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CASE REPORT

I.

II.

PATIENT IDENTITY
Name

: Ali Umar

Age

: 82 years old

Sex

: Male

Address

: Kamang Hilir

ANAMNESIS
An 82 years old patient treated in Neurology ward at Achmad Mochtar Hospital since
6th January 2014 with:
Chief complaint: Weakness at left limbs since 2 days ago
History of present illness:
- Weakness at left limbs since 2 days ago, happened during activity (sit)
- Weakness at left leg felt heavier than left arm
- Couldnt walk since 2 days ago
- Couldnt speak since 2 days ago
- Decrease consciousness (-)
- Vomit (-), Nausea (-)
- Headache (-)
- Seizure (-)
History of previous illness:
- Patient had stroke at right limbs in 2008; patient was treated at hospital for 10 days.
After treatment patient can walk with dragged right feet. Patient has been inactive
since then
- Patient had hypertension history, not frequently controlled and medicated
- No history of head trauma
- Denies history of Diabetes Mellitus and heart disease

History of family illness:


- There are no family members that have same disease
Social and Personal History:
- Patient is not working, minimum physical activity, smoking habit (-), drinking
coffee (-)

III.

PHYSICAL EXAMINATION
A.1. General Condition : Seems moderately ill
2. Consciousness
3. Vital Sign

: E4M6V5 Aphasia
: BP

: 150/90 mmHg

Pulse

: 82 x/minute

RR

: 20 x/minute

Temperature

: 36,8oC

Weight

: 40 kg

Height

: 155 cm

BMI

: 16.7 (Underweight)

B. Internal Status
Skin

: No apparent abnormality

Eyes

: Conjunctiva not anemic, sclera not icteric, Pupil isochoric


D= 3mm/3mm, Light Reflex +/+

Nose

: no abnormality found

Ears

: no abnormality found

Neck

: JVP 5-2 cmH2O, carotid noise (-)

Thorax
Lung
:
Inspection
: Symmetric chest movement
Palpation
: Fremitus difficult to determine
Percussion
: sonor at both chest fields
Auscultation
: vesicular breathing, rhonchi -/-, wheezing -/Heart
:
Inspection
Palpation
Percussion
Auscultation

: ictus cordis (-)


: ictus cordis felt 1 finger Medial LMCS RIC V
: Normal heart borders
: pure heart rhythm, regular, noise (-)

Abdomen
Inspection
Palpation

: no bulging
: Liver and spleen not palbable, tenderness (-), rebound tenderness

(-)
Percussion
Auscultation

: Tympanic
: bowel sounds (+) normal

1.

C. Neurological Status
GCS 15 : E4M6V5 Aphasia
Meningeal stimuli sign

Stiff neck : (-)

Brudzinsky I
: (-)

Brudzinsky II
: (-)

Kernig sign
: (-)
2. Signs and symptoms of increased intracranial pressure

Projectile vomiting (-)

Severe headache (-)


3. Cranial nerve examination
N.I (Olfactory)
smelling
Subjective

Right
Difficult to

Left
Difficult to

Objective

determine
Difficult to

determine
Difficult to

determine

determine

Right
5/20
normal
not examined

Left
5/20
Normal
not examined

N.II (Optic)
Vision
Visual acuity
Visual field
ophthalmoscopy
N.III (Oculomotor)
Eyeball
Ptosis
Vestibulo-ocular reflex
Strabismus
Nystagmus
Exo/Endopthalmus
Pupil
Shape
Light reflex
Accommodation reflex
Convergence reflex

Right
Left
spherical
spherical
Doll eyes movement (+)
round, isochorivc
(+)
(+)
(+)

round, isochoric
(+)
(+)
(+)

N.IV (Trochlear)
Right
good
Ortho
(-)

Left
good
Ortho
(-)

Eye movement to the lower

Right
good

Left
good

medial
Bulbus oculi
Diplopia

Ortho
(-)

Ortho
(-)

right

Left

(+)
(+)
(+)
(+)

(+)
(+)
(+)
(+)

(+)
good

(+)
Good

(+)
Good

(+)
Good

good

Good

Downward eye movement


Bulbus oculi
Diplopia

N.VI (Abdusens)

N.V (Trigeminal)
Motor
Mouth opening
Jaw moving
Biting
Chewing
Sensory
-Ophthalmic division
Corneal reflex
Sensibility
-Maxillary division
Masseter reflex
Sensibility
-Mandible division
Sensibility
N.VII (Facial)
Right
Left
Facial expression
Asymmetric
Tear secretion
(+)
(+)
Palpebral fissure
Good
Good
Moving forehead
Good
Good
Closing eyes
Good
Good
Pout / whistling
(-)
Showing teeth
Good
Good
The sensation of 2/3 rear Difficult to
Difficult to

tongue
hyperacusis
Nasolabial folds

determine
(-)
good

determine
(-)
flatten

N.VIII (Vestibular)
Right
Left
(+)
(+)
(+)
(+)
good
Good
No lateralization

Whisper
Hand watch sound
Rinne test
Weber test
Schwabach test
Elongated
Shorten
Nystagmus
Pendular
Vertical
Cyclical
Influence of head position

(-)

(-)

(-)

(-)

N.IX (Glossopharyngeal)
Right

Left

Sensation of Tongue third Good

Good

rear
Gag reflex

(+)

(+)

N.X (Vagal)
Right

Left

Pharyngeal arch

Asymmetric

Uvula
Swallowing

Deviated to right
difficult

difficult

articulation

Aphasia

Voice

aphasia

N.XI (Accessory)
Look toward right
Look toward left
Shrug right shoulder
Shrug left shoulder

Right
Good

Left
Good

Good
Good

N.XII (Hypoglossal)
Right

Left

Position of tongue inside


Position of tongue when

(-)
(-)

(-)
Deviated to left

stretched out
Tremor
Fasciculation
Atrophy

(-)
(-)
(-)

(-)
(-)
(-)

Motor function examination


A. Body
B. Standing and

Respiration
Sitting down
Spontaneous

walking: cannot be

movement

(-)

Regular
can be done
(-)

done
Tremor
Atetosis
Mioklonik
Khorea
C. Extrimity
Movement
Strength
Trophic
Tonus

(-)
(-)
(-)
(-)

Superior
Right
Left
Active
inactive
333
222
Hypotrophic
Eutrophic
Eutonus
eutonus

(-)
(-)
(-)
(-)
Inferior
Right
Left
Active
inactive
333
111
Hypotrophic
Eutrophic
Eutonus
eutonus

Sensory Examination: exterosceptive and proprioceptive are good


Reflex systems
A. Physiologic
Cornea
Sneezing
Larynx
Masseter
Abdominal reflex
Upper
Middle
Bottom
B. Pathologic
Arms

Right Left
(+)
(+) Biceps
Triceps

Right Left
(+++) (+++)
(+++) (+++)

KPR
(+++) (+++)
APR
(+++) (+++)
Bulbocavernosus
Cremaster
Sphincter
Right Left

Right
Tungkai

Left

Hofmann Tromner

(-)

(-)

Babinsky
Chaddock
Oppenheim
Gordon
Schaeffer
Thigh clonus
Leg clonus

Autonomic function :
No neurogenic bladder
Higher brain function
Consciousness
Speech reaction

Difficult

Dementia signs
Glabella reflex

(-)

to
determine
Difficult Snout reflex

Intellect reaction

(+)

to
Emotional reaction

determine
Difficult Sucking reflex

(+)

to
determine
Grasping reflex
Palmomental reflex
IV.

WORKUPS
Laboratory :
-

Hematology (06-01-2014)
Hb

: 12,6 gr/dL

: 12500 /mm3

Ht

: 36 %

Tr

: 256000 /mm3

Gajah Mada Score : Decrease of consciousness (-)


Headache (-)
Babinsky reflex (-)
Ischemic Stroke

(-)
(-)

(-)
(-)
(-)
(-)
(-)

(-)
(-)
(-)
(-)
(-)

Siriraj Stroke Score :


( 2,5 x consciousness ) + ( 2 x vomit ) + ( 2 x headache ) + ( 0,1 x diastole BP) ( 3 x
atheroma) - 12
(2,5 x 0 ) + (2 x 0 ) + (2 x 0 )- (0,1 x 90 ) ( 3 x 0 ) 12 = -3
Impression: Ischemic Stroke

ECG : Sinus rhythm, HR 85x/minute, ST elevated (-), ST depressed (-), T


inverted (-), LVH (-)

II.

DIAGNOSIS

VI.

Clinical Diagnosis

: Left hemiparesis + Left N.VII paresis central type

Topic Diagnosis

: Right hemisphere cerebral cortex

Etiology Diagnosis

: Cerebral thrombosis

Secondary Diagnosis

: Stage I Hypertension

FURTHER EXAMINATION
Brain CT-Scan
Blood tests (Fasting blood sugar, Post Prandial blood sugar, Total cholesterol, HDL,
LDL, Triglyceride, uric acid)

VII.
-

THERAPY

General : IVFD RL 12 h/kolf


Bed rest with elevated head 30o
Diet MC RG II
NGT
Fluid balance
Specific:
Aspilet 2 x 80 mg (PO)
Citicoline 2 x 500 mg (IV)

VIII.

PROGNOSIS

Quo ad vitam
Quo ad sanam
Quo ad functionam

: dubia ed bonam
: dubia ed bonam
: dubia ed bonam

FOLLOW UP
Day/Date
Tuesday, 7-1-2014

Wednesday, 8-12014

Thursday, 9-12014

Improvement
S/ Weakness at left limb (+)
O/ GC:moderately ill, Consciousness: CM
BP: 150/90, Pulse:82, RR:20, T: 36.4oC
GCS E4M6V5
Motor: 333/222
333/111
Pupil reflex: +/+
Meningeal sign: RF: +/+, RP: -/A: Left Hemipharesis ec Non
hemorrhagic stroke
P/ Brain CT-Scan
S/ Weakness at left limb (+)
O/ GC:moderately ill, Consciousness: CM
BP: 150/80, Pulse:84, RR:20, T: 36.6oC
GCS E4M6V5
Motor: 333/222
333/111
Pupil reflex: +/+
Meningeal sign: RF: +/+, RP: -/A: Left Hemipharesis ec Non
hemorrhagic stroke
P/ Brain CT-Scan
S/ Weakness at left limb (+)
O/ GC:moderately ill, Consciousness: CM
BP: 140/80, Pulse:80, RR:19, T: 36.5oC
GCS E4M6V5
Motor: 333/222
333/111
Pupil reflex: +/+
Meningeal sign: RF: +/+, RP: -/A: Left Hemipharesis ec Non
hemorrhagic stroke
P/ Brain CT-Scan

Therapy
- RL 12 h/kolf
- Aspilet 2 x 80 mg (PO)
- Citicoline 2 x 500 mg (IV)

- RL 12 h/kolf
- Aspilet 2 x 80 mg (PO)
- Citicoline 2 x 500 mg (IV)

- RL 12 h/kolf
- Aspilet 2 x 80 mg (PO)
- Citicoline 2 x 500 mg (IV)
- Start Physiotherapy

DISCUSSION

An 82-years old patient had been admitted to Achmad Mochtar hospital at January 6 th ,
2014 with chief complaint weakness of the left limbs since 2 days ago, which happened when
patient wasnt doing any strenuous activity (patient was sitting). Sudden weaknesses of half side
of the body (especially limbs) are the main symptoms of stroke or cerebrovascular accident
(CVA). The patient was sitting down when the onset occurs. While not doing any intense or
strenuous activity, or while sleeping, ones blood pressure is decreased as the body metabolisms
are reduced into nearly basal level. An already-existing atheroma inside the vascular wall of
cerebral artery (atherosclerosis) made partial disruption of the blood flow, and the pressure inside
the blood vessel is not sufficiently high to make blood pass through. Therefore decreasing
activity level can lead to worsening of those already-existed atheroma which leads to total
blockage of the blood flow, thus inducing brain cell ischemia and eventually infarction. The
weakness itself felt heavier at the left leg than left arm, we can conclude that the damage was in
the cerebral cortex rather than sub cortex, because when pyramidal tracts are involved, both
limbs are equally weakened. There is no decreased level of consciousness, no vomiting, nausea,
and headache so we can almost rule out hemorrhagic stroke.
The patient has history of stroke at 2008 which affected right limbs, which is most likely
ischemic stroke. The patient has been inactive and spends his time mostly without any exercise
since then. Although there is no diabetes mellitus and heart disease history, patient has history of
hypertension and wasnt controlled nor medicated, thus increasing the risk of subsequent stroke
attacks (recurrent stroke).
Strokes affecting the cerebral cortex (i.e. cortical strokes) classically present with deficits
such as neglect, aphasia, and hemianopia. While subcortical strokes affect the small vessels deep
in the brain, and typically present with purely motor hemiparesis affecting the face, arm, and leg.
The patient cannot speak since 2 days ago, before that patient was already difficult to talk (i.e.
slurred speech), because of the damage caused by previous stroke. This subsequent cortical

stroke caused aphasia at the patient. There is slightly asymmetrical at the face to the affected side
which is noticed if looked closely, but facial movement seems not purely weakens since patient
still can move some of the facial muscles. There was some trace of muscle contraction at the left
leg and some small movement of left arm .The right limbs seems hypotrophic since it were
affected by stroke 5 years ago and rarely used. The vagal and hypoglossal nerve seems affected
too since there uvula is deviated away from the lesion and the tongue deviating towards the side
the lesion. There are increased physiological reflexes at both sides, since the right side had been
affected by stroke 5 years ago and the left side had been affected too since 2 days ago.
Hypertonia is common on stroke since there are lesions at the Upper Motor Neuron. There are no
pathological reflexes found but patient had some positive regression reflexes, some signs of
dementia which can be happening in patients with this age and low level of activity.
To determine other risk factors of stroke of this patient, further blood works are planned.
Brain CT-scan is also suggested. The general therapy for stroke patients are bed rest with
elevated head (30o), since it helps the venous return thus not worsening the intracranial pressure.
We suggest to put nasogastric tube since patient have difficulty of swallowing, and low-sodium
diet since the patient has hypertension. For the specific therapy, Antiplatelet such as
Acetylsalicylic acid (aspirin) is useful to break down the blood clot / thrombus which caused the
blockade of the blood flow. Metabolic enhancers supplementation such as citicoline is also useful
to improve the clinical outcome of stroke since it help to reduce penumbral lesions based on
some research in Japan and Europe. However, the largest trial to date, a randomized, placebocontrolled, sequential trial in patients with moderate-to-severe acute ischemic stroke in Europe,
enrolling 2298 patients, found no benefit of administering citicoline on survival or recovery from
stroke as published by Davalos MD, et al at the Lancet journal volume 380 on 2012.

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