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  • CC Neuro 5 Agustus 2018

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    Amelia Imas Voleta
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    This document summarizes a neurological report from a hospital in Surakarta, Indonesia. It includes assessments of consciousness, cranial nerves, motor function, and other neurological exams. Imaging tests like CT scan and chest x-rays were performed. The assessment is a brain tumor causing left lateralized motor function. The treatment plan includes medications, IV fluids, monitoring, labs, and a consult for neurosurgery. Thank you is expressed at the end.

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    This document summarizes a neurological report from a hospital in Surakarta, Indonesia. It includes assessments of consciousness, cranial nerves, motor function, and other neurological exams. Imaging tests like CT scan and chest x-rays were performed. The assessment is a brain tumor causing left lateralized motor function. The treatment plan includes medications, IV fluids, monitoring, labs, and a consult for neurosurgery. Thank you is expressed at the end.

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    4 views11 pages

    CC Neuro 5 Agustus 2018

    Uploaded by

    Amelia Imas Voleta
    This document summarizes a neurological report from a hospital in Surakarta, Indonesia. It includes assessments of consciousness, cranial nerves, motor function, and other neurological exams. Imaging tests like CT scan and chest x-rays were performed. The assessment is a brain tumor causing left lateralized motor function. The treatment plan includes medications, IV fluids, monitoring, labs, and a consult for neurosurgery. Thank you is expressed at the end.

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    of 11

    LAPORAN JAGA NEUROLOGI Disusun Oleh:

    5 Agustus 2018 Dini, Ranti, Imas, Akhlis


    Status Neurologis
    Kesadaran : GCS E3V4M6
    Fungsi luhur : sde
    Meningeal sign : (-)
    Fungsi otonom : BAB dan BAK normal
    Fungsi sensorik : sde
    Fungsi koordinasi : sde
    Fungsi motorik :
    Kekuatan Motorik Tonus R. Fisiologis R. Patologis

    333 555 N N +3/+3 +2/+2 + +


    333 555 sde/+3 +2/+2 sde -
    N N
    Nn. Craniales
    N. II, III : pupil isokor (3 mm/3 mm), reflex cahaya (+/+)
    N. III, IV, VI : gerakan bola mata dbn
    N. V : reflek kornea (+)
    N. VII, N. XII : sde

    Fungsi Collumna Vertebra


    Inspeksi : gibus (-), deformitas (-)
    Palpasi : neri tekan vertebra (-)
    Patrick : (-)/(-)
    Contra Patrick : (-)/(-)
    Lasegue : (+)/(-)
    Tanda Kernig : (-)(-)
    PEMERIKSAAN PENUNJANG
    CT SCAN
    Tanggal 5 / 08/ 2018
    di RS Dr.Oen Surakarta
    Rontgent Thorak
    Tanggal 5 / 08/ 2018
    di RS Dr.Moewardi Surakarta
    ASSESSMENT

    K: penurunan kesadaran, cefalgia kronik


    progresif,, vomit, lateralisasi motorik dextra
    T: korteks cerebri sinistra
    E: SOP cerebri ec susp brain tumor
    TATALAKSANA
    • Infus NaCl 0,9% 20 tpm • Amlodipin 10mg/24 jam PO
    • Injeksi Ketorolac 30mg /12 • Pasang NGT
    jam IV
    • Mondok HCU Ang 2
    • Injeksi Ranitidine 50mg/12
    jam • Cek Lab DR3, Ur/Cr,
    SGOT/SGPT, GDS, Elektrolit,
    • Injeksi mecobalamin 500
    mcg/12 jam • EKG

    • Paracetamol 1000mg/12 • Diet sonde 1800 kkal/hari


    jam (k/p) (PO) • Edukasi keluarga
    • Inj Ceftriaxone 1gr
    PLAN
    • MRI Brain kontras
    • Konsul Bedah Syaraf
    TERIMAKASIH

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