&i"itas : S

* N.?1 : n/rma" menurun

* N.?) : n/rma" menurun

* N.?+ : n/rma" menurun

• D,/t/ri( : Ins$e(si

• istiraat7men%%i%it2• DReBe(s da%u7masseter : n/rma"

• DReBe(s /rnea : n/rma"



• * N.?II FaCia"is2:

D,/t/ri( :

m. Fr/nta"is m. r&i(. /(u"i m. /r&i(. ris

n7n n7menurunn7menurun

D#en%eCa$ )7+ "ida &a%ian de$an : n/rma"

• * N. ?III Aus(u"tasi2 :

• D#enden%aran : n/rma"7 menurun• D'est rinne7e&er : tida( di"a(u(an

• Dun%si @esti&u"aris : tida( di"a(u(an



•

N. I7 G"/ss/$arin%eus7@a%us2 :D#/sisi ar(us $arin(s istiraat7AA2 :

simetris

DReBe(s te"an7munta : menurunD#en%eCa$ 17+ "ida &a%ian &e"a(an%

:n/rma"

DF/nasi :4

D'a(i(ardi7&ardi(ardi :*



• N. I ACCeC/rius2 :

D,ema"in%(an (e$a"a den%an7tan$a taanan : n/rma"

DAn%(at &au : n/rma"

• N. II y$/%"/sus2

De@iasi "ida : *

DFasCiCu"asi : *

DAtr/ :4D'rem/r :*

DAta=ia



e=tremitas su$eri/r e=tremitas ineri/r

• ,/t/ri(:

#er%era(an: n7nn7n

Ke(uatan: 57<57<

>entu( /t/t: eutr/7eutr/ eutr/7eutr/

'/nus /t/t: n7nn7n

• ReBe(s Fisi/"/%is

>iCe$s: n7n

'riCe$s: n7n

Radius: n7nU"na: n7n

#ate"a: n7n

ACi""es: n7n

• K"/nus

Lutut *7*Ka(i*7*



E=tremitas su$eri/r E=tremitas ineri/r

• ReBe(s $at/"/%is

/man: *7**7*

'r/mner:*7**7*>a&ins(i: *7**7*

add/C(: *7**7*

G/rd/n: *7**7*

SCaeer: *7**7*$$eneim: *7**7*

• Sensi&i"itas

Nyeri n7menurunn7menurun

Rasa ra&a a"us n7menurunn7menurun



* Gan%%uan (//rdinasi

'es ari idun%: n/rma"7 su"it di"a(u(an

'es $r/nasi*su$inasi: n/rma"

'es tumit: n/rma"

'es $e%an% ari: n/rma"

- Gan%%uan (eseim&an%an

tes r/m&er% *2

* Gait *2



Resume

anita 60 taun emi$arese sinistra3 nausea*23 @/mitin%*23sea"%ia*23$in%san*2

e&ris*23 sea"%ia (r/ni( $r/%resi *2

reBe(s si/"/%i: n/rma"

reBe(s $at/"/%is: ne%ati

N. rania":

N.? : N?1 N?) N?+

n7menrun n7menurunn7menurun

N.?II m/t/ri(

/r&i(u"aris /ris : $arese sinistra

/r&i(u"aris /(u"i : $arese sinistra

N.I3: reBe(s mene"anmenurun2

,/t/ri(: (e(uatan 57< 57<

Sensi&i"itas: ra&a a"us n7menurunn7menurun



#emeri(saan $enunan%

• ara:

' : +538

> : 1+GS: 1))



ia%n/sa

• ia%n/sa ("inis : emi$arese ty$iCasinistra

• ia%n/sis t/$is : emiser sere&ride=tra

• ia%n/sis eti/"/%i : su$. NS



'era$i

• Anti$a"te"et : As$irin

• Anti(/a%u"an : e$arin

•

Neur/$r/te(tan : Citi(/"in• Neur/tr/$i( : >13 >63>1)



#r/%n/sa

• Hua ad @itam : &/nam

• Hua ad sanati/nem : &/nam



Anuran

• Fisi/tera$i

• ,ena%a $/"a ma(an



is(usi

anita 60 taun emi$arese sinistra3 nausea*23@/mitin%*23 sea"%ia*23$in%san*2

e&ris*23 sea"%ia (r/ni( $r/%resi *2

reBe(s si/"/%i: n/rma"

reBe(s $at/"/%is: ne%ati

N. rania": N.?II m/t/ri(

/r&i(u"aris /ris : $arese sinistra

/r&i(u"aris /(u"i : $arese sinistra

N.I3: reBe(s mene"anmenurun2

,/t/ri(: (e(uatan 57< 57<

Sensi&i"itas: ra&a a"us n7menurunn7menurun



• Ka(i terasa &erat ti&a - ti&a saat &era"anmenunu((an suatu (e"ainan Cere&r/@as(u"arstr/(e2

• 'ida( ada demam menanda(an tida( ada ine(si

• 'ida( ada sa(it (e$a"a (r/ni( $r/%resimenanda(an &u(an dise&a&(an tum/r

• Riayat trauma + &"n yan% "a"u ta$i tida(

men%e"u(an nyeri (e$a"a sete"a (eadian itumenunu((an &u(an dia(i&at(an trauma

• Riayat ,*2 menanda(an &u(an $/"ineur/$ati



• Saat (eadian tida( ada sa(it (e$a"a3tida( ada munta dan tida( ada$enurunan (esadaran menunu((an

sus$. NS

• ari $emeri(saan neur/"/%idida$at(an $arese e=tremitas

sinistra3 i$/anstesia e=tremitassinistra3 $arese ner@us Crania"sinistra menunu((an suatu

emi$arese ty$iCa" sinistra



• 'era$i

mena%a 5>

mena%a A>anti an%resi tr/m&/sit: as$irin 80 m%7ari

neur/$r/teCtan : CitiC/"in )00m%71) am

neur/tr/$i( : >13>63>1)

si/tera$i



• 'ida( di&eri(an antii$ertensi (arenasist/" te(anan daranya masi di&aa ))0 mm% dan masi ase

a(ut 1 min%%u2 (arena da$atmem&uat daera yan% masi n/rma"dise(itar deara inra( $enum&ra2

a(an i(ut mati a(i&at sir(u"asi dara(e /ta( &er(uran%

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Refleksi Kasus hemiparese