KORAN BEDAH SARAF, KAMIS 19JUNI 2014

KORAN BEDAH SARAF SENIN 23 JUNI 2014Lontara 3 Bedah Saraf (Kamar HCU)

1Syarifah HalwiahTTL : 31/12/1962 (51th)RM : 658265MRS : 7/4/2014JKNBed 1NSS: Batuk berlendirO:KU:sedang GCS E4M6V5

A: SDH post craniektomi Cefadroxil 500mg 2x1 As. Mefenamat 3x1 Bisolvon syr 3x10 cc Aff kateterLab 11/6/14Alb: 3.2 Na/K/Cl: 138/3.0/102HCT 37 PLT 296Lab 11/6/14WBC: 10,23, RBC: 4,09, HGB: 10,7 HCT:34,5 PLT: 271Na/K/Cl: 143/3,4/101, Ur/Cr: 8/0.30, GOT/GPT: 56/41, Albumin: 3.0GDS 109Tanggal 8/4/14Foto thoraks PA Efusi pleura min (S) Fraktur ob;iq os clavicula (S) Multiple frak costa IV-VII kiri belakang (flail chest) Dilatasi et elongasi aorta

2ArdiansyahTtl 19/9/99664214Mrs : 20-5-2014Bed 2AAIS : (-)O : KU : sedang GCS 10X (E4M6VX)

A/ ICH post craniektomi H-20 + peningkatan enxim transaminase

IVFD Asering 28 tpmMeropenem 1gr/12j/IVSistenol 3x1Bisolvon syr 3x10 ccNebulizer combivent/ 8JVip albumin 3x2

Lab 16-6-2014WBC: 20 RBC: 3.3 HGB: 9.6 PLT: 487 Ur 21 Cr 0.60 GOT: 254GPT 340 Pro.Tot 6.0 Alb 2.6Na/K/Cl 136/4.0/100

Lab 9-6-2014WBC 10.9 RBC 3.89 HGB 10.9 PLT 343 Na/K/Cl: 136/4.5/99 Ur 16Cr 0.45 GOT/GPT: 121/101 Alb 2.6

CT scan kepala tanpa kontras 19-5-2014- Tidak tampak kelainan intracranial pada CT Scan kepala ini- Hematoma subgaleal regio parietal dextra

3DermawanTTL : 15/4/1994 (22th)RM: 665351MRS: 28-5-14JKN

Bed 3

DWS : hematomO : KU : ss/gc/cmGCS 12 E4M5V3,

A : SDH Post eksternal drainase GCS E4M5V4 IVFD RL 24 tpm Ceftriaxone 1gr/12jam/iv Ranitidine 50 mg/8 j /iv Parasetamol 1gr/8J/IVLab 16/6/2014WBC 38.2 RBC 3.28 HGB 9.9 HCT 30 PLT 297 Ur 61 Cr 1.1 Na/K/Cl 148/4.0/114

Tanggal 28/5/14Foto CT scan kepala Tdk tampak lesi patologik intracranial mutihematosinusTanggal 27/5/14Foto thoraks AP Tdk tampak kelainan Tanggal 27/5/14Foto femur sinistra AP/Lat Frak komunitif 1/3 tengah os femur sinistra Susp corpus alenum pd proksimal dr frak (menyerupai paku kcl)

4Rusdi1-1-2000666979MRS:8-6-2014Bed 4WAS:-O: KU: sedang GCS E4M6V5A:IVHIVFD RL 28 tpmCeftriaxone 1gr/12jRanitidin 50mg/8jPiracetam 3gr/8jSemax 3x15ttsNovalgin 1 amp/8JDulcolax 10mg supp 2Lab 18/6/2014Pro Tot 5.5 Alb 4.0

Lab 14/6/2014GDS:83 Na/K/Cl:146/3,8/105 RBC:4,44 HB:12,5 HCT:37,2 PLT:239 WBC:8,5 CT/BT:8/3 Ur/Cr:32/0,7 GOT/GPT:69/23

5Syamsir66789631-12-1955MRS: 13-6-2014Bed 5NSGCS S4M6V5 ICH parietooccipital (s) Fr. Zygomaticum D

IVFD RL:D5% (1:1) 24 tpmCeftriaxone 1gr/12j/IVRanitidin 50mg/8j/IVKetorolac 30mg/8j/IVLab 17/6/2014GDS 84 Ur/Cr 33/0.90 Pro.tot 6.3Alb 3.8

6Iyan Setiawan31/12/2009665357MRS 28/05/2014Bed 6DWS : (-)O : Ku sedang GCS 14 E4 M6V4 Pupil anisokorA : DAI (depress additional injury) dengan perbaikan GCSIVFD D5 16 tpmPiracetam 600 mg/8 j/ivNicholin 170 mg/12j/IVSemax 3x7 ttsFisioterapiLab 10/06/2014:RBC: 4,13 HGB: 10.1 HCT: 31 PLT: 1,053 WBC: 10Ferritine : 127,19Lab 28-5-2014RBC 4,59: HGB 11,1,6:HCT 34,3, PLT 507 WBC 23,6 :GDS 131 UR/CR 13/0,30 GOT/GPT: 39/19 CT scan kepala 3/6/2014Perdarahan subkronik intracerebral dextra dan intraventrikular

7Muh. Syahrir TjirebonTTL 28/4/1967 (47th)RM: 662343MRS 7/5/2014Umum

Bed 7WAS : Kel: (-)O : Ku SEDANG GCS E4M6Vx

A : EDH frontal post craniektomi Cefadroxil 500mg 2x1 As. Mefenamat 3x1 Bisolvon syr 3x10 cc Aff kateterLab 14/6/14WBC: 11.3, RBC: 3.81 HGB: 11HCT:33, PLT: 563Na/K/Cl: 138/4.3/101, Ur/Cr: 18/0.32 GOT/GPT: 66/136, Albumin: 2.5

8YoelTL: 5-7-1994RM:668243MRS:16-4-2014UmumBed 8

WAGCS 15Fr.depress os frontalICH frontalPost op Craniotomy Aff infuse Cefadroxil 500mg 2x1 As. Mefenamat 3x1 Pindah perawatan biasaLab 16/6/2014WBC 12.3 RBC 3.82 HGB 10.8 HCT 33 PLT 183 Ur/Cr 26/0.70GOT/GPT 50/33 Na/K/Cl 142/4.5/109

Lontara 3 Bedah Saraf (Kamar 1)

Lontara 3 Bedah Saraf (Kamar 2)Angga

10Suarta66665106-02-1966Konsul : 10-6-2014Bed 1

DWPOH 8 VentriculostomyIVFD RL 20 tpmInj. Ceftriaxone 1gr/12j/IVInj. Ketorolac 30 mg/8j/IVInj. Ranitidin 50 mg/8j/IVAwasi KU, TTV dan GCSTerapi lanjut sesuai ts neurologiFoto Thorax 11/6/14:Cardiomegaly dengan dilatation aortaLAB 9/6/2014WBC: 4,72 RBC:4.17 HB:13,2 PLT:196 PT/APTT:11,5/22,6 GDS : 80 UR/CR:25/0,90SGOT/SGPT:17/17NA/K/CL:142/3,3/98 CT ScanKepala 4/6/2014Tidak tampak massa intracranial .Hiperdensive hydrocephalus communicans ec over production iquor cerebro spinalis.-Infark lacunar cerebri kiriFoto lumbo sacral AP 6/6/2014Spondylosis lumbalis CV L1-4

11Muhammad Thamrin6633937/1/19823/6/2014JKNBed 2DW paraparase ec fracture compresi V.Thoracal X

- amoxicillin 2 x 500 mg - ranitidine 2 x 150 mg - neurodex 2 x 1 tab- Menunggu Jadwal Operasi

Foto thorax APFraktur kompresi CV T9-T10MRI T-Spine 2/6/2014 Kesan : - spondylolisthesis CV Th 9 terhadap Th 10 disertai penyempitan discus intervertebralis pada level tersebut - wedging CV Th 10 yang membentuk angulasi ke posterior dan ekstrusio disc level CV T9-T10, menekan thecal sac dan nerve root menyebabkan stenosis totalis canalis spinalis pada level tersebut LAB 1/6/2014WBC 16.8 RBC: 4.64 HB:12.3 PLT:516 CT/BT:1.3/7 PT/APTT:11.1/24.1 GDS:153 UR/CR:22/0.4 SGOT/SGPT:13/12 ALB:3.9 NA/K/CL:142/4.1/108Thorax AP Lateral 30/5/2014Kesan : fraktur kompresi CV T9-T10Usul : MRI Thoracal

Lab 18/6/2014WBC 11.7 RBC: 4.87 HB:12.8 HCT: 39.6 PLT:251 CT/BT:6/4 PT/APTT:11.3/21.2 GDS:121 UR/CR:17/0.4 SGOT/SGPT:16/16 NA/K/CL:141/3.6/108HbsAG non reactiveAnti HCV non reactive

Lontara 3 Bedah Saraf (Kamar 3)

13By. Ester TTL 07-2-2014658780MRS : 7-6-2014K3 B3

WA POH 4 rekonstruksi meningoencephalocele nasofrontal POH VP Shunt et cavin hidrocephalus

Pct syr 3x0,8 drips Cefadroxil syr 2x0,8 drips Rawat luka dan ganti verban/2 hari

Lab. 2/6/2014RBC : 4,20 PT : 10,4 Hb : 12,4 WBC 17,4 GDS : 80, Ur/Cr : 21/0,38 SGOT/SGPT 49/45 CT/BT : 700/200 PT/PTT : 10,4/25,6 Na?K/Cl ; 143/5,6/105 CT-scan kepala 14/4/2014 Meningoencephalocele frontal dengan porencephaly scaphocepaly Foto thorax 21/4/2014Cor dan pulmo dalam batas normal

14Kambisa66793121-10-1941MRS: 14-6-2014K3 B4WATetraparese ec susp fr. CervicalSpinal Cord InjuryHipoalbumin Pujimin 3x2 aps IVFD RL 20 tpm Inj. Ceftriaxone 1gr/12j/IV Inj. Ketorolac 30 mg/8j/IV Inj. Ranitidin 50 mg/8j/IV Metilprednison 125 mg/8j/iv Neurotam 3 gr/8j/ivLab. 20/6/2014RBC : 3.21PLT : 165 HCT: 30,0 Hb : 10.6 WBC: 6,2GDS : 165 Na/K/Cl ; 135/4.5/105Albumin : 2.3

15Suhaeni6682429/5/1962MRS: 17/6/2014Bed 1

WAMeningiomaPOH 1 RL 28 tpm Dexamethason amp/8jam Ranitidin amp/8 jamLab.15/06/2014HCT:33,3, WBC:14,2 , GDS:153, Ur/Kr: 19/0,60, GOT/GPT:30/23, Na/Kl/Cl:136/4,2/105

Lontara 3 Bedah Saraf (kamar 4)

16Irawati66798520/06/1978MRS: 16/6/2014Bed 2WA Oedema brain injury Subarchoid hematoma Subgaleal hematom TCR GCS 15Boleh rawat jalanCefadroxil 500mg 2x1Ranitidin 150mg 2x1As. Mefenamat 500mg 3x1Neurodex 100mg 1x1Aff kateter

Lab. 15/6/2014GDS:153, UR/KR:19/0,60, GOT/GPT:30/23, Na/K/Cl: 136/4,2/105

18Wisno Kasim66601312-11-1974JKNMRS 21-06-2014Bed 1WATumor intracranial susp. AstrocytomaRencana operasi selasa 24/06/2014Lab. 14/6/2014RBC : 4,40 PLT : 304 HCT: 38,2 Hb : 13,0 WBC: 6,02 CT/BT: 700/300 PT/APTT: 11,1/19,1 GDS : 101, Ur/Cr : 23/0,7 SGOT/SGPT 12/11 Na/K/Cl ; 139/4,0/108.

19Adelia66898626/4/2004MRS:22/06/14UmumBed 4AAITCR GCS 15Edema cerebriICH Frontal (D)O2 3 lpmIVFD RL 16 tpm Ceftriaxon 1gr/12 jam Ranitidin amp/8 jam Ketorolac amp/8 jamPasang kateterMannitol 4x50ccDiet lunakLAB 18/6/2014RBC 3.97 HGB 10.7 HCT 30.7 PLT 312 WBC 12.4GOT/GPT 43/14GDS: 98UR/CR 15/0.3

Lontara 3 Bedah Saraf (Kamar 5)Angga

20Harun Dg Bella6688951-1-72UmumMRS 20-6-2014Bed 1NSTCR GCS 15 + Fr. Cervical c5-c6 RL 20 tpm Ceftriaxone 1gr/12j Ranitidin 50mg/8j Ketorolac 30mg/8j Diet biasa Foto MRI Rencana op skull defect jika keluarga setujuLAB 20/6/2014RBC 4.52 HGB 13.7 HCT 39.8 PLT 322 WBC 20.6CT/BT: 7/2.3GOT/GPT 33/32NA/K/CL 139/4.0/107PT/APTT 11.8/21.2GDS: 145UR/CR 21/0,9

21Herman Roa TTL : 31/12/1979RM: 665852MRS: 30/5/2014UMUM

Bed 4WAContusio Cerebri Konsul fisioterapi RL 28 tpm Methyl cobalt tab 2x1 Piracetam 30mg Neurodex 2x1 tab Konsul fisioterapiLAB 15/6/2014RBC 4.791 HGB 14.2 HCT 42.1 PLT 208 WBC 20.6GOT/GPT 34/25NA/K/CL 144/3,6/110PT/APTT 12,1/19GDS 99UR/CR 33/0,90

20/5/2014Kesan : Hematoma Intracranial ilateral dan subarachnoid dengan edema cerebri Frakture kommunitif parietal bilateral dengan hematoma sukutis

22SyamsuddinTTL : 31/12/1979RM: 668006MRS: 15/6/2014UMUM

Bed 5WASubarachnoid hemorrhage Aff infus Cefadroxyl 2x500 mg As mefenamat 3x500 mg Ranitidin 2x150mg Neurodex 1x1

LAB 15/6/2014RBC 4.791 HGB 14.2 HCT 42.1 PLT 208 WBC 20.6GOT/GPT 34/25NA/K/CL 144/3,6/110PT/APTT 12,1/19GDS 99UR/CR 33/0,90

23M Nurdin6690178-4-67MRS 22-6-2014JKDBed 6AAITCR GCS 15 + Perdarahan cerebri reg. temporal (S) RL 20 tpm Ceftriaxone 1gr/12j Ranitidin 50mg/8j Ketorolac 30mg/8j Diet biasaCT Scan Kepala 22/06/14 Perdarahan cerebri regio temporal kiri

24Ilham Sanjaya66875412-1-97MRS: 19-6-2014UMUMBed 2NSTCR GCS 14 + EDH Temporobasal (S) POH 5 Craniotomy RL 20 tpm Ceftriaxon 1gr/12 jam Ranitidin amp/8 jam Ketorolac amp/8 jam Diet susu GVLAB 19/6/2014RBC 3.23 HGB 9.6 HCT 28.7 PLT 146 WBC 6.8GOT/GPT 50/32NA/K/CL 143/4.4/106GDS: 100UR/CR 33/0.9HbsAG non reactiveAnti HCV non reactive

Foto Skull AP/Lat 19/6/2014 Susp fr. Ramus mandibula (S) Usul: CT scan wajah

CT Scan Kepala 19/06/14 Depressed fr. Greater wings os sphenoidalis (S) disertai epidural hematom dan pneumocephal sisi regio tersebut Fr. Os Zygomaticum (S) disertai hematom lateral perioculer sinistra Hematom subgaleal regio frontotemporoparietalis (S) disertai emfisema subkutis

25Arisal66891311-11-90MRS: 21/6/14UmumBed 3NSPOH 2 Kraniotomi IVFD RL 20 tpm Ceftriaxone 1gr/12 jam Ranitidin amp/8 jam Ketorolac amp/8 jam Diet biasa

LAB 20/6/2014RBC 4.65 HGB 13.2 HCT 38.4 PLT 262 WBC 10.5GOT/GPT 13/9NA/K/CL 137/4.0/107GDS: 99UR/CR 21/0.7HbsAG non reactiveAnti HCV non reactive

CT Scan kepala 20/06/14Depressed fr os frontalis disertai perdarahan intracrebri regio frontalis dan pneumocephalMultiple fr. Pada os zygomaticum bilateral, orbital floor, dan orbital rim bilateral os nasal, os vomer, lamina papyracea os ethmoidalis bilateralhematosinus

Lontara 3 Bedah Saraf (Kamar 6)Angga

26Ilham M63155914-4-1993MRS 19-6-2014Bed 1NSPOH 3 craniotomy ec. Skull defectRL 20 tpmCeftriaxon 1 gr/12 jamKetorolac 30 mg/8jamRanitidin amp/8jamAff drainLAB 11/6/2014RBC 4.71 HGB 15.2 HCT 44.7 PLT 225 WBC 5.5CT/BT: 7.3/3GOT/GPT 22/22NA/K/CL 147/4.4/104PT/APTT 12.5/23.7GDS: 83UR/CR 13/0,94HbsAG non reactiveAnti HCV non reactive

27Stefanus PararakMR 667579TTL 23/6/1982

Bed 2NSICH Frontal Aff infus Ranitidin 2x150mg Neurodex 1x1

LAB 12/6/14CT/BT 800/400 PT/APTT 10,6/ 20,8GDS 114 UR/CR 29/0.90 GOT/GPT 37/25NA/K/CL 138/4,0/107RBC 4,64 HBG 14,7 HCT 43,7 PLT 225 WBC 18,1

LAB 17/6/14GDS 83 Protein total 5.8Albumin 3.4Kolesterol total 144HDL/LDL: 40/96TG: 85

28Abd. Zam-zam66801512-4-2000MRS:15-6-2014Bed 3WAEDH temporobasal (d)+ Fr. Zygoma (d)Perawatan hari ke 10Cefadroxyl 2x500mgAs.Mefenamat 3x500mgRanitidin 2x150mgNeurodex 1x1

Lab 15/6/14RBC:4,41 HB:12,0 HCT:36,2 WBC:15,5 PT/APTT:13,0/32,8 GDS:132 Ur/Cr:21//0,60 GOT/GPT:33/22 Na/K/Cl:144/3,7/89 HbsAg(-)

CT Scan 15/6/14- Perdarahan region temporalis (d)- Fr.os.zygomaticus (d) disertai perselubungan pada sinus sphenoidalis bilateral dan ethmoidalis

29Isra6690711-9-2003Mrs 23/6/2014Bed 4AAI

Closed fr. Os frontal (D)RL 12 tpmCeftriaxon 500 gr/12 jamKetorolac 1/2amp/8jamRanitidin 1/2amp/8jamDiet biasa

ICU

30Idris30/8/1978286748MRS 28/05/2014ICU VIP 1DWS: (-)O: Ku: lemahGCS tersedasiPupil isokor RL + A: ICH + IVH post craniectomy Post tracheostomy Rawat trakeostomi Suction on demand Terapi sesuai TS Anestesi Lab 5/62014:RBC: 4,17 HGB: 16,51 HCT: 36,3 PLT: 324 WBC: 15,51Got/gpt :183/238Na/K/Cl : 148/3.6/106CT : 600BT : 300GDS 225UR/CR :48/0,78Albuin 2,4

31Salmiati muzakkarTTL 01-12-1978663904MRS 17/05/2014ICU VIP3DWS : (-)O : KU SedangGCS TersedasiA : Edema cerebri SDH Spondilolithesis C.V C.VI dan C.VII Post tracheoostomy hari I

Rawat trakeostomi Terapi sesuai ts anestesi dan ortopedi

USG ABDOMENKesan tidak Nampak kelainan radiologic pada USG abdomen ini

Lab 1/6-2014RBC 4,58: HGB 11,9 :HCT 35.3 PLT 156 WBC 12,2 :GDS 97 GOT/GPT 31/31:NA 140 :K3.4:CL106 albumin 2,5 PT/APTT 24,0/13,4Foto Thorax PA/AP 17/05/2014:- Cor dan pulmo normal- Fraktur 1/3 tengah os clavicula disertai openyempitan sendi acromioclavicularis- Fraktur komunitif os scapula dextra

32

Abd.RahimTTL 19/12/1963RM 668007MRS 15/6/2014JKNBed 1

WASDH + ICH Tempoparietal post Craniotomy Mannitol 2x125cc Lain-lain sesuai TS AnatesiLAB 17/6/2014RBC 3,49 HGB 10.2 HCT 31 PLT 94 WBC 9.8GOT/GPT 36/20NA/K/CL 142/3.9/104GDS 108UR/CR 37/0.78

AGD PH 7.399 pCO2 47.5 SO2 99.9 PO2 237.2 HCO3 29.6 ctO2 15.1 BE 4.8 Kesan : Asidosis respiratorik terkompensasi sempurna.

LAB 15/6/2014RBC 3,961 HGB 11,61 HCT 35,0 PLT 133 WBC 21,0GOT/GPT 27/18NA/K/CL 145/3,4/107PT/APTT 11,0/25,0GDS 128UR/CR 34/0,90

CT-Scan 15/6/2014KESAN :-Pendarahan intracerebri disertai pendarahan subdural regio temporal sinistra-Hematom subgelael regio temporoparietal dextra-Multiple hematosinus

33TUNRENGTTL 1/7/1925RM 667000MRS 9/6/2014JKNBed 2

WA

S (-)O : KU lemahGCS TersedasiA : SDH+ ICH TEMPORAL post craniotomyPost trakeostomi

Rawat trakestomi Section On demand Sesuai TS anstesiLab 8/6/14RBC 4.52 HB 11.6 HCT 36.3 PLT 170 WBC 9.3 CT/BT 8/3 PT/APTT 12.5/26.1 GDS 117 Ur/Cr 35/0.70 GOT/GPT 24/15 Na/K/Cl 135/3.8/105

34Suradi66816519-10-1992MRS:16-6-2014JKNBed 7WAS: Kesadaran menurunO: KU: lemahGCS 9x E2M4VxA: -SAH-Edema cerebri-Mannitol 3x100cc-Ceeremax 50mg/SP-Lain2 sesuai TS anestesiLab 17/6/2014RBC:4,39 HB:13,6 WBC:14,7 HCT:19,3 PLT:354 CT/BT:8/3 PT/APTT:13,2/28,6 GDS:65 Ur/Cr:25/0,7 GOT/GPT:72/24 Alb:3,3 Na/K/Cl:144/8,0/108CT Scan 16/6/2014- sugestif perdarahan subarachnoid disertai herniasi subpalatina dan fr.regio occipitalis (d)- hematoma subgaleal regio occipital- multisinusitis

35ArdiTTL: 3/4/1997RM 668791MRSJKNBed 3S: -O: KU lemahGCS E1M3VxA: EDH post craniotomy + IVH Mannitol 4x125 cc Lain2 sesuai TS anestesiLab 20/6/2014WBC 27.8 RBC 4.17 HGB 11.8 PLT 247Ur/Cr 35/0.80 Na/K/Cl 138/4.2/110

PICUangga

36A.Putri Thahirah28/9/2012Mrs 25/5/2014JKNPICU bed 1

NSPOH 10 VP shunting ec. Hydrocephalus terapi lain lanjut sesuai bagian pediatri simex 4x5 tetesLab 12/6/2014RBC:4,86 WBC:8,42 HCT:40,5 HGB:13,7 PLT:278 GDS:105 Ur/Cr:15/0,15 Alb:3,3 Na/K/Cl:144/3,7110LAB 9/6/2014RBC : 4,44, HGB : 13,0 HCT : 37,9 PLT : 124, WBC : 9,4 na : 135 k ; 3,1 cl ; 104 CT/BT : 9/330CT scan kepalaHypertensive hydrocephalusDandy walker syndromePerdarahan subarachnoid

37Azzahra Perempuan TTL 11/2/2014RM: 656676JKNPICU Bed 8NSPOH 18 drainase eksternal hidrocephalus

- Terapi lanjut sesuai TS pediatrik- Awasi GCS dan TTV- tunggu hasil LCSLAB 6/6/2014RBC : 3,51, HGB : 9,6, HCT : 28,4 PLT : 599, WBC : 13,54; GOT 23;GPT 17; albumin 2,8; Na/k/cl: 125/5,2/86

Lab 24-5-2014 :RBC : 3,27, HGB : 9,7, HCT : 28,9 PLT : 514, WBC : 13,9GDS 65; Ureum 4;kreatinin 0,20; GOT 25;GPT 27; albumin 3,4; Na/k/cl: 114/5,0/84Hasil Ct scan 5/5/2014Meningoencephalitis dengan hidrosefalus disertai massa hipodens pada lobus frontalis kanan dan parietal kiri suspek abses

NICU

38By. Zainab03/06/2014666896NICU Bed 1Hydrocephalus

Lab 06/06/2014:WBC:9,45 MPV: 10,5 PCT: 0,3 PLT: 366 PDW: 11,7

PALEM BAWAH

39Abdullah66172330/12/1950Mrs 09/6/2014B1/7UMUMNSS : nyeri pinggang O: ku : ss/gs/sadarGCS 15 (E4M6V5)A: LBP ec spondylosis lumbalis IVFD RL 28 tpm Myonal 2 dd 1 Rubal plus 3 dd 1

Lab 17/6/2014RBC:4,40 WBC:12,47HCT:36,8 HGB:12,4 PLT:305 GDS:112 Ur/Cr:30/1,23 Na/K/Cl:140/3,3/106

PALEM ATAS

40Hj. St NabharaPerempuan1/3/49RM 661411MRS 29/04/2014Kamar b1/2DWPOH 3 tracheostomiGv/ 2 hariTerapi sesuai TS neuro dan anestesiLab 17/6/2014Na/K/Cl:138/4,6/97 alb: 2,8

Lab 13/6/2014RBC:3,44 WBC:8,46 HCT:31,8 HGB:9,9 PLT:391 GDP:103 Ur/Cr:12/0,40 Na/K/Cl:143/2,6/97

IRD

41Wahyuni /14-4-2000/ 668380NSmeningioma IVFD RL 28 tpm Ceftriaxone 1gr/12j Ranitidin 50mg/8j Ketorolac 30mg/8j Brainact 250mg/ivLab 17-6-2014RBC 3,82 HGB 11,1 HCT 32,9 PLT 309 WBC 16,2Ct-scan:Bone window : WNLBrain wimdow : EDH regiotemporoparietal

42Sudirman/3-11-1979/668773NSTCR GCS 15+ Fr. OS frontalis depressed (S) + Fr. Zigomaticum (S)Rencana kamis 26-6-2014

43AdeAryandi/1-1-1999/668781DWTCB GCS 2X IVFD RL 28 tpm Ceftriaxone 1gr/12j Ranitidin 50mg/8j Ketorolac 30mg/8j CT scan Lab Lengkap

44Jumadi /1-7-1990DWTCB GCS 6X (E2M4VX)ICH DextraSAH IVFD RL 28 tpm Ceftriaxone 1gr/12j Ranitidin 50mg/8j Ketorolac 30mg/8j Mannitol 4x100cc Observasi tanda vital

45Ilham Sanjaya/12-1-1997/668754NSPOH 0 Craniotomy ec EDH temporobasal (S)Lab 19-6-2014RBC 3,23 HGB 9,6 HCT 28,7 PLT 146 WBC 6,8

46Naura Aqila Sahra/15-8-2013NSHidrocephalusLab lengkapCT scan

47H. Deppu/1-7-1960NSTCB GCS E2M4V2 IVFD RL 28 tpm Ceftriaxone 1gr/12j Ranitidin 50mg/8j Ketorolac 30mg/8j

Lab 19-6-2014RBC 3,51 HGB 10,7 HCT 32,3 PLT 211 WBC 21,8CT 800 BT 3,OO PT 14,4 Control 22,2 INR 1,20 APTT 22,6 Control 24,5 Ur/Kr 58/1,30 SGOT/SGPT 271/226 Na/K/Cl 143/4,2/108

LONTARA 1 PAKIS

LONTARA 1 Atas Depan

LONTARA 2 ONKOLOGI Atas Belakang

LONTARA 2 ORTHO Bawah Belakang

48

Surya Amri66738320-09-2004

WATCR GCS 15Trauma maxilla

LONTARA 2(Bawah Depan) Urologi

LONTARA 2 (Atas Depan) Digestif

LONTARA 3 NEURO

LONTARA 3 THT

L3AD49MurniatiTL : 31-12-1962MRS : 19-06-2014RM : 668747TCR GCS 15Konserfatif Ceftriaxone 1gr/12j Maintenance monitol Lab tgl 19/06/2014Ct: 6.00, Bt: 3.00, GDS: 123, ur: 26, cr:0.60, SGOT:72, SGPT: 34, Albumin: 3.8, Na: 138, K:3.5, Kl: 111

Lab 19/06/2014Wbc :14.8, Rbc: 3.58, HB: 10.5, Hct: 31.2, Plt:240

CT Scan kepala 19/06/2014 Fraktur os supra orbita sinistra Multihematosinus Hematoma subgalealregio frontal Persisten cavum pellucidum et vergae Emphysema infaorbita sistra

L4AD

50Naura AqilaHidrocefalus noncomunicans P : IVFD D5 10 tpm Pct : syr 3 cc

Lab 18/06/2014Wbc :14.2, Rbc: 5.44, HB: 13.2, Hct: 40.0, Plt: 95Lab 20/06/2014Ct: 5.00, Bt: 3.00, GDS: 93, ur: 12, cr:0.30, SGOT:42, SGPT: 32, Albumin: 3.8, Na: 139, K:4.9, Kl: 101

LONTARA 3 KULIT KELAMIN (atas belakang belakang)

L3 AB

51Yohanis GapongTl : 04-08-1977MRS : 17-06-2014RM : 668258DWCefalgia KronikP : IVFD RL 28/tpmCeftriaxone 1gr/12j/ivKetorolak 30mg/8j/ivRanitidin 50mg/8j/ivTunggu hasil labPulcula x supp1xsuppCT Scan Kepala 17/06/2014 Massa intraaxial dengan perifokal edema regio frontotemporaloparietal kiri susp.astrocytoma dengan tanda-tanda herniasi subfalcine DD/ perdarahan intra cerebralsub kronik region fronto temporoparietal kiri. Brain swelling Sinusitis ethmoidalis kiri

Lab tgl 17/06/2014Ct: 6.00, Bt: 3.00, GDS: 91, ur: 22, cr:0.60, SGOT:223, SGPT: 19, Albumin: 3.6, Na: 142, K:4.3, Kl: 109

LONTARA 4 (Bawah Depan) OBGYN

L4BD

52NurazisaTL : 19-08-1985MRS : 09-06-2014Konsul Tgl:RM : 596230WACerebral Malaisia- Observasi tanda-tanda peningkatan intracranial - Th/ dari neuro dan GynLab 19/06/2014Wbc :16.29, Rbc: 4.51, HB: 10.7, Hct: 35.5, Plt:343Ct: 7.00, Bt: 2.00, GDS: 77, ur: 26, cr:0.44, SGOT: 13, SGPT: 9, Albumin: 3.5, Na: 139, K:3.3, Kl: 102,

LONTARA 4 (Bawah Belakang) NIFAS

LONTARA 4 ANAK

IC

PCC

53PCC Lantai 4 kamar 421/ VIP BNy. Dra. Sugiharti66555550thn17/12/63MRS 29/5/14JKN

DPJP: DW

S: Kel : sesak (+)O: KU SS/GC/CMTD: 130/80 N: 80x/iS: 36C R: 20x/iA: Paraplegi + Destruksi CV Th7 + ca mammae D metastase Tulang, pulmo

Terapi lanjut Ts. PulmoCeftriaxone 1 gr/12j/IVDrips neurobion amp/hari/drips Diet biasa

LAB 20/6/2014GDP 121

Lab 13/6/2014 PEMERIKSAAN Sputum : BTA (-)

Lab 13/6/2014RBC 3,16WBC 16,9HBG 8,5HCT 25,7PLT 432PCT 0,304GDS 105Ur/ Kreatinin 35/0,60SGOT 55SGPT 92Protein toral 5,3Albumin 2,5Globulin 2,8Asam urat 3,2N/K/CL 136/ 4,3/ 105

Lab 13/6/2014 MSCTScan Thorax : - Massa paru D dengan lesi-lesi noduler curiga metastasis Efusi Pleura Bilateral

USG mamma kiri dan hemithorax kanan 2-06-2014Hasil fibroadenoma mamma kiri-tidak tampak lesi residif pada hemithorax kanan

Hasil PA 03-06-2014Suspect phylloides tumor mammae yang sudah metastase ke kepala

54PCC 209Ny. A. Munawwarah66837448thn14/8/1965MRS 17/6/14JKN

DPJP: NS

S: nyeri berkurangMual(-) muntah (-)O: KU SS/GC/CMTD: 150/90 N: 80x/iS: 36C R: 20x/iA: POH III VP Shunt

Inj. Ceftriaxone 1 gr/12j/ivKetorolac 30 mg/8 j/ivRanitidine 50 mg/8j/ivDiet biasaBladder training

CT Scan kepala 18/6/14Hasil pemeriksaan : sesuai astrocytoma low grade +hypertensive hydrocephalus(peninggian TIK)

RSUH

55Ny. Damaris Rante06/06/1958L4 Kamar 403 B023065

DPJP: NSS: Kel (-)O: KU SS/GC/CMTD: 180/60 N: 80x/iS: 36C R: 20x/iA: POH 14craniectomy Hipertensi grade IITerapi lanjut Ts. Interna GHCefadroxil 2x500 mgRanitidin 3x50 mgVip albumin 3 x 2Drips manitol 3x 100 mg/24jamDiet biasaBladder trainingAff hecting

Lab 17/6/2014pemeriksaan histopatologiKesimpulan: atypical meningioma (WHO Grade II)

Lab 10/6/2014WBC : 9,70RBC 4,43HB 13,7HCT 40,2MCV 90,7MCH 30,9PLT 92PCT 0,09

Lab 9/6/2014CT : 730BT: 230PT: 11,5INR 1,0APTT 23,5GDS 120UR/KR 31/0,8SGOT 29SGPT 15CK 106CM-MB 13,9N/K/CL 140/5,3/106

56Lantai 4 Kamar 426Ny. Mastiah02345019/7/1967DPJP: S: kel (-)O: KU SS/GC/CMTD 140/90 N 80x/I S: 36 c P: 20x/iA: TCS GCS 14 + POH 4 CraniotomiTh/ lanjutInj. ceftriaxone 1gr/12j/ivInj. ketorolac amp/8j/ivInj. ranitidine amp/8j/ivGv Semox 4 tts/ka/kiAmlodipine 10 mg 1x1

Lab 18/6/2014Wbc 14,92Rbc 4,94Hb 13,4Hct 41,9MCV 84,8MCH 27,1PLT 292PCT 0,26N/K/CL 146/3,8/112SGOT 31SGPT 31Glukosa 155

57Lantai 2ICU Bed 4Rukawati01/05/1977023610S: kel (-)O: ku: lemah A: POH II ec ICH temporal SINSTRUKSI POST OP:IVFD RL 20 tpmInj. ceftriaxone 1gr/12j/ivInj. ketorolac amp/8j/ivInj. ranitidine amp/8j/ivAwasi KU, GV, GCSDrips manitol 6x100cc/24jLab 22/6/2014Wbc 9,62Rbc 3,06HGB 8,9HCT 26,6MCV 86,9MCH 29,1PLT 59PCT 0,06

7