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    © All Rights Reserved
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    10 views7 pages

    FU Mar 4

    Uploaded by

    DKA

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
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    SAR BOB NNN, Claudia, Juyata, Wetie) PUNNE Stanton Female / ph: ob127765668 ne 2 OR Sion, U8 0040-2-47 oo i2tul98L(1By Ta 24) erGAMTAL S = KELAS 1 / 19n2202260008 16.17 ‘Yerenia Invanuel, 8p / 8798 1 rs © Topi : tates ctor © Etlologt : veslat hamivecse bpte, patece <0 Stee BE don lonnn tertedoe Fetieg Kall palit macan. Parien SYR mengatam; peniinan beret badan 4 We ko dation 1 buan tuachie, une fat Thy Palin Auda Kae margatami Wal - muntale « RPD: Ao. tree h roto s ron 1 OMT, KT, Pater eontumb aicaraia Fervetin RPK: Tat ade Ceuunon feugn Life style: rtoe © Aroret ©” Kesadaran: (4 GCS: Ex My, Vs TD: "he yNi XhouRR: IL, ,8: Ve, SpO2 st Kepala : ronnercphatce, d formros (} Mata: (8-14.51 44 THT : Serve lease (1. Guter deferens 6), berparang WE PR rast der, Leher : hom), duos watt 6, fanlasurcn crt €2 Ua req. Mourswe (1, atloet-) Pulmo :vestiaste (e/ehum (1, oat) Abd: WeH.WTe Eka, Superior : £1225, atratbangur -ondena pinig { bas tnerr: 3 heer eae ge ‘Pemeriksaan Penunjang ? (2/3/22) Hemaroerit 460% Reineosie $6 10" HL Plateler 19. 00.10 AL oa We —* (04f03/2022) ca tet an a os KU: taller datarg angen Walinan fallt mater Mam Lemmas ream § minggu (KE 1 Pematin tn © Kaku kuduk: -) U han Stee entero | Laseque: ¢¥*/> 10° RPS: Paian sarang dengan eelvban sult mara | © Keriq: as dna? fey rae sean 4 inggu SARC, emamin memverat | ¢ Brudinskd I © Sqae chad Re. Qe ee © Brudzinski ie ee ‘Cranial Nerve: © CNT; ted otaean CNT tpt, toto Barn linn, VOM 2 . an CNV: © Motori © Sensorik: NVI: CN VT akan tion tertnggat CN VIN: 4/4 bomen grteon NIX X: doformn 4, dafegio nat: sf ae a EN XIE : pO po vei Kekuatan motorik: deed“ sery 000 | owe Lanes Refleks fisiologis : © Biceps 6a © Triceps 42/12 © Patella 1/41 © Achilles #1 Refleks patologis : Babinski Chaddock Oppenheim Gordon Schaffer Rossolimo Mendel Beethrew * Hoffman trommer Semsorik: Swminet Jalon atas normal Koordinasi : Tes tunjuk bidung © Tumit lutut jo iaji © Disdisdokokinesis Otonom : © BAB: faxes BAK: Ponies fo Sckresi Keringat : dame > Mee Terapl @/ ondansetron yma W ne Z 3 dat *Teajperone tultatem EW ne A La F/ Fotawt Yoomeg PO no Y Treat ——— FL Ramstoliee $0 mq WW Mok fad 4 400 nek N Coruna (tab pons f hed Feagnin lot PO no adae BT Urinver Yoo m4 PO no fr adi (TM eat hte Chia, Nitty Feberanee, buer Mobiles Jeeven Calbire) O40 C7/ LLL © Topis: Kgrcax Clabes © Etiologi : vajuul 4 Patologi : Zshomj k Hees Tages [daly tulre moka das lay RPS : Pity doug gts healer dulee mala dem (dd ef a moaggs fay, alin rembirns Sysh (hart fo. [Pein MEA lag , mend munrel, das otk teria ferap bal Pers mln, pares Magny pratense burns balay tt0'y labo vaca hues trmbhirs tanciady Prican cla mugaleni tenal- aval ler bole Mardin, alte RPK : dal ade balahin fete Life style: Ralutel, Allalyl l- Hjal VUdygy SoaRFidan dena ars Moboone [basil PD sly. fea clone Aald20"s DM Te HT, fore kath Kesadaran: cm GCS: EyM, Ve TO: he 1: fe JRR: Ube ,S: 5304 Sp02: 33% Kepala: Normally, deaemroy Mata: (A(/-), &1 G-) THT: fytun dunoye bay fac dabatttey (2), Otay Mey talk hee Leber: puayntd, devi wubeal) , fom busdras Kae) Cor: GL ngalin pmurbur ty, galley) Pulmo: Wilalar (4/4 -whuary (-, theeshs 6”) Meningeal sign: © Kaku kuduk: (-) © Brudzinski Cranial Nerve: © CNT: tel dilabales © CNT: Papi] bales, trabor © CN TITY, Viz GM Morne JAC (4), S] o/ rte Cte (t 4) Ima] ,>4 «CNV: Deans, Oder © Motorik: 4. d:pae ° Sensorik: } sabe dil e CNVI: @ CN VIL: fig bay buinh wramyp| © CN VINE: 4/4 buplas, & fyclon. © CNIX,X: dither Gdn fyod-) © CNXI: ~ 2 ewnt: | le lg Kekuatan motorik : yyy] qa Mewtg | Mer Shy Nerve! Ae Refleks fisiologis : * Biceps 4/tl K/Faloie 400 mcg Fe wT [pesat Did a hJcarcamn (rah Pa Ne Abd: 200), NT b-) 7 Eks. Superior : tlt = Chaddock Eks. Inferior : Jot >es, Mol baeey earn ae + Oprentein Pemeriksaan Penunjang : 7 Set fe <[- Ub ialovvaay ubowaco | Set, He + 346% Ma. 9F © Mendel Becthrew 2c: 10% i * Hoffman trommer cs besa se Sensorik: dalaw, butar herna| Plo. tg ¥ lo? Koordinasi : © Tes tunjuk hidung Nas (er © Tumit lutut } ube : * Disdiadokokinesis kaw Otonom : cli 9s © BAB: finfin = BAK: Memrary : : a Keringat : formal Terapi: NY Rawiading $084 (U eB U7 (haphen (oo hy PO “ares 4 wpa lal? Vaiyar k doe Wy Fo GZ Yunnter 400 by fo Or Venn Galbarou, 2) WV NeET Sal pal DT). a6 ee Tl TeTIEK sux HR 0. ESL / Fenale / ph: 0811528221 $.01-09-26-89 / 008: 2 URNTAT S = seuas 1/19 Lilie Lalisang . 0000000000 ul-1946 (75y Ta 5 0007 14,08, 510s - ar 2 é Diagnosis : © Kins = Hamcparess dates Afas eat © Topis : tater cerebe, area torah were, © Etiologi :wsuster BU Baie darang dengan talukan ealemahan anggotr MAK Ele Cee munggu SHAS, menberat { han CHES RPS : Ration datang dengan ealuhan gltmahan arygora Seme eiei cyar ( munggu SMA. mumbarat (han Mel: Pasian oamaied riwayar Croke 4 20 4ahun yang Lalu , C07 Wingna anogear quae tanan patin mtlemad, Pailin Memilict riayat frarnir di tang faba t (tamun Yang (alu, dan Remenjar gmene, motllsan poser 446° Ganggu. Pain memes etlthan Tule berlacara dan Ey memaeand: Qonbiaroan. Muslimah smaen tte SNe ocende, Ponds fater Carpal mergalons Yaar RPD : Bisayat’ HTC, jantngts), Bee eet RPK Life style: Roree © Aleonoi© Kesadaran : Sommoten GCS TD: 4/40, Nz B67, RR: 1b7/ , S: 36,96 SpO2: O71} 0 epi lone suerte ne th Mata : CA (-/-), 9. C-/-) THT: Denon Ceprum @ , Secret Leher: Mara@, Reveroran GSO), davon rarer © Cor: Sa raguter, gatioy @, murmur © YM Vagana globes Pulmo : Veneuter (4/4) ,conehi (=/-) herring (-19) Abd: fuget, nyen reean ©, BU (4), Eks. Superior Eks. Inferior : tert enaets CORE, ttingedonn SHE Pemeriksaan Penunjang ? Lab (05 /03/ 10229 Saor Seer (26/02 [way s Miounin Wot 6 EEG (03 /03/wr> ~ Atma Fibntlanen = Arytnmia, AU blooe Kee T Motta 1 ¢ Patologi : Zeuerh Meningeal sign: Kaku kuduk: - Laseque: 7° /7, + ee wang Kerniq: 75/7135 Brudzinski Brudzinski II: -/~ Nerve: CNT: bul aieays CNIT: OCU (4 (rd, RETE (4 fr), OM CNII, IV, VI: n008!), recor g 20m /imin CNV: © Motorik: © Sensorik: CNVI: cNVt: cN VIII CNIX,X cNXI cNXxIT estar Sele deal? Kekuatan motorik : niet gat dia Refleks fisiologis : + Biceps tere Triceps ama Patella ¢2/¢2 * Achilles 24© Refleks patologis : Babinski Chaddock Oppenheim Gordon Schaffer Rossolimo Mendel Becthrew Hoffman tromier Sensorik : Arla daqae covefe Koordinast : Tes tunjuk hidung Tumit Tueut } Ardell dapat _ Disdiadokokinesis dea Otonom : BAB :de BAK: on catheter Sckresi Keringat : vtmay Terapi: Hema waters bale oof S3éa ep Htrontaae beboe wo we —_——_— H aver 311g tab 0 side Sida Hina Sut Bf aservagarin 204th no S$ 1dd1 40 SH farogenrae 209 Heb na Se se Side too TasapraWie 7om9 Fa WO eo Spill tole OC. 4 fab Seong cops 00 F om L 4 L NOMA SM) ( Chettiaphen 1 SHven, Patra, eka) TATIEK SUXESI / Fenale / ph: ne1169"9" MR Ho: RSUS.01-09-26-89 / DOB: 27-Jul-1946 (75) S105 ~ LANTAT 5 ~ KELAS 1 / 182202240007 14.08 Hemiparesis Aaplex, afore 4'¥a| Topis : Feeters Zretor'+ Etiologi: vastuta- « _Patologi : brkemih KU: datang dengan keuhan FRemaban Angyet quanta ceuk 2 wing SMES yare membeat | har smts. 5 ota RPS : Parien datany deropa Keldhan Keltmaban arapye guak Hiri sepite 1 age ‘SMES dan wembernt b lank SPAS. fosien wemitiei visiayed Shake # totals Yang Inte, bgp JAngpite gerak karen pasien melemals. RAsien Jip wendie\ ea yat father dittars aha thdabun yang lala don sen Soak cde maleiisnsi poser teraangges. Pasven memes Relatan Sulit bedtara dam fut menahami perbiarnan. 10:79, N:86Y/an4y RR: Yoandy S:3.9°G SPO2: 947 on mmg NC 2. Leen Kepala : Normaceptaly, defor nits C-) Mata: ChC-/-), St -7-> THT : Devass veg hem C4), SkrehC-) Leher : Hass (-) ,yemberaran a6 (-), devian Ankes (-) Cor: 5482 eeguter, gaer (-), miemur t=) Pulmo : vesttaten C+/€), remit 6-/-), sheers C-/=) Abd: supel, BUG), yer tekent—> Eks. Superior : Eks. Inferior : } Pemeriksaan Penunjang : bate (o3/o3/or) | (/orren) = S6oT 1S -Aieumin 2,08 “SGPT 6 EEG (03/2 arr) AMAL freciation ~ Arytlmia AV lock Ape IE mole 1 Rial hangat pcp7> 2 dete RAnes Lo Hunl, mental, nytri kepala Atrarefal: Pade havi Komi 164] Melosncny: Aen tempad woereplecet Kasai AOeie CALE GEA AAT t ; rest degen OOS mene Range eat maces easy o Motorik: Vigns 2d o Sensorik: PD: Pomynt HTCED, gerbe (+), PM (>) ines K «© CNVI: sth RPK: ; Life style: Patek (=, altehel (=) . cui: Kesadaran:Sornoten GCS: E4Ms Vagasta stebal . XX: * CNXI: © CNX: Meningeal sig © Kaku kuduk: (-) © Laseque: > 70°/>7°" Kerniq: >(35°/>135* Brudzinskil: - /- © Brudzinski II: - /- Cranial Nerve: | CNT: sali atta CN IL: Ree (4/4), RETE 4/4),prpih bu CN IIL, IV, VI: thsis iste 62 Kekuatan motorik : naak dager dias, Refleks fisiologis : © Biceps #¥/+t © Triceps 42/40 © Patella /¢e © Achilles 42/4. Refleks patologis Babinski -/- Chaddock -/- Oppenheim - / - Gordon -/- Schaffer - /- Rossolimo -/- Mendel Becthrew -/- Hoffman trommer - /_ RAaR degat obikn j BAK: & catheter Sekresi Keringat : Aww eee eens Sensoril Koordinasi : Tes tunjuk hidung Tumit lutut 7 Tilak deg dike . Staar at Terapi: A] Semlfah Spe iee-D 1] Atwvnsmnin BY Mew dutabs th nw Z SAA the Stdat ae S3ddr we Fh] Betadine moutinutah ne. P]eamsemide to F/merondaarle bénbae L Feel LLL “tT tan "Bene Sue Vea Sono ws wg eee igisle Ate tad E/ seat) Pome cops ne. ticdninecame coe Shearing Wo ned t/a ROMS eos ma SE Fhanneatie ony mu Srda( tre ac [eee 55 tae ne Euaalt S31 F/ Trager tooms LV wes] ——=_ =F arth bre | Herb bey ES his een pee (Claudia, Felix, dulieta, Nixie) — Shite agi by Hemiratese Duplex, yartse CN YN" parece ov Gi central Sintra, Bllodynic hrperregiert ctmetra, hipestes'q nig SGo4 Senequred Cloric PEWC, shrace ELLEN pupa) Diagnosis! Kemerrhmoty lama co AR No: rs Fenale / Ph: 08111880392, 08159024491, 0 7 2-21-17 | 008: 31-0et-1963 (58y 4a 3d ibe anne 42203030002 aS-nar-2022 07:48 cata Pg mir (ar. Henny Kartika Putri / aps 1 te PD 3x se]ak malam hari SHAS Iylatamet © «Kaku kuduk: RPS: Baitn datang dengan Keluhan KeJang beaunng| > paseee: Shang 3x Se : ea% Jax mata hari MRE ( 21.00, 18.20, a my tense Aurasi So dete (2120), 2 ment © Brodzinsld MI: 00) , dan 80 atkk (03.00). tosien RK pase | Cranial Nerve: $2at Kejang dan setelon nejang . Steelum Kejong, | © CNI: Nomal Sui atkoy reson nengclom’ musi munen» Saor weeny. Vain + ONT: inp \/te / > 60, SEE) pasen mengalam! ke lojotan dan djveritan ‘etoed © CNIILIV, VI: vermal, prensC-/-} melalui dutur. Lida rersisit, kejana poda saat * CNV: Kaur sadan, kejang wing diprou olth para aray © Motorik: (/-) RPD; SAYA disangual. lasien pernah mengabmi © Sensorik: (+ /-) Stree Pada akun 2019 tan mengatami ° CNV : © trex: “lemahon pada angrota nora , domiman © CNVE: Fisi GR get'nggal soct peryeuger peat en 49M Ferrnh meron tom! F249 4 CVE: BIsttan dan geretar Jon CHAD omfes meet GCSTEAMGVS 26 mini, | © CNIX,X: Dlstagia 6), drsfontac> (Dp tas . 7 Herjodi xs. © CNX: +/+ ¢minimat) ” TD: Moo NSF |RREIB 48: 4.4,SpO2: 99% ral CNT: pore Kepala: Norm ocethaly ,deform#os (~) 3335 | e000 Mata: C1) 92 C-/) Kekuatan motorik: 3355 [ovoo THT : spim devas ¢9, rhinenhto Gs) defers) | Refleks fisiologis : Leber: masta) dexiag targa C) femberaran best) Biceps +2 /+5 © Triceps 42/45 Cor: Sirereuer, mormon C>,ralleg’d Spat 42 /a lod gms - Pulmo: Varbule (4/4), HET wh CLP © Achilles *€ /alletynta ‘ Refleks patologis : Abd: BU Ct), AYEA Rkan OD et ae Eks. Superior: Abra] haat, CET<2dehy - © Chaddock -!~ Eks. Inferior: Atml hangar , Cet <2deik - : Oppenheim - /— F ef reap : A mg UP shunt melalui paritral kante dtwhn 6 sere secede : = tnceprate relacis i Cia EAYEE Karan 7 Hoffman trommer -/ ledajar ral Yor; loo) Horta! Kone oor Iohas temgerel Wer ee cr tren trgen_| Sensorikc: ia o 5 diaras excavse veentel Koordinasi: + | Allodys| teretit heen _ Tes tunjuk hidung Hb + 9.8 Mev! 46) anemia. mverocne. Wipo rom: a i . Met + 4 if -becar peetaranan wfcildi et ute tay} WE 5 W000 +leuonrore | “PIER enveera iri | | al He 5 30% ingore \arne pacin ee a glsbus palletes jean Feres (enoicar ecualt blood © BAB: ONf9mr26 BAK: on pamport 03123) 4 Sckresi Keringat: Normad:: Terapi: Neorcor 416 my rob n0-D A Ceeperatme- Samora h ane 10 Y Feriteia too my tae no Jidat 7 neg Lidat ng F/Arorvastiate tomy Hab 10.0 1 3dat R/ tkerlox 1@0 my rob 3 Ltaat alte Josten. lomt divave mg” /fmledipin F my tab no.D K/ Clopideneel 45 my pabno.D Jidat - Dida RPO: sriwayar sroKe tahun a0lD =rlweyat higenensi ferkentro} ~ Riayat CAO o/p per, srimoype Fejang 1 buian SHAS Aenge Auras + G meni, serjadi ix sala + riweyas uP shun (+) ReO + - Phenytoine yoo my ax - Concor Aw my IKI = Amlodi@Me & ome yx! OF (03 (2020 5to4. ELLEN PUOdTRO / Female / Ph: 08111880392, 08159024491, 0 HR No: RSUS.00-27-21-17 / DOB: 31-Okt-1963 (SBy 48 3d) 5803 - LANTAL 5 = NELAS 1 / 1982209030008 09.37 Retna Jayantri en PIS 1 Kaya $x sey malam Wari Shas. 4 KU: 3K SEE yaadame Was SUAS Cpt 21.00 , 23:00, 03.60) doen 3 the (21.00) torent (23.0) dae 0 rey (09.0) Pomin tet mdar pada sank weyies dan Setdah MeFRes Pont sadn, Sethi GRAY, Nite Mengalants meal. Saat YES adn papion mergalant Hapa n dan Aloeriban S#eDTA wrelalas view, Lida Keyait, errs fade cach Base Fen, Aca HOH taney Cobeye ddargleel. fasten penal morgalans shake pace fhe 2019 chen RPD} M* rem Mens Life style Kesadaran? ngs mews GCS Ey Mg Vs TD: %» JN: 76 RR: (f — ,S:36.7°, SpO2: Kepala : Nermeceptaly, Aefrrmtos (-) Mata: CA (-/-), SEL-/-) THT! Seghon Aeeiny: (2), ehinerchenl) , Atferiter(-)| Leher : Macsnc-), deviar takes (-), pembrarman bs ( Cort 515%. repater, meme 6-2, gaieg 2 Polo: Vester C47), rene Co/-), recy (4 3) Abd: ce), ope teban C=) Eks. Superior : Els. Inferior : sana ty CAT ea dene Pemeriksaan Penuajang? © Of pac (03/03/10) flab (03/03/zerry) Hpamng ve teat welata: govern! Pen Te a eg th ee wen 73a P ethlermalacin dt Ope exteone C= 30 Fete Fae 5g fe ee prea 95 | wens ini | Ase tala erent Meets Uy | HBC: 2.80 fevbesten Let betta ates Ceres lengleap ( 63/orysenn) AEE Stang NASOPRY, Or) ON RPS : pasign datang derepr ted 1 ts ed merge Maen fe mem ont Decne pe aah Bo Hemtparese duptec, gaere cw I sanien Were 6 HL Stahl inten atedynry Topis : SHbcortew Centers, cortex terete Etiologi: Vartan, Vewpetice « Kaku kuduk: © Laseque: Balle Anes © Kerniq er ° Brad CNI: CN IL views U0 /21py neele/4) G/L) CN IIL, IV, VIE Meena), Bais C/ ©) CNV: im : © Motorik: (+/-) © Sensorik: (+/-) CNVI: CN VII : $i bei beratreyal son ta CN VIII: bisitean dan Seether Jari (47; CNIX,X: Atfuyes 62), disfonia(-) CNX: 4/4 (neiont) CNX: veal ee Coen trenormed | Bigot Relleks fisologis : ™~° | megs © Biceps 42/43 © Triceps 4. /+3 © Patella +2 /Alodyaca © Achilles #2 /pUsdynin Refleks patologis : Babinski ~/- Chaddock -/- Oppenheim ~/- Gordon ~/~ Schaffer - /- Rossolimo ~/~ Mendel Becthrew Hoffman trommer ~/— Kekuatan motorik n -/- Sensoril see Koordinasi : FY Aedgeia! © Tes tunjuk hidung ‘* Disdiadokokinesis, Otonom : BAB ie perges BAK: on pepe Death SA) Sckresi Keringat: dow Terapi CYemcar VSG RD ne TE TYP aleumn Ue ne TL inn Hoong tak ne St rm Sraat ade Wai | LL " htevastatin Lome AB ne ST ~Bulpact ¥ om ae “5 ~ Hebroreee Leactnm Dame WV nee en b < L Live Cont Anne ey Tacky bag Bel “Waewaane to vee | WUclopdag-el mymery SIAM ap PPC ern Leaae 7 iad oC, soa FRED: riaapat Shake hemerayte tahen 209 # ROO: - Prenytecn leony 341 vrimeanh basaag vray VP ito coy ce nenin Wetends dectantel creat CAP sro oes

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