29 Juli 2016

S -Penurunan Kesadaran
O -Sensorium : Apatis-TD : 220/130 HR :112 RR:28 T:37,0-Peninggian
TIK (-)-R.Meningeal,Kaku Kuduk (-)-N.kranialis II,III : Rc +/+ ,pupil
bulat isokor ,3mm III,IV,VI : dolls eye phenomenon (+)
V : Refleks Kornea (+) VII: Sudut mulut jtug di kiri
VIII : sdn IX,X: refleks muntah (+) XI : sdn
XII : lidah istirahat medial-R.Fisiologis B/T : ++/++ ++/++
APR/KPR : ++/++ ++/++-R.Patalogis H/T : -/- -/-
Babinski : - -K.Motorik sdn,kesan lateralisasi ke kiriSP: Bronkial
+/+ST:Ronki Basah di lapangan paru bawah kiri
A Apatis +Hemiparese sinistra + N.VII UMN sinistra ec Stroke Iskemik

P -Head CT scan non kontras-Bedrest-O2 2,4l/i gtt/i-IVFD NaCl 0,9%

30-Inj.Ceftazidine 8g/8jam-Inj.Ranitidine 50mg/12jam-Captopril
2x25mg-Valsartan 1x8mg
 30 Juli 2016

S - Penurunan Kesadaran

O -Sensorium : Apatis-TD :180/100mmHG HR:100x/i RR:24x/i T:36,4oC-Peningkatan TIK(-)-Rangsangan

Meningeal(-)-N.kranialis II,III : Rc +/+ ,pupil bulat isokor ,3mm III,IV,VI : dolls eye phenomenon (+)
V : Refleks Kornea (+) VII: Sudut mulut jatuh di kiri VIII : sdn IX,X: refleks muntah (+)
XI : sdn XII : lidah istirahat medial-R.Fisiologis B/T : ++/++ ++/++ APR/KPR : ++/++ ++/++-
R.Patalogis H/T : -/- -/- Babinski : - -K.Motorik sdn,kesan lateralisasi ke kiriSP: Bronkial +/
+ST:Ronki Basah di lapangan paru bawah kiri

A Apatis +Hemiparese sinistra + N.VII UMN sinistra ec Stroke Iskemik

P -Bedrest, head up 30o-O2 2-4 L/i via NF-NGT,kateter terpasang-IVFD R Sol 20gtt/i-Inj.Ceftriaxon 1gr/12jam
-Inj.Ranitidin 1amp/12jam -Inj.Furosemid 1amp/24jam-B.Kompleks 3x1 tablet-Inj.Citicholine 250mg/12jam-R/konsul
kardio
 31 Juli 2016

S - Penurunan Kesadaran

O -Sensorium : Apatis-TD :130/80mmHG HR:100x/i RR:20x/i T:35,6oC-Peningkatan TIK(-)-Rangsangan

Meningeal(-)-N.kranialis II,III : Rc +/+ ,pupil bulat isokor ,3mm,ki=ka III,IV,VI : dolls eye phenomenon (+)
V : Refleks Kornea (+) VII: Sudut mulut jatuh di kiri VIII : sdn IX,X: refleks muntah (+)
XI : sdn XII : lidah istirahat medial-R.Fisiologis B/T : ++/++ ++/++ APR/KPR : ++/++ ++/
++-R.Patalogis H/T : -/- -/- Babinski : - -K.Motorik sdn,kesan lateralisasi ke kiriSP: Bronkial +/
+ST:Ronki Basah di lapangan paru bawah kiri

A Apatis +Hemiparese sinistra +N. VII UMN sinistra ec Stroke Iskemik + CHF FC III

P -Bedrest, head up 30o-O2 2-4 L/i via NF-NGT,kateter terpasang-IVFD R Sol 20gtt/i-Inj.Ceftriaxon 1gr/12jam
-Inj.Ranitidin 1amp/12jam -Inj.Furosemid 1amp/24jam-Inj.Citicholine 250mg/12jam-Tab b.Kompleks 3x1 tablet
 01 AUGUSTUS 2016

S - Penurunan Kesadaran

O -Sensorium : Apatis-TD :162/96mmHG HR:96x/i RR:29x/i T:36,4oC-Peningkatan TIK(-)-Rangsangan Meningeal(-)-

N.kranialis II,III : Rc +/+ ,pupil bulat isokor ,3mm III,IV,VI : dolls eye phenomenon (+) V : Refleks
Kornea (+) VII: Sudut mulut jatuh di kiri VIII : sdn IX,X: refleks muntah (+) XI : sdn
XII : lidah istirahat medial-R.Fisiologis B/T : ++/++ ++/++ APR/KPR : ++/++ ++/++-R.Patalogis
H/T : -/- -/- Babinski : - -K.Motorik sdn,kesan lateralisasi ke kiriSP: Bronkial +/+ST:Ronki Basah di
lapangan paru bawah kiri

A Apatis +Hemiparese sinistra + N.VII UMN sinistra ec Stroke Iskemik + CHF FC III

P -Bedrest, head up 30o-O2 2-4 L/i via NF-NGT,kateter terpasang-IVFD R Sol 20gtt/i-Inj.Ceftriaxon 1gr/12jam
-Inj.Ranitidin 1amp/12jam -Inj.Furosemid 1amp/24jam-Inj.Citicholine 250mg/12jam-Captopril 2x50mg-KSR
1x600mg--Tab b.Kompleks 3x1 tablet -R/konsul Cardio
 02 AUGUSTUS2016

S -Penurunan Kesadaran

O -Sensorium : somnolenTD:203/102mmHg HR: 96x/i RR:34x/i (ronki (+)) T:37CN.kranialis II,III : Rc +/+ ,pupil
bulat isokor ,3mm diameter V : Refleks Kornea (+) VII: sulit dinilai terpasang guedel XII :
lidah sulit dinilai terpasang guedel-R.Fisiologis B/T : ++/++ ++/++ APR/KPR : ++/++ ++/++-R.Patalogis
H/T : -/- -/- Babinski : - -Kekuatan motoric : sulit dinilai,kesan lateralisasi kiri

A Somnolen+hemiparese sinistra ec stroke iskemik+CHF FC II +susp pneumonia

P -Bedrest, head up 300-O2 8-10 L/i via NF-NGT,kateter dan guedel terpasang-IVFD R Sol 20gtt/i-inj.maropenen
2amp/12jam-inj.manitol 100cc/6jam-inj. Deltiazem 1amp+40cc NaCl 0.9% via syringe pump mulai 2cc/jam up fitrasi /
15menit dan pantau TD/15menit (target TD :140/90mmHg-inj. Ozid 1amp/24jam-inj.citicholine 250mg/12jam-aptor
1x100mg/tab- -KSR 1x600mg- R/ Konsul Paru- R/ Konsul Endokrin
 3 AUGUSTUS 2016- 4 AUGUSTUS 2016

S -Penurunan Kesadaran

O -Sensorium : somnolenTD:186/115mmHg HR: 93x/I RR:30x/I (ronki (+)) T:37,7CN.kranialis II,III : Rc +/+ ,pupil
bulat isokor ,3mm diameter V : Refleks Kornea (+) VII: sulit dinilai terpasang guedel XII :
lidah sulit dinilai terpasang gredel-R.Fisiologis B/T : ++/++ ++/++ APR/KPR : ++/++ ++/++-R.Patalogis
H/T : -/- -/- Babinski : - -Kekuatan motoric : sulit dinilai,kesan lateralisasi kiri

A Somnolen+hemiparese sinistra ec stroke iskemik+DM tipe 2 +CHF FC II + pneumonia

P -Bedrest, head up 300-O2 8-10 L/I via NF-NGT,kateter dan guedel terpasang-IVFD R Sol 20gtt/i-inj.manitol
100cc/6jam-inj. Deltiazem 1amp+40cc NaCl 0.9% via sryge pump mulai 2cc/jam up fitrasi /15menit dan pantau
TD/15menit (target TD :140/90mmHg-inj. Ozid 1amp/24jam-aptor 1x100mg/tab- -KSR 1x600mg
 5 AUGUSTUS 2016
S -Penurunan Kesadaran
O -Sensorium : somnolenTD:164/106mmHg HR: 91x/I RR:18x/I
(terpasang ETT dan tersambung ke ventilater) T:37,6CN.kranialis II,III
: Rc +/+ ,pupil bulat isokor ,3mm diameter V : Refleks
Kornea (+) VII: sulit dinilai terpasang ETT XII : lidah
sulit dinilai terpasang gredel-R.Fisiologis B/T : ++/++ ++/++
APR/KPR : ++/++ ++/++-R.Patalogis H/T : -/- -/-
Babinski : - -Kekuatan motoric : sulit dinilai,kesan lateralisasi kiri

A Somnolen+hemiparese sinistra ec stroke iskemik+DM tipe 2 +CHF FC

II + pneumonia
P -Bedrest, head up 300-NGT,kateter dan ETT terpasang-IVFD R Sol
20gtt/i-inj.manitol 100cc/12jam-inj. Deltiazem 1amp+40cc NaCl 0.9%
via sryge pump mulai 2cc/jam up fitrasi /15menit dan pantau
TD/15menit (target TD :140/90mmHg-inj. Ozid 1amp/24jam-aptor
1x100mg/tab- -KSR 1x600mg