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  • Identitas' Leade R Diagnosis Plan Dan Terapi Awal Plan Dan Terapi Akhir

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    The document is a medical record for an 82-year-old female patient (MRS). It summarizes the patient's diagnoses, initial treatment plans, and final treatment plans from several specialists, including neurology, internal medicine, cardiology, and dermatology. The neurologist diagnosed the patient with non-hemorrhagic stroke from an embolism based on her medical history and symptoms of motor aphasia. The initial treatment plan included oxygen, intravenous fluids, medications, and diagnostic tests. The final plan adjusted some medications.

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    The document is a medical record for an 82-year-old female patient (MRS). It summarizes the patient's diagnoses, initial treatment plans, and final treatment plans from several specialists, including neurology, internal medicine, cardiology, and dermatology. The neurologist diagnosed the patient with non-hemorrhagic stroke from an embolism based on her medical history and symptoms of motor aphasia. The initial treatment plan included oxygen, intravenous fluids, medications, and diagnostic tests. The final plan adjusted some medications.

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    6 views2 pages

    Identitas' Leade R Diagnosis Plan Dan Terapi Awal Plan Dan Terapi Akhir

    Uploaded by

    adigama
    The document is a medical record for an 82-year-old female patient (MRS). It summarizes the patient's diagnoses, initial treatment plans, and final treatment plans from several specialists, including neurology, internal medicine, cardiology, and dermatology. The neurologist diagnosed the patient with non-hemorrhagic stroke from an embolism based on her medical history and symptoms of motor aphasia. The initial treatment plan included oxygen, intravenous fluids, medications, and diagnostic tests. The final plan adjusted some medications.

    Copyright:

    © All Rights Reserved
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    of 2

    Identitas`

    ny. Sul
    82 tahun
    0131xxxx
    Aster 4 / j
    MRS: 2 nov
    2015

    Konsul
    Kulit: 7 nov
    2015

    Leade
    r

    Neuro

    Diagnosis

    Plan dan Terapi Awal

    Plan dan Terapi


    Akhir

    Neuro:
    K: riwayat penkes,
    latelarisasi dx,
    afasia motorik
    T: kortex parietal
    E: Stroke non
    hemorrhagic susp
    Emboli

    Neuro:
    O2 nasal canul 3 lpm
    Headup 30O
    IVFD Asering 20 tpm
    Inj. Ranitidin 50 g/12 jam
    Inj sohobion 1 amp/ 24 j
    (drip)
    Aspilet 1x 80 mg

    Neuro:
    IVFD Asering 20 tpm
    Inj. Ranitidin 50 g/12 jam
    Inj vit b12 1 amp/24j

    Interna:
    DM Tipe 2 non
    obese

    Interna:
    Diet DM 1700 kkal
    Inj. Novorapid 4-4-4

    Cardio:
    Aspilet 1x 80mg
    Simvastatin 1x 20mg

    Cardio:
    Ax: OMI
    anteroseptal
    Fx: Fc NYHA II
    Ex: PJK

    Cardio:
    Aspilet 1x 80mg
    Simvastatin 1x 20mg
    Ramipril 1x 5 mg
    Bisoprolol 1x 5mg

    Kulit:
    Kompres NaCl 0.9% 20
    menit + asam fusidat
    cream 2% + intrasit gel
    1x / hari tufup kasa
    lembap

    Kulit:
    Ulkus Dekubitus
    derajat I

    Kulit:
    Kompres NaCl 0.9% 20
    menit + asam fusidat
    cream+ intrasit gel 1x /
    hari tufup kasa basah
    kering

    Interna:
    Diet DM 1700 kkal
    Inj. Novorapid 4-4-4

    DPH 0

    DPH 6

    Regio gluteus tampak erosi ukuran 13cm x 6 cm x 0,1


    cm batas tegas, tepi ireguler, pus (-) darah (+), slough
    (-), jar nekrotik (+)

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