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
February 22nd, 2016

Impression : Infark Cerebri

Dextra
Diagnosis
Medical : Hemiparese sinistra et cause Non-Haemorrhage Stroke

Surgery : -

Diagnosis Fungsional
 Impairment
1. Non-Haemorrhage Stroke
2. Left Hemiparesis on Extremities
3. Transfer Impairment
4. Coordination Impairment
5. Joint Spaticity on Left Extremities
6. Hypertension
 Disability
1. Balance Disturbance
 Handicap
1. Cannot Work as a Farmer

Problem List
 Medical : Non-Haemorrhage Stroke + Hemiparese sinistra + Hypertension
 Surgical : -
 Rehabilitation Medicine :
1. R1 (Ambulation) : -
2. R2 (ADL) : -
3. R3 (Communication) : -
4. R4 (Psyhological) : He worried about his condition
5. R5 (Social Economy) : Supported by family
6. R6 (Vocational) : Cannot work as Farmer
7. R7 (Others) :
1. Left Hemiparesis on Extremities
2. Transfer Impairment
3. Coordination Impairment
4. Joint 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
1. PDx : Cerebral CT-Scan
2. PTx :
1. IVFD RL 20 tpm
2. Citicoline 500 mg/ 12 jam/IV
3. Ranitidine 50 mg/ 12 jam/IV
4. Sohobion 1 amp/ 24 jam/IM
5. Aspilet 80 mg/ 24 jam/oral
3. PMx : Sign and Symptoms
4. PEx : Education about the disease, control risk factors and regularly
control to neurology department
 Rehabilitation Medicine
1. R1 (Ambulation) : -
2. R2 (ADL) : -
3. R3 (Communication) : -
4. 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
5. R5 (Social Economy) : Supported by family
6. 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

7. R7 (Others) :
1. Left Hemiparesis on Extremities
2. Transfer Impairment
3. Coordination Impairment
4. Joint 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. ADL Exercise
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