S O AP

Hari/Tanggal S O A P
Selasa, Kelemahan KU : lemah D. Klinis: Planning
separuh Vital Sign: Hemiparesis diagnosis
11/08/2015
badan sebelah TD: 150/90 mmHg sinistra, parese n - CT-Scan
kiri. Nadi :60x/m, VII & XII - EKG
RR:20 x/m sinistra sentral - DL
t:37 0C - Kimia Darah
Status interna: D. Topis :
K/L: A/I/C/D -/-/-/- ACM (D) Planning Terapy
Thorax : Pulmo: - Bed rest
normochest, simetris, D. Etiologis: - Infuse RL
v/v, rh -/-, wh -/- Susp. CVA 29 tpm
Cor: S1S2 tunggal, m infark - diet TKTP
(-), g (-) Dd:
- injeksi
Abdomen: -CVA infark
NT (-) meteorismus(-) thrombosis citikolin 3x1
Hepar/Lien ttb -CVA infark (500mg)
Ekstremitas: emboli - Aspirin
Edema 1x325mg
- -
- -
CRT <2 detik
Akral hangat kering
merah
Status neurologis:
GCS : 456
MS: -
N. Cranialis
: PBI
3mm/3mm; RC +/
+
N. Cranialis lain:
parese n VII &
XII sinistra sentral
Motorik :
555 111
555 222
Sensorik: dbn
Reflek superfisial:
dinding perut (-)
R. Fisiologis:
BPR+2 / +1
TPR +2 / +1
KPR +1 / +1
APR +1 / +1
R. Patologis:
 Babinski -/-
Chaddock -/-
Oppenheim -/-
Gordon -/-
Gonda -/-
Schaefer -/-
Rosolimo -/-
Stranski -/-
Mendel Bechterew
-/-
Hoffmann -/-
Tromner -/-
ANS: BAK (dbn)
BAB (dbn)
Rabu, Kelemahan KU : lemah D. Klinis: Planning
separuh Vital Sign: Hemiparesis diagnosis
12/08/2015
badan sebelah TD: 130/90 mmHg sinistra, parese n - CT-Scan
kiri Nadi :60x/m, VII & XII - DL
RR:20 x/m sinistra sentral Hb: 12,6
t:37 0C Leu: 11,290
Status interna: D. Topis : Ht: 37,4
dbn ACM (D) Tro: 208.000
Status neurologis: - Kimia Darah
GCS : 456 D. Etiologis: GDA: 125
MS: - CVA infark Uric: 8,3
N. Cranialis trombotik Total
: PBI cholesterol:
3mm/3mm; RC +/ 175
+ TG: 114
N. Cranialis lain: HDL: 53
parese n VII & LDL: 115
XII sinistra sentral
Motorik : Planning Terapy
- Bed rest
555 111
555 111 - Infuse RL
Sensorik: dbn 29 tpm
- diet TKTP
Reflek superfisial:
- injeksi
dinding perut (-)
citikolin 3x1
R. Fisiologis:
(500mg)
BPR+2 / +1 - Aspirin
TPR +2 / +1
1x325mg
KPR +2 / +1
APR +2 / +1
R. Patologis:
Babinski -/-
Chaddock -/-
Oppenheim -/-
Gordon -/-
Gonda -/-
 Schaefer -/-
Rosolimo -/-
Stranski -/-
Mendel Bechterew
-/-
Hoffmann -/-
Tromner -/-
ANS: BAK (dbn)
BAB (dbn)

Kamis Kelemahan KU : lemah D. Klinis: Planning

separuh Vital Sign: Hemiparesis diagnosis
13/8/2015
badan sebelah TD: 140/90 mmHg sinistra, parese n - CT-Scan
kiri, gak bisa Nadi :60x/m, VII & XII - DL
pipis RR:20 x/m sinistra sentral Hb: 12,6
t:37 0C Leu: 11,290
Status interna: D. Topis : Ht: 37,4
Abd: supel, NT -, ACM (D) Tro: 208.000
bising usus (+) - Kimia Darah
normal, suprapubis D. Etiologis: GDA: 125
(dbn) CVA infark Uric: 8,3
Status neurologis: trombotik Total
GCS : 456 cholesterol:
MS: - 175
N. Cranialis TG: 114
: PBI HDL: 53
3mm/3mm; RC +/ LDL: 115
+
N. Cranialis lain: Planning Terapy
parese n VII & - Bed rest
XII sinistra sentral - Infuse RL
Motorik : 29 tpm
555 222 - diet TKTP
555 222 - injeksi
Sensorik: dbn citikolin 3x1
Reflek superfisial: (500mg)
dinding perut (-)
R. Fisiologis:
BPR+2 / +1
TPR +2 / +1
KPR +2 / +1
APR +2 / +1
R. Patologis:
Babinski -/-
Chaddock -/-
Oppenheim -/-
Gordon -/-
Gonda -/-
Schaefer -/-
 Rosolimo -/-
Stranski -/-
Mendel Bechterew
-/-
Hoffmann -/-
Tromner -/-
ANS: BAK (-)
BAB (dbn)

Jumat Kelemahan KU : lemah D. Klinis: Planning

separuh Vital Sign: Hemiparesis diagnosis
14/8/2015
badan sebelah TD: 140/90 mmHg sinistra, parese n - CT-Scan
kiri, gak bisa Nadi :60x/m, VII & XII - DL
pipis RR:20 x/m sinistra sentral Hb: 12,6
t:37 0C Leu: 11,290
Status interna: D. Topis : Ht: 37,4
Abd: supel, NT -, ACM (D) Tro: 208.000
bising usus (+) - Kimia Darah
normal, suprapubis D. Etiologis: GDA: 125
(dbn) CVA infark Uric: 8,3
Status neurologis: trombotik Total
GCS : 456 cholesterol:
MS: - 175
N. Cranialis TG: 114
: PBI HDL: 53
3mm/3mm; RC +/ LDL: 115
+
N. Cranialis lain: Planning Terapy
parese n VII & - Bed rest
XII sinistra sentral - Infuse RL
Motorik : 29 tpm
555 222 - diet TKTP
555 222 - injeksi
Sensorik: dbn citikolin 3x1
Reflek superfisial: (500mg)
dinding perut (-)
R. Fisiologis:
BPR+2 / +1
TPR +2 / +1
KPR +2 / +1
APR +2 / +1
R. Patologis:
Babinski -/-
Chaddock -/-
Oppenheim -/-
Gordon -/-
Gonda -/-
Schaefer -/-
Rosolimo -/-
 Stranski -/-
Mendel Bechterew
-/-
Hoffmann -/-
Tromner -/-
ANS: BAK (dbn)
BAB (dbn)