Kronologis Pasien.pdf

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Kronologis Pasien

Nama

: Tn. Daniel Silaban

No MR

: 392210

Umur

: 19 th Tanggal 1/10/18

Keterangan Pasien dating ke Poli penyakit saraf dengan diagnose : Susp stroke Pasien mendapat terapi difenhidramin 2cc IM (1x dipoli)

1/10/18

Pasien dirawat diruang rawat lantai 3 Terapi :

IVFD RL 20tpm Inj Piracetam 4x3gr Inj Citicolin 2x1000g Manitol 3x125cc Ranitidin 2x1 amp Flunarizin 3x10mg Betahistin 3x12mg

Tindakan :

Lakukan pemeriksaan darah lengkap, Ureum, Creatinin, GDS, SGOT SGPT, Elektrolit Check serologi anti HIV Check Serologi HbsAg CT-Scan dengan kontras 02 3l/menit (nasal canule)

2/10/12

Pasien mengalami penurunan kesadaran GCS :9 Diagnosa

Penurunan kesadaran ec Susp Ensefalitis + Edema cerebri

Terapi :

+ Inj Metilprednisolon 4x125mg

IVFD RL 30tpm Inj Ranitidin 3x1amp Inj Ceftriaxone 1x2gr Inj Neurobion 1x5000mg Inj Metocloperamide 2x10mg ISDN 3x5mg Drip Tramadol 1amp/8jam Inj Omeprazol 1amp/12jam

Tindakan:

Pasang NGT Pemasangan Monitor perawatan di pindah ke ruang ICU Ro Thorax Cardiometri Pasang Urn Kateter EKG AGD

3/10/18

Pasien dirawat Di ICU hari ke 2. Gcs : 8 Diagnosa: cerebri

Penurunan kesadaran ec Susp Ensefalitis + Edema

Terapi :

Paracetamol inf 3x1g Sda

Tindakan: 4/10/18

Sda

Pasien dirawat Di ICU hari ke 3. Gcs : 9 Diagnosa: cerebri

Penurunan kesadaran ec Susp Ensefalitis + Edema

Terapi :

Sda

Tindakan: Pemeriksaan Lab Darah rutin, Elektrolit, GDS, Ureum, Creatinin, SGOT SGPT, Protein, Albumin Globulin Sda 5/10/18

Pasien dirawat Di ICU hari ke 4. Gcs : 8 Diagnosa: cerebri

Penurunan kesadaran ec Susp Ensefalitis + Edema

Terapi :

+ Inj Ketorolac 3x1amp + Metilprednisolon 3x125mg + Tramadol 1amp/8jam Sda

Tindakan:

Sda Sda

6/10/18

Pasien dirawat Di ICU hari ke 5. Gcs : 8 Diagnosa: cerebri

Penurunan kesadaran ec Susp Ensefalitis + Edema

Terapi :

+Miloz 5mg/ jam Sda

Tindakan: 7/10/18

Sda

Pasien dirawat Di ICU hari ke 6. Gcs : 8 Diagnosa: cerebri

Penurunan kesadaran ec Susp Ensefalitis + Edema

Terapi :

+Midazolam 5mg/jam +Miloz 9mg/ jam +Cairan Rf loading 500cc + Cpz 25mg ix pemberian Sda

Tindakan:

Sda

8/10/18

9/10/18

Pasien dirawat Di ICU hari ke 7. Gcs : 10 Diagnosa: cerebri

Penurunan kesadaran ec Susp Ensefalitis + Edema

Terapi :

Sda

Tindakan:

Sda

Pasien dirawat Di ICU hari ke 8. Gcs : 10 Diagnosa: cerebri

Penurunan kesadaran ec Susp Ensefalitis + Edema

Terapi :

+Inf Aminoleban/24jam HepaQ tab 3x1 Urdafalk tab 3x1 Sda

Tindakan:

+Konsul dan rawat bersama dokter Sp.PD Periksa lab Igm antiHAV Periksa lab Ureum, Creatinin, SGOT dan SGPT Sda

10/10/18

Pasien dirawat Di ICU hari ke 9. Gcs : 12 Diagnosa: cerebri

Penurunan kesadaran ec Susp Ensefalitis + Edema

Terapi :

Sda

Tindakan:

+ Periksa Narkoba Sda

11/10/18

Pasien dirawat Di ICU hari ke 10. Gcs : 13 Diagnosa: cerebri

Penurunan kesadaran ec Susp Ensefalitis + Edema

Terapi :

+ Candesartan 1x16mg Sda

Tindakan: 12/10/18

Sda

Pasien dirawat Di ICU hari ke 11. Gcs : 13 Diagnosa: cerebri

Penurunan kesadaran ec Susp Ensefalitis + Edema

Terapi :

+Clobazam 10mg

Tindakan:

Pindah perawatan ke ruang rawat inap lt3 Periksa SGOT dan SGPT Periksa Darah Lengkap Periksa Elektrolit

13/10/18

Pasien dirawat Di Ruang rawat inap lt3 . Gcs : 14 Diagnosa: Gangguan perilaku + Tetraparesa UMN ec Susp Ensefalomielitis Terapi :

+ Metilprednisolon 125mg Piracetam 4x3mg Citicolin 2x1gr Ranitind 3x1amp Omeprazole 1x40mg Flunarizin 3x10mg po Meropenem 3x1gr iv Metocloperamid 3x10mg Clobazam 1x100mg

Tindakan: 14/10/18

-

Pasien dirawat Di Ruang rawat inap lt3 . Gcs : 14 Diagnosa: Gangguan perilaku + Tetraparesa UMN ec Susp Ensefalomielitis Terapi :

+ Metilprednisolon 125mg

Piracetam 4x3mg Citicolin 2x1gr Ranitind 3x1amp Omeprazole 1x40mg Flunarizin 3x10mg po Meropenem 3x1gr iv Metocloperamid 3x10mg Clobazam 1x100mg + Trihexipenidile 2x2gr + Alprazolam 1x0.5 po malam Haloperidol 2x1.5mg po Tindakan: 15/10/18

-

Pasien dirawat Di Ruang rawat inap lt3 . Gcs : 14 Pasien Minta pulang atas permintaan sendiri (PAPS) Diagnosa: Gangguan perilaku + Tetraparesa UMN ec Susp Ensefalomielitis Terapi :

Obat pulang Clobazam 1x10mg Alprazolam 1x0.5mg Haloperidol 2x1.5mg THP 2x2g po HepaQ 3x1hari Urdafalk 3x1hari

Tindakan:

Tanda tangan persetujuan PAPS

Mengetahui,

Pekanbaru

/

…………………………

…………………………

/2018

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