Dr. dr. Nova Dian Lestari, Sp.

S(K)
06/11/2021
Mina 1
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K1b1 Muhammad Kelemahan E4 Hemiparesis dextra + 30/10/2021 - Clopidogrel 1x75 mg
Ali, lk, 71 thn anggota M6 paresis N VII,XII dextra Hb 15,1 - Iv Citicolin 500 mg/8 jam
gerak V5 sentral ec stroke iskemik Leu 15,9 - Iv Piracetam 3 gr/12 jam
Gangguan kognitif ec - Iv Paracetamol 1 gr/8 jam
Tro 219
demensia vaskuler - Iv Mecobalamin 500 mcg/12 jam
Ht 41
Kgds 120
Ur/Cr 33/1,3
Na/K/Cl
137/3,9/101
Zamzam 4
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K20 Riski Ananda, Kelemahan E4 Tetraparesis tipe LMN + 04/11/2021 - IV Omeprazole 40 mg/12 jam EMG
pr, 25 thn anggota M6 parastesi L2-L3, L3-L4, Hb 12,3 -
DPJP IPD gerak V5 L5-S1 sinistra ec susp Leu 7,6 - IV Citicolin 500 mg/8 jam
neuropati perifer post - IV mecobalamin 500 mcg/8 jam
Tro 370
vaksin - IV Metilprednisolone 125
Ht 37 mg/12jam
Kgds 95 - Asam folat 2x1 tab
Ur/Cr 18/0,7 - Gabapentin 1x300 mg (malam)
Na/K/Cl
145/4,2/108
ICU
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
B5 Nurdin bin Penurunan E Penurunan kesadaran + 19/10/2021 - IV Citicolin 500 mg/12 jam
M.Amin, lk, 78 kesadaran M hemiparesis dextra+ Hb 14,3 - IV mecobalamin 500 mg/12 jam
thn V paresis N.VII dextra Leu 16,9 - IV Omeprazole 40 mg/12 jam
sentral ec stroke - IV perdipin titrasi dose
Tro 277
hemorragik (ICH+IVH) - IV Nimodipin 2,1 cc /jam
Ht 40
Hipertensi emergency Kgds 136
DPJP B Ur/Cr 33/1,1
saraf
Post EVD Na/K/Cl
Post VP shunt 138/3,6/101
21/10/21
Hb 12,8
Leu 19,1
Tro 271
Ht 35
D dimer 1870
Ur/cr 76/1,1
Na/k/Cl
139/3,9/109
Ca/Mg 8,9/2,4