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  • LEMBAR FOLLOW UP DOKTER MUDABAGIAN/SMF SARAF RSUD KOTA MATARAM

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    DewiAnitaAmelia
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    The document summarizes a medical examination of a patient who presented with sudden onset of headache, vomiting, and slurred speech. The 3-sentence summary is: The examination notes the patient's vital signs, medical history of diabetes and heart disease, and findings from neurological and physical examinations including normal cranial nerve function and no motor or sensory deficits. Laboratory tests showed abnormal cholesterol and blood glucose levels. The working diagnoses were hypertension, diabetes, and possible stroke requiring CT scan for confirmation.

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    VFYT

    Original Title

    Lembar Follow Up (Stroke)

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    The document summarizes a medical examination of a patient who presented with sudden onset of headache, vomiting, and slurred speech. The 3-sentence summary is: The examination notes the patient's vital signs, medical history of diabetes and heart disease, and findings from neurological and physical examinations including normal cranial nerve function and no motor or sensory deficits. Laboratory tests showed abnormal cholesterol and blood glucose levels. The working diagnoses were hypertension, diabetes, and possible stroke requiring CT scan for confirmation.

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    © All Rights Reserved
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    26 views6 pages

    LEMBAR FOLLOW UP DOKTER MUDABAGIAN/SMF SARAF RSUD KOTA MATARAM

    Uploaded by

    DewiAnitaAmelia
    The document summarizes a medical examination of a patient who presented with sudden onset of headache, vomiting, and slurred speech. The 3-sentence summary is: The examination notes the patient's vital signs, medical history of diabetes and heart disease, and findings from neurological and physical examinations including normal cranial nerve function and no motor or sensory deficits. Laboratory tests showed abnormal cholesterol and blood glucose levels. The working diagnoses were hypertension, diabetes, and possible stroke requiring CT scan for confirmation.

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    © All Rights Reserved
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    of 6

    LEMBAR FOLLOW UP

    DOKTER MUDABAGIAN/SMF SARAF


    RSUD KOTA MATARAM
    NamaPasien :
    Umur
    :
    Dm
    :
    KeluhatanUtama :

    Ruangan
    Alamat
    L/P

    :
    :
    :

    RPS :Terjadimendadak
    Saataktivitas
    Nyerikepala
    Muntah
    Bicarapelo
    Wajahmencong
    RPD:HT
    DM
    PenyakitJantung
    RPK :
    R. Pengobatan
    Status Generalis
    1. Tanda-tanda vital
    Kesadaran/GCS :
    /E V M
    Vital Sign : TD :
    RR :
    N :
    T :
    2. Status interna
    Kepala: Bentuk normal ( )
    Mata : CA ( ), SI ( ), RP ( ),
    Telinga :Bentuk normal ( ), secret ( ), pendengaran normal ( ),
    Mulut :Bentuk simestris ( ), pucat ( )
    Leher : Deviasi Trakea ( ), Tyroid ( )
    Thorax :Pulmo : Bentuksimestris ( ),Ves ( ), rh ( ), wh( ),
    Cor
    : S1S2 tunggal, regular ( ), murmur ( ), gallop ( ),
    Abdomen :Distensi ( ), BU ( ), timpani ( ), NT ( ), H/L ( ),
    Extermitas: AH
    Edema
    3. Status Neurologis

    Rangsangan Meningeal :
    Kakukuduk
    Kernig
    Brudzinki I
    Brudzinki II
    Brudzinki III
    Brudzinki IV
    Nervus Cranial
    Nervus I
    Nervus II

    : Tes Penciuman
    : Cahaya tak langsung
    Cahaya langsung
    Nervus III, IV, VI : Gerak bola mata
    Kedudukan bola mata
    Pupil
    Nervus V
    : Membuka mulut
    Nervus VII
    : Mengerutkan dahi
    Menutup mata
    Meringis
    Bersiul/mencucu
    Nervus VIII
    : Tes garpu tala
    Tes keseimbangan
    Nervus IX
    : Tes pengecapan
    Nervus X
    : Tes menelan
    Fonasi
    Nervus XI
    : Mengangkat bahu
    Menengok
    Nervus XII
    : Menjulurkan lidah
    Atrofi
    Tremor
    Kesimpulan N. Cranialis :
    PemeriksaanMotorik
    Power
    :
    Tonus
    :
    Trofi
    :
    Kesimpulan Motorik :
    RefleksFisiologis
    Bisep
    :
    Trisep
    :
    Radialis :
    Patella
    :
    Achilles :
    RefleksPatologis

    Hoffman - tromner:
    Babinsky
    :
    Chaddock
    :
    Schaeffer
    :
    Gordon
    :
    Gonda
    :
    Openheim
    :
    Bing
    :
    Rosolimo
    :
    Mendel - bachtrew :
    PemeriksaanPenunjang
    a. Laboratorium :
    1. DL
    LED
    2. Profil Lipid
    Cholesterol Total
    Trigliserida
    LDL
    HDL
    3. Gula Darah
    Sewaktu
    2 jam PP
    Puasa
    HbA1C
    4. Ureum
    Kreatinin
    5. Asam urat
    6. Urine Lengkap
    b. EKG
    Atrial Fibrillation
    Left Ventrikel Hipertrofi
    c. Rontgen
    Left Ventrikel Hipertrofi
    d. CT - Scan
    Diagnose Banding
    1.
    2.
    3.
    4.
    5.

    Skor Siriraj :
    Keterangan : interprestasi:
    Kesadaran (K) : 0compos mentis> 1 : Perdarahan (stroke perdarahan)
    1somnolen
    -1 s/d 1 : Perlu CT - Scan
    2tidakada<-1 : Infark Serebral
    Vomitus (V)

    : 0tidak ada
    1ada

    Headache (H) : 0tidak ada


    1ada
    Ateroma

    : 0tidak ada
    1ada

    Rumus: ( 2,5 x kesadaran )+( 2 x vomitus )+( 2 x headache )+ (0,1 x diastole BP )-(3 x ateroma )-12

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