14 Okt 2018 15 Okt 2018 16 Okt 2018

Subjektive Nyeri kepala (+) Nyeri kepala (+) Nyeri kepala (<)
Objective GCS E3VxM5 GCS E3VxM5 GCS E3VxM5
TD 140/90 mmHg TD 140/80 mmHg TD 140/90 mmHg
HR 78x/menit HR 72x/menit HR 78x/menit
RR 24x/menit RR 20x/menit RR 20x/menit
T 36,0 T 36,0 T 36,6
Assesment Massa otak multiple Massa otak multiple Massa otak multiple
+ Afasia global + Afasia global + Afasia global
Planning O2 3 lpm O2 3 lpm O2 3 lpm
IVFD NS 20 tpm IVFD NS 20 tpm IVFD NS 20 tpm
Inj Ceftriaxone 2x1 Inj Ceftriaxone 2x1 Inj Ceftriaxone 2x1
gr gr gr
Inj Dexa 4x5 mg Inj Dexa 4x5 mg Inj Dexa 4x5 mg
Inj Ranitidin 2x50 Inj Ranitidin 2x50 Inj Ranitidin 2x50
mg mg mg
Maintanance fenitoin Maintanance fenitoin Maintanance fenitoin
3x100 mg 3x100 mg 3x100 mg
Konsul IPD, rencana
alih rawat IPD

17 Okt 2018 18 Okt 2018 19 Okt 2018

Subjektive Nyeri kepala (-) Nyeri kepala (-) Nyeri kepala (-)
Objective GCS E3VxM5 GCS E3VxM5 GCS E3VxM5
TD 140/90 mmHg TD 130/70 mmHg TD 130/70 mmHg
HR 78x/menit HR 72x/menit HR 72x/menit
RR 20x/menit RR 20x/menit RR 20x/menit
T 36,6 T 36,7 T 36,7
Assesment Toksoplasmosis Toksoplasmosis Toksoplasmosis
intrakranial intrakranial intrakranial
Planning O2 3 lpm O2 3 lpm O2 3 lpm
IVFD NS 20 tpm IVFD NS 20 tpm IVFD NS 20 tpm
Inj Ceftriaxone 2x1 Inj Ceftriaxone 2x1 Inj Ceftriaxone 2x1
gr gr gr
Inj Dexa 4x5 mg Inj Dexa 4x5 mg Inj Dexa 4x5 mg
Inj Ranitidin 2x50 Inj Ranitidin 2x50 Inj Ranitidin 2x50
mg mg mg
Maintanance fenitoin Maintanance fenitoin Maintanance fenitoin
3x100 mg 3x100 mg 3x100 mg
Konsul IPD, rencana Konsul IPD (+) saran Konsul IPD (+) saran
alih rawat IPD konsul neurologi konsul neurologi
Tunggu jadwal MRI Tunggu jadwal MRI Tunggu jadwal MRI
 20 Okt 2018 21 Okt 2018 22 Okt 2018
Subjektive Nyeri kepala (-) Keluhan (-) Keluhan (-)
Objective GCS E3VxM5 GCS E4VxM5 GCS E4VxM5
TD 130/70 mmHg TD 110/70 mmHg TD 110/60 mmHg
HR 72x/menit HR 66x/menit HR 68x/menit
RR 20x/menit RR 18x/menit RR 16x/menit
T 36,7 T 36,3 T 36,7
Assesment Toksoplasmosis Toksoplasmosis Toksoplasmosis
intrakranial intrakranial intrakranial
Planning O2 3 lpm O2 3 lpm IVFD NS 20 tpm
IVFD NS 20 tpm IVFD NS 20 tpm Rencana MRI 13Des
Inj Ceftriaxone 2x1 Inj Ceftriaxone 2x1 2018
gr gr Po Kotrimoksazole
Inj Dexa 4x5 mg Inj Dexa 4x5 mg 2x2 tab
Inj Ranitidin 2x50 Inj Ranitidin 2x50
mg mg
Maintanance fenitoin Maintanance fenitoin
3x100 mg 3x100 mg
Konsul IPD (+) saran Rencana MRI 13Des
konsul neurologi 2018
Tunggu jadwal MRI Po Kotrimoksazole
2x2 tab

23 Okt 2018
Subjektive Keluhan (-)
Objective GCS E4VxM5
TD 110/60 mmHg
HR 68x/menit
RR 16x/menit
T 36,7
Assesment Toksoplasmosis
intrakranial
Planning BLPL
Rencana MRI 13Des
2018
Po Kotrimoksazole
2x2 tab