LONTARA 2 ORTHOPEDI BAWAH BELAKANG

K7bB6MansurMR: 701311Tanggal Lahir:10/02/1985Tanggal MRS:13/02/2015

DPJP:dr. Andi Ihwan, Sp.BS

S: sesak berkurangO: KU: baikGCS 15 (E4M6V5)Motorik 5 5 - -

Sensorik N N - -

A: Paraplegia e.c fraktur kompresi CV L1

RL:NaCl 0,9%= 28 tetes/menitCeftriaxone 1 gr/12 jam/IVRanitidin 50 mg/8 jam/IVKetorolac 30 mg/8 jam/IVNeurobion 1 amp/12 jam/IV

Lab 15/02/2015WBC: 18.3RBC: 2.72HGB: 8.4HCT: 26PLT: 397Na/K/Cl: 136/4.3/106

K7bB9Effendi SafruddinMR: 701171Tanggal Lahir:24/03/1998Tanggal MRS:12/02/2015

DPJP:Dr. dr. Nasrullah, Sp.BS

S: keluhan tidak adaO: KU: baikGCS 15 (E4M6V5)

A: Trauma capitis ringan GCS 15

RL 28 tetes/menitCeftriaxone 1 gr/12 jam/IVRanitidin 50 mg/8 jam/IVKetorolac 30 mg/8 jam/IV

Lab 12/02/2015WBC: 8.2RBC: 2.81HGB: 8.2HCT: 24.5PLT: 243CT/BT: 7’00/2’00PT/APTT: 9.7/27.4GDS: 83Ur/Cr: 34/0.80SGOT/SGPT: 149/48Na/K/Cl: 147/4.6/118HBsAg: nonreactive

K9B3DawaniMR: 699487Tanggal Lahir:01/07/1973Tanggal MRS:10/02/2015

DPJP:Prof.Dr.dr.A.Asadul I., Sp.BS

S: nyeri kepalaO: KU: baikGCS 15 (E4M6V5)

A: Susp. meningioma sphenoidal

RL 28 tetes/menitKetorolac 30 mg/8 jam/IVDexamethasone 5 mg/8 jam/IVOmeprazole 40 mg/24 jam/IVTunggu hasil MRITunggu jadwal operasi

Lab 03/02/2015WBC: 5.86RBC: 5.14HGB: 14.5HCT: 42.4PLT: 320CT/BT: 7'00/3'00PT/APTT: 10.6/25.8GDS: 108Ur/Cr: 19/0.7SGOT/SGPT: 26/31Na/K/Cl: 146/3.4/111HBsAg: nonreactive

MSCT kepala (dengan kontras) 10/02/2015Kesan: brain swelling

LONTARA 3 SARAF BAWAH BELAKANG

K4B5NurhaedahMR: 699289Tanggal Lahir :06/09/1975Tanggal Konsul:02/02/2015

S: nyeri kepalaO: GCS 15 (E4M6V5)

A: Astrocytoma high grade

- Tunggu jadwal operasi

- Terapi sesuai TS Neuro

Lab 11/02/2015WBC: 7.5RBC: 3,9HGB: 11,9HCT: 34PLT: 333Ur/Cr: 7/0,40

DPJP:Dr. dr. Nasrullah, Sp.BS

SGOT/SGPT: 29/38Na/K/Cl: 146/3.2/106T.chole: 205HDL: 42LDL: 139TG: 149BT: 2’00”CT: 6’00”

CT scan kepala axial tanpa kontras 27/01/2015- Abses lobus frontalis kiri

disertai edema perifokal luas- Sinusitis ethmoid kiri

K5B3SikannaMR: 701169Tanggal Lahir :31/12/1930Tanggal Konsul:17/02/2015

DPJP:Dr. dr. Djoko Widodo, Sp.BS

S: lemah ekstremitas kananO: GCS 15 (E4M6V5)Motorik N

N

A: Tumor metastasis intracranial

- Konservatif- Terapi sesuai TS

Neuro

Lab 12/02/2015WBC: 9.0RBC: 5.03HGB: 14.7HCT: 44.0PLT: 339Ur/Cr: 22/0,7SGOT/SGPT: 15/12Na/K/Cl: 133/4.1/107Asam urat: 3.3

CT scan kepala (tanpa kontras) 12/02/2015Lesi heterogen dengan perifocal edema yang luas pada regio temporalis kiri suspek metastasis tu. DD/ perdarahan intraserebri kiri

MSCT kepala (dengan kontras) 16/02/2015Multipel lesi heterogen hemispher cerebri kiri sesuai tumor metastasis

LONTARA 3 THT ATAS DEPAN

K1B2Andi IlhamMR: 696842Tanggal Lahir:01/11/1983Tanggal MRS:09/02/2015

DPJP:Dr. dr. Nasrullah, Sp. BS

S: nyeri kepalaO: KU: baikGCS 15 (E4M6V5)

A: Astrocytoma high grade

RL 20 tetes/menitDexamethasone 1 amp/8 jam/IVKetorolac 30 mg/8 jam/IVOmeprazole 1 amp/24 jamCiticolin 2x1Rencana MRI di RS Awal Bros

Lab 28/01/2015WBC: 15.1RBC: 5.64HGB: 16.8HCT: 52PLT: 282CT/BT: 3'00/2'00PT/APTT: 9.7/24.4GDS: 192Ur/Cr: 21/0.5SGOT/SGPT: 24/1.1Na/K/Cl: 140/3.5/99HBsAg: nonreactive

MSCT scan kepala 12/01/2015Massa regio temporoparietalis sugestif high grade astrocytoma

K1B6AsisMR: 701393Tanggal Lahir:31/12/1961Tanggal MRS:14/02/2015

DPJP:dr. Andi Ihwan, Sp. BS

S: nyeri luka operasiO: KU: sakit sedang/sadarGCS 15 (E4M6V5)Regio kepala:- Tampak kassa

penutup luka operasi

- Drain intake- Produksi ±50 cc/24

jam

A: Post craniectomy sinistra POD-2 e.c ICH regio frontal sinistra et dextra

RL:D5= 28 tetes/menitCeftriaxone 1 gr/12 jam/IVKetorolac 30 mg/8 jam/IVRanitidin 50 mg/8 jam/IVAsam tranexamat 500 mg/8 jam/IVTakar produksi drain/ 24 jamTransfusi PRC 1 bah (Hb post op: 8,7)

Lab 16/02/2015WBC: 8.0RBC: 2.92HGB: 8.7HCT: 26.9PLT: 100

Lab 14/02/2015WBC: 13.2RBC: 3.40HGB: 10.4HCT: 31PLT: 131CT/BT: 8'00/3'00PT/APTT: 14.5/32.2GDS: 111Ur/Cr: 28/0.70SGOT/SGPT: 41/13Na/K/Cl: 142/3.8/110HBsAg: nonreactive

CT scan kepala (tanpa kontras) 14/02/2015Intracerebral hemorrhage regio frontalis bilateral

K2B3SalmiaMR: 630916Tanggal Lahir:31/12/1990Tanggal MRS:11/02/2015

DPJP:Dr. dr. Djoko Widodo, Sp. BS

S: nyeri kepalaO: KU: sakit sedangGCS 15 (E4M6V5)

A: Post removal tumor intracranial

RL 28 tetes/menitCeftriaxone 1 gr/12 jam/IVRanitidin 50 mg/8 jam/IVKetorolac 30 mg/8 jam/IVDulcolax supp 1 tab/12 jam/rectal

Lab 11/02/2015WBC: 17.1RBC: 4.63HGB: 12.1HCT: 37PLT: 195CT/BT: 8'00/3'00PT/APTT: 10.9/23.0GDS: 134Ur/Cr: 14/0.6SGOT/SGPT: 15/16Na/K/Cl: 143/3.6/109HBsAg: nonreactive

CT scan kepala (tanpa kontras) 11/02/2015- Lesi kistik dengan mural node

di dalamnya yang berhubugan dengan ventrikel IV & III disertai pendarahan intraventrikel

- Brain Swelling- VP shunt terpasang pada

ventrikel lateralis kiri

- Defect os occipitalis- Cavum septum pellucidum

persisten

K6B1Muh. NasirMR: 701400Tanggal Lahir:31/12/1965Tanggal MRS:14/02/2015

DPJP:dr. Andi Ihwan, Sp. BS

S: nyeri kepala berkurangnyeri perut berkurangO: KU: baikGCS 15 (E4M6V5)Abdomen: datar, supel, bising usus normal

A: Trauma capitis ringan GCS 15 + trauma tumpul abdomen

RL 28 tetes/menitCeftriaxone 1 gr/12 jam/IVRanitidin 50 mg/8 jam/IVKetorolac 30 mg/8 jam/IVNeurobion 1 amp/12 jam/IV

Lab 14/02/2015WBC: 14.8RBC: 5.16HGB: 13.2HCT: 46PLT: 200CT/BT: 6'30/2'30PT/APTT: 11.0/25.4GDS: 154Ur/Cr: 30/1.00SGOT/SGPT: 317/379Na/K/Cl: 141/4.3/104HBsAg: nonreactive

Foto kepala AP/lateral 14/02/2015Tidak tampak kelainan radiologik pada foto skull ini

USG abdomen atas+bawah (whole abdomen) 14/02/2015- Tidak tampak tanda-tanda

laserasi/hematom pada USG abdomen saat ini

- Tampak echo cairan bebas minimal pada morrison pouch