STROKE
5
FOLLOW UP (20 Maret 2015 – 30 Maret 2015) 20 Maret 2015 21 Maret 2015 22 Maret 2015 S Pusing berputar, Tidak bisa tidur Pusing berputar, mual (-), sudah bisa tidur, telinga berdenging (-) Pusing Kepala Berputar O TTV : TD : 184/ 116, RR 22x/menit, T : 37,2 o C, HR : 71x/menit KU : Tampak sakit sedang, kesadaran : CM, GCS : E 4 V 5 M 6 TTV : TD : 173/ 110, RR 18x/menit, T : 36 o C, HR : 88 x/menit TTV : TD : 188/ 132, RR 20x/menit, T : 37.0 o C, HR : 78x/menit A Vertigo Perifer dd Central Vertigo Perifer dd Central Vertigo Perifer dd Central P Infus RL 20 tpm Inj. Ceftriaxon 2x1 gr (skin test) Inj. Ranitidine 2x1 amp Inj. Kalmeco 1x1 amp Inj. Piracetam 2x3 gr p.o Mertigo 3x1 tab p.o Valsartan 1x80 mg p.o Unalium 2x5 mg Terapi Lanjut Terapi lanjut B B B B G K 5/5/ 5 5/5/ 5 5/5/ 5 5/5/ 5 B B B B G K 5/5/ 5 5/5/ 5 5/5/ 5 5/5/ 5 B B B B G K 5/5/ 5 5/5/ 5 5/5/ 5 5/5/ 5
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STROKE
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FOLLOW UP (20 Maret 2015 30 Maret 2015)20 Maret 201521 Maret 201522 Maret 2015
SPusing berputar, Tidak bisa tidurPusing berputar, mual (-), sudah bisa tidur, telinga berdenging (-) Pusing Kepala Berputar
OTTV : TD : 184/ 116, RR 22x/menit, T : 37,2oC, HR : 71x/menit KU : Tampak sakit sedang, kesadaran : CM, GCS : E4V5M6BBBBGK5/5/55/5/55/5/55/5/5
TTV : TD : 173/ 110, RR 18x/menit, T : 36oC, HR : 88 x/menit BBBBGK5/5/55/5/55/5/55/5/5
TTV : TD : 188/ 132, RR 20x/menit, T : 37.0oC, HR : 78x/menit BBBBGK5/5/55/5/55/5/55/5/5
AVertigo Perifer dd CentralVertigo Perifer dd CentralVertigo Perifer dd Central
P Infus RL 20 tpm Inj. Ceftriaxon 2x1 gr (skin test) Inj. Ranitidine 2x1 amp Inj. Kalmeco 1x1 amp Inj. Piracetam 2x3 gr p.o Mertigo 3x1 tab p.o Valsartan 1x80 mg p.o Unalium 2x5 mg Terapi Lanjut Terapi lanjut
Ket
23 Maret 201524 Maret 2015 25 Maret 2015
SNyeri kepala berputar, Telinga berdenging (-/+)Nyeri kepala berputar berkurangNyeri Kepala Berputar masih terasa
OTTV : TD : 208/ 140, RR 20x/menit, T : 36,5oC, HR : 76x/menit BBBBGK5/5/55/5/55/5/55/5/5
TTV : TD : 168/ 120, RR 18x/menit, T : 36oC, HR : 80 x/menit BBBBGK5/5/55/5/55/5/55/5/5
TTV : TD : 140/ 70, RR 20x/menit, T : 37.0oC, HR : 88x/menit Nistagmus (+) BBBBGK5/5/55/5/55/5/55/5/5
AVertigo Perifer dd central, OMAVertigo Perifer dd CentralVertigo Perifer dd Central
P Terapi lanjut Infus RL 20 tpm Inj. Ranitidine 2x1 amp Inj. Kalmeco 1x1 amp Inj. Piracetam 2x3 gr Inj. Furosemide 3x1 amp p.o Mertigo 3x1 tab p.o Valsartan 1x80 mg p.o Unalium 2x5 mg p.o Diltiazem tab 3x30 mg Terapi Lanjut p.o Clonidin tab 3x1 Inj. Cernevit 1x1 drip
Ket
26 Maret 201527 Maret 201528 Maret 2015
SNyeri kepala berputar, terutama jika menengok dan jika melirik ketika tidur, badan terasa gregesNyeri Kepala Berputar (+) mual (+), lemes (+) Nyeri Kepala Berputar (+) mual (+), lemes (+)
OTTV : TD : 104/ 58, RR 18x/menit, T : 37oC, HR : 88x/menit BBBBGK5/5/55/5/55/5/55/5/5
TTV : TD : 124/ 90, RR 18x/menit, T : 37oC, HR : 59x/menit BBBBGK5/5/55/5/55/5/55/5/5
TTV : TD : 134/ 90, RR 18x/menit, T : 37oC, HR : 65x/menit BBBBGK5/5/55/5/55/5/55/5/5
AVertigo Central Vertigo CentralVertigo Central
P Terapi lanjut p.o Clobazam 2x5 mg Terapi Lanjut Terapi Lanjut Inj. Dexamethason 3x1 amp
Ket
29 Maret 201530 Maret 2015
SNyeri kepala berputar, terutama ketika tidurNyeri Kepala Berputar (+) mual (+), lemes (+)
OTTV : TD : 135/ 97, RR 18x/menit, T : 37oC, HR : 67x/menitBBBBGK5/5/55/5/55/5/55/5/5
Nistagmus (+)
TTV : TD : 136/ 90, RR 18x/menit, T : 37oC, HR : 59x/menit BBBBGK5/5/55/5/55/5/55/5/5
AVertigo Central Stroke Vertebrobasiller
P Terapi lanjut
Terapi Lanjut
Ket
PrognosisDeath:Dubia ad bonam
Disease:Dubia ad bonam
Disability:Dubia ad bonam
Discomfort:Dubia ad bonam
Dissatisfaction:Dubia ad bonam
Distitution:Dubia ad bonam
