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    Laporan Kasus (NHS Stroke)

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    keluargacendana
    The document summarizes the medical examination, diagnosis, problem list, treatment goals, and rehabilitation plan for a patient who suffered a non-hemorrhagic stroke resulting in left hemiparesis. Laboratory and radiology test results showed signs of stroke and hypertension. The diagnosis was non-hemorrhagic stroke with left hemiparesis. The treatment plan involved medication, rehabilitation exercises to improve strength and mobility, and lifestyle changes to prevent future strokes and allow the patient to return to work.

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    Laporan Kasus (NHS Stroke)

    Uploaded by

    keluargacendana
    27 views8 pages
    The document summarizes the medical examination, diagnosis, problem list, treatment goals, and rehabilitation plan for a patient who suffered a non-hemorrhagic stroke resulting in left hemiparesis. Laboratory and radiology test results showed signs of stroke and hypertension. The diagnosis was non-hemorrhagic stroke with left hemiparesis. The treatment plan involved medication, rehabilitation exercises to improve strength and mobility, and lifestyle changes to prevent future strokes and allow the patient to return to work.

    Original Description:

    REHAB MEDIK

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    The document summarizes the medical examination, diagnosis, problem list, treatment goals, and rehabilitation plan for a patient who suffered a non-hemorrhagic stroke resulting in left hemiparesis. Laboratory and radiology test results showed signs of stroke and hypertension. The diagnosis was non-hemorrhagic stroke with left hemiparesis. The treatment plan involved medication, rehabilitation exercises to improve strength and mobility, and lifestyle changes to prevent future strokes and allow the patient to return to work.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    27 views8 pages

    Laporan Kasus (NHS Stroke)

    Uploaded by

    keluargacendana
    The document summarizes the medical examination, diagnosis, problem list, treatment goals, and rehabilitation plan for a patient who suffered a non-hemorrhagic stroke resulting in left hemiparesis. Laboratory and radiology test results showed signs of stroke and hypertension. The diagnosis was non-hemorrhagic stroke with left hemiparesis. The treatment plan involved medication, rehabilitation exercises to improve strength and mobility, and lifestyle changes to prevent future strokes and allow the patient to return to work.

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    Supporting Examination

    •Laboratory
    February 22nd, 2016

    PT 10,4 detik WBC 7,7 103/mm3


    APTT 25,4 detik RBC 3,68 106/mm3
    Glukosa GDS 99 mg/dl HB 12,3 g/dl
    Ureum 38 mg/dl HCT 37,7%
    Kreatinin 1,13 mg/dl PLT 216 103/mm3
    SGOT 24 U/L
    SGPT 15 U/L
    Natrium 144 mmol/l
    Kalium 4,1 mmol/l
    Klorida 112 mmol/l
    Kolesterol Total 153 mg/dl
    Kolesterol HDL 41 mg/dl
    Kolesterol LDL 102 mg/dl
    Trigliserida 111 mg/dl
    Radiology CT-Scan

    • Radiology CT-Scan
    Impression :
    Infark Cerebri Dextra
    Hipodens Lesion in
    Capsula Interna Dextra
    Diagnosis

    • Medical : Hemiparese sinistra et cause Non-Haemorrhage Stroke


    • Surgery : -
    Diagnosis Fungsional
    1. Impairment
    Non-Haemorrhage Stroke
    Left Hemiparesis on Extremities
    Transfer Impairment
    Coordination Impairment
    Muscle Spaticity on Left Extremities
    Hypertension
    2. Disability
    Balance Disturbance
    Transfer Disturbance
    Self Hygine disorder
    Activity Daily Life Dependent
    3. Handicap
    Cannot Work as a Farmer
    Problem List

    • Medical : Non-Haemorrhage Stroke + Hemiparese sinistra + Hypertension


    • Surgical : -
    Rehabilitation Medicine :
    R1 (Mobilization) : -
    R2 (ADL) : Activity Daily Life Dependent
    R3 (Communication) : -
    R4 (Psyhological) : He worried about his condition
    R5 (Social Economy) : Supported by family
    R6 (Vocational) : Cannot work as Farmer
    R7 (Others) :
    Left side Muscle Weakness
    Left side Sensory disorder
    Transfer Impairment
    Coordination Impairment
    Muscle Spaticity on Left Extremities
    Treatment Goals

    • Short Term
    1.Improve muscle strength of the right
    extremities
    2. Improve balance
    3. Preserve coordination
    4. Sharpening Proprioceptive sensoric
    • Long Term
    1. Prevent for the 2nd stroke attack
    2. Back to work
    3. Improve quality of life
    Planning

    • Medical
    • PDx: Cerebral CT-Scan
    • PTx :
    IVFD RL 20 tpm
    Citicoline 500 mg/ 12 jam/IV
    Ranitidine 50 mg/ 12 jam/IV
    Sohobion 1 amp/ 24 jam/IM
    Aspilet 80 mg/ 24 jam/oral
    • PMx : Sign and Symptoms
    • PEx : Education about the disease, control risk factors
    and regularly control to neurology department
    Planning (Cont)
    • Rehabilitation Medicine
    R1 (Mobilization) : -
    R2 (ADL) :
    PDx :-
    PTx : Activity Daily Life Exercise
    PMx :-
    Pex :-
    R3 (Communication) : -
    R4 (Psyhological) : He worried about his condition
    PDx :-
    PTx : Give explanation about the disease and treatment goals
    PMx : Psychological condition
    PEx : Give motivation to the patient and support for his family
    R5 (Social Economy) : Supported by family
    R6 (Vocational) : Cannot work as Farmer
    PDx :-
    PTx :-
    PMx : Vital sign, muscle strength, neurological status
    PEx : Need family support, suggest him to back to work if his
    condition is improved
    Planning (Cont)
    • R7 (Others) :
    Left Side Muscle Weakness
    Left Side Sensory disorder
    Transfer Impairment
    Coordination Impairment
    Muscle Spaticity on Left Extremities
    PDx : MMT on Extremities
    PTx : 1. Breathing exercise active with deep breathing
    Therapeutic Exercise
    1. Active range of motion exercise of upper and lower extremities
    2. Strenght Exercise, especially for Gatrocnemius Muscle
    3. Electrical Stimulation on Tibialis anterior and Gastrocnemius sinistra
    4. Gradual Transfer Exercise (Mobilization From Sitting To Standing)
    5. Coordination Exercise for left extremities
    6. Standy Balance Exercise
    7. Sensory reeducation on left side of body
    PMx : Clinical sign and symptom, Vital Sign, musculoskeletal and neurological condition
    PEx :
    1. Explanation about the benefit, purpose of the exercise and planning program
    2. Suggest the patient and support family to do exercise regularly
    3. Active range of motion exercise of upper and lower extremities,
    4. Healthy lifestyle and dietary

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