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    This document summarizes the follow up of a patient with slight right hemiparesis and right hemiparesthesia over 4 days. Examinations showed stable vital signs and neurological functions. The patient was diagnosed with a left internal capsule stroke and treated with head elevation, oxygen supplementation, hydration, neuroprotective medications, and gabapentin. The condition was stable with no significant changes over the 4 day period.

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    DOC-20171214-WA0042

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    This document summarizes the follow up of a patient with slight right hemiparesis and right hemiparesthesia over 4 days. Examinations showed stable vital signs and neurological functions. The patient was diagnosed with a left internal capsule stroke and treated with head elevation, oxygen supplementation, hydration, neuroprotective medications, and gabapentin. The condition was stable with no significant changes over the 4 day period.

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    © All Rights Reserved
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    7 views8 pages

    Wa0042

    Uploaded by

    venadewatarie
    This document summarizes the follow up of a patient with slight right hemiparesis and right hemiparesthesia over 4 days. Examinations showed stable vital signs and neurological functions. The patient was diagnosed with a left internal capsule stroke and treated with head elevation, oxygen supplementation, hydration, neuroprotective medications, and gabapentin. The condition was stable with no significant changes over the 4 day period.

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    of 8

    BAB II

    FOLLOW UP

    10/12/17 S : kesemutan anggota gerak knan


    06.00 O:
    DPH 0 Vital sign : TD 190/120 mmHg
    RR 20 x/menit
    N 100 x/menit
    T 37 OC
    Kesadaran : GCS E4V5M6
    Fungsi luhur : dalam batas normal
    Meningeal sign : kaku kuduk (-)
    Nn. Craniales
    Nn. Craniales
    N. II, N.III = pupil isokor 3mm/3mm, RCL (+/+)
    N. III, N. IV, N. VI = gerak bola mata dalam batas normal
    N. VII, N. XII = parese N. VII (D) UMN

    Fungsi motorik :
    Kekuatan Tonus
    +4+4+4 555

    +4+4+4 555

    R. Fisiologis R. Patologi

    + H,T -
    - -

    Fungsi sensorik : hemiparesthesia dextra


    Fungsi otonom : dalam batas normal
    Fungsi kolumna vertebralis : dalam batas normal
    A:
    Klinis : Slight hemiparese dextra, hemiparesthesia dextra
    Topis : Capsila interna sinistra
    Etiologi : Stroke infark trombotik

    P:
    1. head up 33o C
    2. O2 Nasal kanul 3 lpM
    3. Inf RL 20 tpm .
    4. Inj. Citicoline250 mg /12 jam
    5. Inj. ranitidin 50 mg/ 12 jam
    6. Inj, Mecobalamin 500 mcg/12 jam
    7. Inj. Aspilet 80mg

    Pemeriksaan penunjang : pemeriksaan lab puas berat


    11/12/17 S : kesemutan anggota gerak kanan, dan kelemahan anggota gerak kanann
    06.00 O:
    DPH 1 Vital sign : TD 170/120 mmHg
    RR 20 x/menit
    N 85 x/menit
    T 36.2 OC
    Kesadaran : GCS E4V5M6
    Fungsi luhur : dalam batas normal
    Meningeal sign : kaku kuduk (-)
    Nn. Craniales
    N. II, N.III = pupil isokor 3mm/3mm, RCL (+/+)
    N. III, N. IV, N. VI = gerak bola mata dalam batas normal
    N. VII, N. XII = parese N. VII (D) UMN

    Fungsi motorik :
    Kekuatan Tonus
    +4+4+4 555

    +4+4+4 555

    R. Fisiologis R. Patologi
    + H,T -
    - -
    Fungsi sensorik : hemiparesthesia dextra
    Fungsi otonom : dalam batas normal
    Fungsi kolumna vertebralis : dalam batas normal
    A:
    Klinis : Slight hemiparese dextra, hemiparesthesia dextra
    Topis : Capsila interna sinistra
    Etiologi : Stroke infark trombotik

    P:
    1. head up 33o C
    2. O2 Nasal kanul 3 lpM
    3. Inf RL 20 tpm .
    4. Inj. Citicoline250 mg /12 jam
    5. Inj. ranitidin 50 mg/ 12 jam
    6. Inj, Mecobalamin 500 mcg/12 jam
    7. Inj. Aspilet 80mg

    Pemeriksaan penunjang : pemeriksaan lab puas


    12/12/17 S : kesemutan anggota gerak kanan, dan kelemahan anggota gerak kanann
    06.00 O:
    DPH2 Vital sign : TD 200/90 mmHg
    RR 22x/menit
    N 72 x/menit
    T 36.6 OC
    Kesadaran : GCS E4V5M6
    Fungsi luhur : dalam batas normal
    Meningeal sign : kaku kuduk (-)
    Nn. Craniales
    N. II, N.III = pupil isokor 3mm/3mm, RCL (+/+)
    N. III, N. IV, N. VI = gerak bola mata dalam batas normal
    N. VII, N. XII = parese N. VII (D) UMN

    Fungsi motorik :
    +4+4+4 555
    Kekuatan Tonus
    +4+4+4 555
    R. Fisiologis R. Patologi

    + H,T -
    - -

    Fungsi sensorik : hemiparesthesia dextra


    Fungsi otonom : dalam batas normal
    Fungsi kolumna vertebralis : dalam batas normal
    A:
    Klinis : Slight hemiparese dextra, hemiparesthesia dextra
    Topis : Capsila interna sinistra
    Etiologi : Stroke infark trombotik

    P:
    1. head up 33o C
    2. O2 Nasal kanul 3 lpM
    3. Inf RL 20 tpm .
    4. Inj. Citicoline250 mg /12 jam
    5. Inj. ranitidin 50 mg/ 12 jam
    6. Inj, Mecobalamin 500 mcg/12 jam
    7. Inj. Aspilet 80mg
    8. Inj, Gabapentin 100g/12 jam

    13/12/17 S : kesemutan anggota gerak kanan, dan kelemahan anggota gerak kanann
    06.00 O:
    DPH 3 Vital sign : TD 150/90 mmHg
    RR 20 x/menit
    N 86 x/menit
    T 36.4 OC
    Kesadaran : GCS E4V5M6
    Fungsi luhur : dalam batas normal
    Meningeal sign : kaku kuduk (-)
    Nn. Craniales
    N. II, N.III = pupil isokor 3mm/3mm, RCL (+/+)
    N. III, N. IV, N. VI = gerak bola mata dalam batas normal
    N. VII, N. XII = parese N. VII (D) UMN

    Fungsi motorik :
    Kekuatan Tonus
    +4+4+4 555

    +4+4+4 555

    R. Fisiologis R. Patologi

    + H,T -
    - -

    Fungsi sensorik : hemiparesthesia dextra


    Fungsi otonom : dalam batas normal
    Fungsi kolumna vertebralis : dalam batas normal
    A:
    Klinis : Slight hemiparese dextra, hemiparesthesia dextra
    Topis : Capsila interna sinistra
    Etiologi : Stroke infark trombotik

    P:
    1. head up 33o C
    2. O2 Nasal kanul 3 lpM
    3. Inf RL 20 tpm .
    4. Inj. Citicoline250 mg /12 jam
    5. Inj. ranitidin 50 mg/ 12 jam
    6. Inj, Mecobalamin 500 mcg/12 jam
    7. Inj. Aspilet 80mg
    8. Inj. Gabapentin 100g/12 jam
    14/12/17 S : kesemutan anggota gerak kanan, dan kelemahan anggota gerak kanann
    06.30 O:
    DPH 4 Vital sign : TD 150/90 mmHg
    RR 20 x/menit
    N 86 x/menit
    T 36.4 OC
    Kesadaran : GCS E4V5M6
    Fungsi luhur : dalam batas normal
    Meningeal sign : kaku kuduk (-)
    Nn. Craniales
    N. II, N.III = pupil isokor 3mm/3mm, RCL (+/+)
    N. III, N. IV, N. VI = gerak bola mata dalam batas normal
    N. VII, N. XII = parese N. VII (D) UMN

    Fungsi motorik :
    Kekuatan Tonus
    +4+4+4 555

    +4+4+4 555

    R. Fisiologis R. Patologi

    + H,T -
    - -

    Fungsi sensorik : hemiparesthesia dextra


    Fungsi otonom : dalam batas normal
    Fungsi kolumna vertebralis : dalam batas normal
    A:
    Klinis : Slight hemiparese dextra, hemiparesthesia dextra
    Topis : Capsila interna sinistra
    Etiologi : Stroke infark trombotik
    P:
    1. head up 33o C
    2. O2 Nasal kanul 3 lpM
    3. Inf RL 20 tpm .
    4. Inj. Citicoline250 mg /12 jam
    5. Inj. ranitidin 50 mg/ 12 jam
    6. Inj, Mecobalamin 500 mcg/12 jam
    7. Inj. Aspilet 80mg
    8. Inj. Gabapentin 100g/12 jam

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