SOAP

I. Jum’at, 18 Agustus 2017

S = Kesadaran membaik
O = Vital Sign  Tensi : 160/90
Nadi : 80x/menit
Suhu : 36
RR : 20x/menit
Status interna : dbn
Status neurologis : GCS : 224
Motorik : Kesan lateralisasi sinistra
Rf +2|+2 Rp babinski -/-
+2|+2
Lab : BSN : 175
2JPP : 204
TG : 189
A = Dx klinis : hemiparesis sinistra, HT
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+2
P = RL 14 tpm
Manitol 4x100
Citicolin 3x 250
Ketorolac 3x1
Ranitidine 2x1
Ondansetron 2x1
Neurosanbe 1x1 (drip)

II. Sabtu, 19 Agustus 2017

S = Kesadaran membaik
O = Vital Sign  Tensi : 170/100
Nadi : 80x/menit
Suhu : 37
RR : 20x/menit
Status interna : dbn
Status neurologis : GCS : 446
Motorik 555|111
555|111
A = Dx klinis : hemiparesis sinistra, , HT
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+3
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 3x100
Citicolin Inj 3x250
Ketorolac 3x1
Ranitidine 2x1
Ondansetron 2x1
Neurosanbe 1x1 (drip)
1
 p.o amlodipin 10mg 0-0-1

III. Minggu, 20 Agustus 2017

S = Belum Buang Air Besar

O = Vital Sign  Tensi : 150/100
Nadi : 70x/menit
Suhu : 36
RR : 20x/menit
Status interna : dbn
Status neurologis : GCS : 335
Motorik : Lateralisasi sinistra
A = Dx klinis : hemiparesis sinistra, konstipasi, HT
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+4
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 2x100
Citicolin Inj 3x250
Ketorolac 3x1
Ranitidine 2x1
Ondansetron 2x1
Neurosanbe 1x1 (drip)
p.o amlodipin 10mg 0-0-1
Laxadine syr 3xCI

IV. Senin, 21 Agustus 2017

S = Perut begah belum BAB

O = Vital Sign  Tensi : 150/70
Nadi : 70x/menit
Suhu : 36
RR : 22x/menit
Status interna : Abdomen BU menurun
Status neurologis : GCS : 335
Motorik : Lateralisasi sinistra
A = Dx klinis : hemiparesis sinistra, konstipasi, HT
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+5
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 2x100
Citicolin Inj 3x250
Ketorolac 3x1
Ranitidine 2x1
Ondansetron 2x1
Neurosanbe 1x1 (drip)
p.o amlodipin 10mg 0-0-1
Laxadine syr 3xCI

2
V. Selasa, 22 Agustus 2017

S = Pusing, BAB (+)

O = Vital Sign  Tensi : 140/90
Nadi : 80x /menit
Suhu : 36
RR : 20x/menit
Status interna : dbn
Status neurologis : GCS : 456
Motorik 555|111
555|111
Lab : GDA : 158
A = Dx klinis : hemiparesis sinistra, HT
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+6
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 2x100
Citicolin Inj 3x250
Ketorolac 3x1
Ranitidine 2x1
Ondansetron 2x1
Neurosanbe 1x1 (drip)
p.o amlodipin 10mg 0-0-1

VI. Rabu, 23 Agustus 2017

S = Pusing berkurang
O = Vital Sign  Tensi : 130/80
Nadi : 80x/menit
Suhu : 36,5
RR : 20x/menit
Status interna : dbn
Status neurologis : GCS : 456
Motorik 555|111
555|111
A = Dx klinis : hemiparesis sinistra
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+7
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 1x100
Piracetam 4x15
Ketorolac 3x1
Ranitidine 2x1
Ondansetron 2x1
Neurosanbe 1x1
p.o amlodipin 10mg 0-0-1

3
VII. Kamis, 24 Agustus 2017

S = kesadaran menurun
O = Vital Sign  Tensi : 150/90
Nadi : 88x/menit
Suhu : 36,6
RR : 24x/menit
Status interna : dbn
Status neurologis : GCS : 113
Motorik : Lateralisasi sinistra
Lab : Hb : 11,4
GDA : 168
A = Dx klinis : hemiparesis sinistra
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+8
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 4x100
Piracetam 4x15
Ketorolac 3x1
Ranitidine 2x1
Ondansetron 2x1
Neurosanbe 1x1 (drip)
p.o amlodipin 10mg 0-0-1

VIII. Jum’at, 25 Agustus 2017

S = Sakit kepala cekot-cekot di bagian belakang sejak kemarin malam

O = Vital Sign  Tensi : 170/90
Nadi : 84x/menit
Suhu : 36
RR : 22x/menit
Status interna : dbn
Status neurologis : GCS : 346
Motorik 555|111
555|111
A = Dx klinis : hemiparesis sinistra
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+9
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 4x100
Piracetam 4x15
Ketorolac 3x1
Ranitidine 2x1
Ondansetron 2x1
Neurosanbe 1x1 (drip)
p.o amlodipin 10mg 0-0-1

4
IX. Sabtu, 26 Agustus 2017

S= -
O = Vital Sign  Tensi : 130/80
Nadi : 84x/menit
Suhu : 35,9
RR : 18x/menit
Status interna : dbn
Status neurologis : GCS : 446
Motorik 555|222
555|222

A = Dx klinis : hemiparesis sinistra

Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+10
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 4x100
Piracetam 4x15
Ketorolac 3x1
Ranitidine 2x1
Ondansetron 2x1
Neurosanbe 1x1 (drip)
p.o amlodipin 10mg 0-0-1

X. Minggu, 27 Agustus 2017

S = pusing
O = Vital Sign  Tensi : 140/90
Nadi : 76x/menit
Suhu : 35,9
RR : 24x/menit
Status interna : dbn
Status neurologis : GCS : 346
Motorik 555|111
555|111
A = Dx klinis : hemiparesis sinistra
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+11
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 3x100
Piracetam 4x15
Ketorolac 3x1
Ranitidine 2x1
Ondansetron 2x1
Neurosanbe 1x1 (drip)
p.o amlodipin 10mg 0-0-1

5
XI. Senin, 28 Agustus 2017

S = kesadaran menurun, demam

O = Vital Sign  Tensi : 150/90
Nadi : 88x/menit
Suhu : 38
RR : 20x/menit
Status interna : dbn
Status neurologis : GCS : 235
Motorik : Lateralisasi sinistra
Lab : Leukosit : 14.500
A = Dx klinis : hemiparesis sinistra, HT
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+12
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 1x100
Piracetam 4x15
Antrain Inj 3x1
Ranitidine 2x1
p.o amlodipin 10mg 0-0-1
p.o pamol 3x500mg

XII. Selasa, 29 Agustus 2017

S = demam menurun
O = Vital Sign  Tensi : 140/90
Nadi : 84x/menit
Suhu : 37
RR : 20x/menit
Status interna : dbn
Status neurologis : GCS : 335
Motorik : Lateralisasi sinistra
A = Dx klinis : hemiparesis sinistra
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+13
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 1x100
Piracetam 4x15
Antrain Inj 3x1
Ranitidine 2x1
p.o amlodipin 10mg 0-0-1
p.o pamol 3x500mg

6
XIII. Rabu, 30 Agustus 2017

S= -
O = Vital Sign  Tensi : 180/90
Nadi : 85x/menit
Suhu : 37
RR : 20x/menit
Status interna : dbn
Status neurologis : GCS : 456
Motorik 555|111
555|111
A = Dx klinis : hemiparesis sinistra, HT
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+14
P = Head up 30 derajat
RL 14 tpm
Manitol Inf 1x100
Piracetam 4x15
Antrain Inj 3x1
Ranitidine 2x1
p.o amlodipin 10mg 0-0-1
p.o pamol 3x500mg

XIV. Kamis, 31 Agustus 2017

S = BAK nyeri
O = Vital Sign  Tensi : 160/90
Nadi : 80x/menit
Suhu : 36,7
RR : 22x/menit
Status interna : dbn
Status neurologis : GCS : 456
Motorik 555|111
555|111
A = Dx klinis : hemiparesis sinistra, HT, ISK
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+15
P = Head up 30 derajat
RL 14 tpm
Piracetam 4x15
Antrain Inj 3x1
Ranitidine 2x1
Ciprofloxacin 2x400
p.o amlodipin 10mg 0-0-1

7
XV. Jum’at, 1 September 2017

S = Masih lemah
O = Vital Sign  Tensi : 160/90
Nadi : 80x/menit
Suhu : 36,7
RR : 22x/menit
Status interna : dbn
Status neurologis : GCS : 456
Motorik 555|111
555|111
A = Dx klinis : hemiparesis sinistra, HT
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+16
P = Head up 30 derajat
RL 21 tpm
Piracetam 4x15
Antrain Inj 3x1
Ranitidine 2x1
Ciprofloxacin 2x400
p.o amlodipin 10mg 0-0-1

XVI. Sabtu, 2 September 2017

S = Masih lemah
O = Vital Sign  Tensi : 140/90
Nadi : 72x/menit
Suhu : 36,5
RR : 20x/menit
Status interna : dbn
Status neurologis : GCS : 456
Motorik 555|111
555|111
Lab : Hb : 10,6
Hct : 31,1
Trom : 487.000
A = Dx klinis : hemiparesis sinistra, HT
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+17
P = Head up 30 derajat
RL 21 tpm
Piracetam 4x15
Antrain Inj 3x1
Ranitidine 2x1
Ciprofloxacin 2x400
p.o amlodipin 10mg 0-0-1
Acc KRS

8
XVII. Minggu, 3 September 2017

S= -
O = Vital Sign  Tensi : 120/90
Nadi : 72x/menit
Suhu : 36,7
RR : 22x/menit
Status interna : dbn
Status neurologis : GCS : 456
Motorik 555|111
555|111
A = Dx klinis : hemiparesis sinistra
Dx topis : subkorteks dextra
Dx etiologis : CVA haemorrhagic H+18
P = Head up 30 derajat
RL 21 tpm
Piracetam 4x15
Antrain Inj 3x1
Ranitidine 2x1
Ciprofloxacin 2x400
p.o amlodipin 10mg 0-0-1
R/ KRS