Admission to

No Identity Diagnose Treatment

ER

1 Mr. M. Sofyan/ 32 July 10th DOC ec O2 2-4 lpm

y.o 2017 meningitis + IVFD RL 20 tpm
Communicating Inj. Ceftriaxone 2x1g
hydrocephalus + Inj. Ranitidine 2x50mg
acute ischemic Inj. Antrain 3x1 amp
cerebral (k/p)
infarction Inj. Dexamethasone
thalamus 3x1 amp
bilateral + Edema
cerebri+ TB paru Co. to neuro surgery
hospitalized
Cito vp shunt
Post op in
bougenville care
 Mr. Ferdinandes / 51y.o

Chief Complain :
Headche

History of Current Disease:

Patient complained headche since 4 years ago and become heavy
since 4 day. Headche like pulsed. Patient feel decreased of vision since
one years ago. Patients get vomitting. Patient feel his hand and foot
like numb. Seizure (-), decreased of conscious (-).
Patient is referred from dr. Doris Sylvanus Hospital
 Vital Signs
GCS E5V5M6
BP : 140/70 mmHg
HR : 105 bpm
RR : 24 tpm
T : 36,4C
 Head : symmetric, normocephal,
Eye : Anemic conj. (-/-), icteric sclera (-/-), isocor
Head (3mm/3mm)
Mouth : Moist mucous membrane
Neck:Increased level of JVP (-)
Physical Diagnostic

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
Thorax P : Sonor at all lung fields
A : symmetric VBS, no rhonchi , no wheezing

I : distension (-) ,

Abdomen A : Bowel sound (+) normal

P : timpany
P : massa defans muscular (-)

Warm extremities
Extremity Sensibility
Lateralitation (-)
 Mini Neurologis Examination
GCS E4V5M6
Pupil : RC (-/-) 3mm/3mm
Lateralisasi : (-)
BH(-/-), BO (-/-), BR (-/-), BS (-/)
Meningeal reflex : -
Pemeriks
Laboratorium Results (bukan
Hasil (Satuan) Nilai Pemeriks Hasil (Satuan) Nilai
aan Rujukan aan Rujukan
Hb 14,4g/dl hasil )12.50 Limfosit# 1,1 ribu/ul 1.25 4.0
16.70 MID# 0,8 ribu/ul
Lekosit 17,5 ribu/ul 4.65 10.3 Hasil PT 12,4 detik 3.5-5.5
Eritrosit 4,87 juta/ul 4.10 6.00 INR 1.15 6.2-8.0
Hematokr 38,6 vol% 42.00 Contoh 11,4 detik
it 52.00 normal PT
Trombosit 376 ribu/ul 150 -356 Hasil 27,3 detik 22,2-37,0
RDW-CV 14,3 % 12.1 14.0 APTT
MCV 79,4 75.0 96.0 GDS 165 mg/dl <200
MCH 29,5 28.0 32.0 SGOT 38 U/l 0 46
MCHC 37,5 % 33.0 37.0 SGPT 53 U/l 0 45
Gran% 89,4 % 50.0 70.0 Ureum 16 mg/dl 10 50
Limfosit% 6,3 % 25.0 40.0 Creatinin 1,24 mg/dl 0.7 1.4
MID% 4,3 % 4.0 11.0 Natrium 122 mmol/l 135 146
Gran# 15,6 ribu/ul 2.50 7.00 Kalium 3,8 mmol/l 3.4 5.4

Chloride 92 mmol/l 95 100

CT scan
X-ray
Working Diagnosis

Tumor Parasellar S +
peritumor bleeding +
edema cerebri
 Planning
IVFD NS + drip tramadol 20 tpm
Inj. Ranitidine 2x50mg
Inj. Dexamethasone 3x1 amp
Inj. Kalnex 3x 500 mg
Inj. Ondancentron 3x8mg (k/p)

Co. to neuro surgery

Control to polyclinic
Tramadol 2 x 1 tab
 Mr. M. Syafei / 60y.o
Chief complain :
 Vital Signs
BP : 180/90 mmHg
HR : 95 bpm
RR : 22 tpm
T : 37,0C
 Head : symmetric, normocephal,
Eye : Anemic conj. (-/-), icteric sclera (-/-), isocor
Head (3mm/3mm)
Mouth : Moist mucous membrane
Neck:Increased level of JVP (-)
Physical Diagnostic

I : Symmetric respiratory movement, no retraction

P : Symmetric VF
Thorax P : Sonor at all lung fields
A : symmetric VBS, no rhonchi , no wheezing

I : distension (+) ,

Abdomen A : Bowel sound (+) decrease

P : timpany
P : tenderness (+)

Warm extremities
Extremity Sensibility
Lateralitation (+) D