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Keluhan Vital Sign Status Neurologis Assestment Terapi planing

Tanggal

GCS : E4 M6 V5 TetraParese Spastik Ivfd NaCL 20 gtt / i

jumat KU: TD :124/60 MRI whole Spine
Pupil : Bulat Isokor 3mm/3mm RCL Kronik Progresif ec Iv Ceftriaxone 1 Gr / 12 jam
04/09/2017 kelemahan mmHg (+/+)RCTL (+/+) Dd Iv Citicholin 500mg / 12 jam
N.Cranialis : Parese Nervus (-) - Syryngomelia Mecobalamin 500 mg /12
keempat N : 66 X/i
Motorik : k.otot 3444/3444 - Tumor medula Jam
H2 anggota RR : 22 X/i 2222/2222 spinalis IV metylprednisolon 125
R.Fisiologis : sup +/+ , Inf +4/+4,Klonus - Spondilitis mg/ 8 jam
gerak T : 36,8 C
Achiles (+) - HNP Iv ketorolax 1 amp / 8 jam
KT : Nyeri NRS : 6-7 R.Patologis : Babinski, Chadock, sceifer Gabapentin 3x300 mg
(+/+),
Pinggang
Sensorik : Ext Sup +/+, Ext Inf +/+
Otonom : Fungsi Miksi (-)
defekasi (+)

GCS : E4 M6 V5 TetraParese Spastik Ivfd NaCL 20 gtt / i

sabtu KU: TD :114/70 MRI whole Spine
Pupil : Bulat Isokor 3mm/3mm RCL Kronik Progresif ec Iv Ceftriaxone 1 Gr / 12 jam
05/09/2017 kelemahan mmHg (+/+)RCTL (+/+) Dd Iv Citicholin 500mg / 12 jam
N.Cranialis : Parese Nervus (-) - Syryngomelia Mecobalamin 500 mg /12
keempat N : 76 X/i
Motorik : k.otot 3444/3444 - Tumor medula Jam
H3 anggota RR : 21 X/i 2222/2222 spinalis IV metylprednisolon 125
R.Fisiologis : sup +/+ , Inf +4/+4,Klonus - Spondilitis mg/ 8 jam
gerak T : 36,8 C
Achiles (+) - HNP Iv ketorolax 1 amp / 8 jam
KT : Nyeri NRS : 4 R.Patologis : Babinski, Chadock, sceifer Gabapentin 3x300 mg
(+/+),
Pinggang
Sensorik : Ext Sup +/+, Ext Inf +/+
Otonom : Fungsi Miksi (-)
defekasi (+)

GCS : E4 M6 V5 TetraParese Spastik Ivfd NaCL 20 gtt / i

sabtu KU: TD :110/70 MRI whole Spine
Pupil : Bulat Isokor 3mm/3mm RCL Kronik Progresif ec Iv Citicholin 500mg / 12 jam
12/09/2017 kelemahan mmHg (+/+)RCTL (+/+) Dd Mecobalamin 500 mg /12
N.Cranialis : Parese Nervus (-) - Syryngomelia Jam
keempat N : 76 X/i
Motorik : k.otot 3444/3444 - Tumor medula Iv ketorolax 1 amp / 8 jam
H 10 anggota RR : 21 X/i 2222/2222 spinalis Gabapentin 3x300 mg
R.Fisiologis : sup +/+ , Inf +4/+4,Klonus - Spondilitis Duragesic patch 12,5
 gerak T : 36,8 C Achiles (+) - HNP
R.Patologis : Babinski, Chadock, sceifer
KT : Nyeri NRS : 8
(+/+),
Pinggang Sensorik : Ext Sup +/+, Ext Inf +/+
Otonom : Fungsi Miksi (-)
defekasi (+)

GCS : E4 M6 V5 TetraParese Spastik Ivfd NaCL 20 gtt / i

Minggu KU: TD :110/70 MRI whole Spine
Pupil : Bulat Isokor 3mm/3mm RCL Kronik Progresif ec Iv Citicholin 500mg / 12 jam
20/09/2017 kelemahan mmHg (+/+)RCTL (+/+) - Tumor medula Mecobalamin 500 mg /12 Tampak lesi
N.Cranialis : Parese Nervus (-) spinalis ( intradural Jam
keempat N : 76 X/i hipointens pada
Motorik : k.otot 3444/3444 extramedula) Iv ketorolax 1 amp / 8 jam
H 18 anggota RR : 21 X/i 2222/2222 Gabapentin 3x300 mg T1Wi dan menjadi
R.Fisiologis : sup +/+ , Inf +4/+4,Klonus Duragesic patch 12,5 (K/P)
gerak T : 36,8 C intermediate
Achiles (+)
KT : Nyeri NRS : 5 R.Patologis : Babinski, Chadock, sceifer signal pada T2Wi
(+/+),
Pinggang di intradural
Sensorik : Ext Sup +/+, Ext Inf +/+
Otonom : Fungsi Miksi (-) ekstramedulla
defekasi (+)
setinggi VC 6-7.
berbatas tegas,
tepi reguler.

Konsul Bedah
Saraf
Konsul Bedah
GCS : E4 M6 V5 TetraParese Spastik Ivfd NaCL 20 gtt / i
Senin KU: TD :110/70 Saraf
Pupil : Bulat Isokor 3mm/3mm RCL Kronik Progresif ec Iv Citicholin 500mg / 12 jam
21/09/2017 kelemahan mmHg (+/+)RCTL (+/+) - Tumor medula Mecobalamin 500 mg /12 laminectomi
N.Cranialis : Parese Nervus (-) spinalis ( intradural Jam
keempat N : 76 X/i removal tumor
Motorik : k.otot 3444/3444 extramedula) Iv ketorolax 1 amp / 8 jam
H 19 anggota RR : 21 X/i 2222/2222 Gabapentin 3x300 mg ( Post OP ICU )
R.Fisiologis : sup +/+ , Inf +4/+4,Klonus Duragesic patch 12,5 (K/P)
gerak T : 36,8 C
Achiles (+)
KT : Nyeri NRS : 5 R.Patologis : Babinski, Chadock, sceifer
(+/+),
Pinggang
Sensorik : Ext Sup +/+, Ext Inf +/+
Otonom : Fungsi Miksi (-) defekasi (+)
 Konsul Bedah
GCS : E4 M6 V5 TetraParese Spastik Ivfd NaCL 20 gtt / i
Senin KU: TD :100 /60 Saraf
Pupil : Bulat Isokor 3mm/3mm RCL Kronik Progresif ec Iv Citicholin 500mg / 12 jam
28/09/2017 kelemahan mmHg (+/+)RCTL (+/+) - Tumor medula Mecobalamin 500 mg /12 laminectomi
N.Cranialis : Parese Nervus (-) spinalis ( intradural Jam
keempat N : 66 X/i removal tumor
Motorik : k.otot 3444/3444 extramedula) Iv ketorolax 1 amp / 8 jam
H 26 anggota RR : 21 X/i 2222/2222 Gabapentin 3x300 mg ( Post OP ICU )
R.Fisiologis : sup +/+ , Inf +4/+4,Klonus
gerak T : 36,8 C
Achiles (+)
KT : Nyeri NRS : 4 R.Patologis : Babinski, Chadock, sceifer
(+/+),
Pinggang
Sensorik : Ext Sup +/+, Ext Inf +/+
Otonom : Fungsi Miksi (-) defekasi (+)
Konsul Bedah
GCS : E2 M4 Vett ( on Sedasi) TetraParese Spastik Ivfd NaCL 20 gtt / i
Selasa KU: TD :135 /90 Saraf
Pupil : Bulat Isokor 3mm/3mm RCL Kronik Progresif ec Iv Citicholin 500mg / 12 jam
29/09/2017 penurunan mmHg (+/+)RCTL (+/+) - Tumor medula Mecobalamin 500 mg /12 laminectomi
N.Cranialis : SDN spinalis ( intradural Jam
kesadaran N :86 X/i removal tumor
Motorik : SDN extramedula) Gabapentin 3x300 mg
H27 RR : 12 X/i Fisiologis : sup +/+ , Inf +, Klonus Achiles ( Post OP ICU )
R.Patologis : Babinski, Chadock, sceifer
POD 1 T : 36,8 C
(+/+),
NRS : sdn Sensorik : Ext Sup +/+, Ext Inf +/+
Otonom : Fungsi Miksi (-) defekasi (+)