Scribd Logo
Upload

Welcome to Scribd!

  • 30 views

    Case CVDNH at Brain Stem

    Uploaded by

    Rara
    - A 64-year-old man was brought to the hospital unconscious and weak, with a history of uncontrolled high blood pressure. - Physical examination revealed delirium, elevated blood pressure, and signs of brainstem involvement on neurological examination. - Imaging showed an infarct in the pons and cerebellopontine angle. - The working diagnosis was brainstem ischemic stroke, likely due to the patient's long-standing hypertension. Treatment included medications to control blood pressure and prevent further clotting.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Case CVDNH at Brain Stem

    Uploaded by

    Rara
    30 views22 pages
    - A 64-year-old man was brought to the hospital unconscious and weak, with a history of uncontrolled high blood pressure. - Physical examination revealed delirium, elevated blood pressure, and signs of brainstem involvement on neurological examination. - Imaging showed an infarct in the pons and cerebellopontine angle. - The working diagnosis was brainstem ischemic stroke, likely due to the patient's long-standing hypertension. Treatment included medications to control blood pressure and prevent further clotting.

    Original Description:

    case cerebral vascular disease non hemorrage at brain stem

    Original Title

    Case Cvdnh at Brain Stem

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    - A 64-year-old man was brought to the hospital unconscious and weak, with a history of uncontrolled high blood pressure. - Physical examination revealed delirium, elevated blood pressure, and signs of brainstem involvement on neurological examination. - Imaging showed an infarct in the pons and cerebellopontine angle. - The working diagnosis was brainstem ischemic stroke, likely due to the patient's long-standing hypertension. Treatment included medications to control blood pressure and prevent further clotting.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    30 views22 pages

    Case CVDNH at Brain Stem

    Uploaded by

    Rara
    - A 64-year-old man was brought to the hospital unconscious and weak, with a history of uncontrolled high blood pressure. - Physical examination revealed delirium, elevated blood pressure, and signs of brainstem involvement on neurological examination. - Imaging showed an infarct in the pons and cerebellopontine angle. - The working diagnosis was brainstem ischemic stroke, likely due to the patient's long-standing hypertension. Treatment included medications to control blood pressure and prevent further clotting.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 22

    NEUROLOGY ROTATION

    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

    You might also like