*M Hasan /46 th/H4MRS*

S/ Pasien belum sadar penuh

O/

ku : lemah

TD : 120/70

N: 88

RR : 20

tax 37,0

status neurologi

GCS 4X5

N2/3 : RC +/+ 3mm/3mm pupil bulat isokor

motorik : lat -

sensorik : respond to pain (+)

otonom BAK (+) 2000 cc/24 jam DC, BAB (-)

A/ ICH + COS + SDH + CF clavicula D + Trepanasi dekompresi evakuasi ICH + SDH

P/

Inf D5 ½ NS 1000 cc/24 jam

Inf Manitol 2 x 100

Inj ceftriaxone 3x1

Inj antrain 3x1

Inj Piracetam 3x3

Inj Ranitidin 2x1

Inj Phenitoin 3x100

*Tn Satar /46 th/H5MRS*

S/ Gelisah
O/

ku : lemah

TD : 110/70

N: 84

RR : 24

tax 36,9

status neurologi

GCS 435

N2/3 : RC +/+ 3mm/3mm pupil bulat isokor

motorik : lat -

sensorik : respond to pain (+)

otonom BAK (+)DC, BAB (-)

A/ Post craniotomy evakuasi H5MRS ec SDH

P/

Inf Manitol 1x100

Inj ceftriaxone 2 x1

Inj Antrain 3x1

Inj Kutoin 3x100

Inj Metoclopramid 3x1

Inj Kalnex 3x500

Inf Pamol 3x1

Concor 2,5 mg

Tanapres 5 mg

Amlodipin 10 mg

*R Amelia /27 th/H2MRS*

S/ Muntah (+) Mual (+)

O/

ku : lemah

TD : 100/70

N: 78

RR : 22

tax 36,0

status neurologi

GCS 456

N2/3 : RC +/+ 3mm/3mm pupil bulat isokor

motorik : lat -

sensorik : respond to pain (+)

otonom BAK (+) , BAB (-)

A/ Malfungsi shunt

P/

Pro revisi shunt

IVFD PZ 20 tpm

Inj Ondancentron 3x8 mg

Inj Antrain 3x1

Rencana op senin pagi

*R Amelia /27 th/H2MRS*

S/ Muntah (+) Mual (+)

O/

ku : lemah

TD : 100/70

N: 78
RR : 22

tax 36,0

status neurologi

GCS 456

N2/3 : RC +/+ 3mm/3mm pupil bulat isokor

motorik : lat -

sensorik : respond to pain (+)

otonom BAK (+) , BAB (-)

A/ Malfungsi shunt

P/

Pro revisi shunt

IVFD PZ 20 tpm

Inj Ondancentron 3x8 mg

Inj Antrain 3x1

Rencana op senin pagi

*Burani /51 th/H4MRS*

S/ Nyeri bekas luka op

O/

ku : lemah

TD : 110/70

N: 72

RR : 22

tax 36,7

status neurologi

GCS 456

N2/3 : RC +/+ 3mm/3mm pupil bulat isokor

motorik : lat -

sensorik : respond to pain (+)

otonom BAK (+) , BAB (-)

A/ Skull defect post cranioplasty H2

P/

p/o cefixime 2x1

Ranitidin 2x1

Asam mefenamat 3x1

*Agung /18 th/H5MRS*

S/ Pasien belum sadar penuh

O/

ku : lemah

TD : 110/70

N: 82

RR : 20

tax 36,7

status neurologi

GCS 446

N2/3 : RC +/+ 3mm/3mm pupil bulat isokor

motorik : lat -

sensorik : respond to pain (+)

otonom BAK (+) 2500 cc/24 jam , BAB (-)

A/ COS + OF impresi frontal + EDH post craniotomy decompresi evakuasi EDH H4

P/
p/o cefixime 2x100

Kutoin 3x100

Asam mefenamat 3x500

*Burani /51 th/H4MRS*

S/ Nyeri bekas luka op

O/

ku : lemah

TD : 110/70

N: 72

RR : 22

tax 36,7

status neurologi

GCS 456

N2/3 : RC +/+ 3mm/3mm pupil bulat isokor

motorik : lat -

sensorik : respond to pain (+)

otonom BAK (+) , BAB (-)

A/ Skull defect post cranioplasty H2

P/

Inf PZ 1500 cc/24 jam

Inj ceftriaxone 2x1

Inj citicolin 2x250

Inj Metilprednisolon 2x2,5

Inj antrain 3x1

Inj Kalnex 3x1

Neb Pulmicort 1x1
*Suparman / th/H5MRS*

S/ Nyeri pada kaki

O/

ku : lemah

TD : 130/70

N: 70

RR : 20

tax 36,6

status neurologi

GCS 456

N2/3 : RC +/+ 3mm/3mm pupil bulat isokor

motorik : lat -

sensorik : respond to pain (+)

otonom BAK (+) , BAB (-)

A/ Skull defect post cranioplasty H2

P/

p/o cefixime 2x1

Ranitidin 2x1

Asam mefenamat 3x1

*Asyari / th/H3MRS*

S/ Tangan kanan sakit

O/

ku : lemah

TD : 100/70
N: 72

RR : 18

tax 36,6

status neurologi

GCS 456

N2/3 : RC +/+ 3mm/3mm pupil bulat isokor

motorik : lat -

sensorik : respond to pain (+)

otonom BAK (+) , BAB (-)

A/ COR + CF Antebrachii (D)

P/

Inf PZ 1500 cc/24 jam

Inj Ranitidin 2x500

Inj santagesik 3x1

Inj ondancentron 3x8