LONTARA 2 ORTHOPEDI BAWAH BELAKANG

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/24 jam/IVOmeprazole 40 mg/24 jam/IVCeftriaxone 1 gr/12 jam/IV

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) 10/02/2015Brain swelling

MRI kepala 17/02/2015Tidak tampak SOL

LONTARA 2 DIGESTIF ATAS DEPAN

K1B1Irfan ReynaldyMR: 701665Tanggal Lahir:09/03/1995Tanggal Konsul:21/02/2015

DPJP:dr. Willy Adhimarta, Sp. BS

A: TCS GCS 13 (E4M6V5) + post laparotomi eksplorasi + splenectomy

Citicholin 250 mg/12 jam/IVRanitidin 50 mg/12 jam/IVSohobion 1 amp/24 jam/IMDexamethasone 1 amp/6 jam/IV

CT scan kepalaTanda-tanda ischemic cerebri dextra

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)

A: Post craniectomy sinistra POD-4 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 jam

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

K2B1St. SaidahMR: 701744Tanggal Lahir:01/01/1945Tanggal MRS:17/02/2015

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

S: nyeri kepala berkurangO: KU: sedangGCS 15 (E4M6V5)

A: Trauma capitis ringan GCS 15 + ICH regio frontal

RL 28 tetes/menitCeftriaxone 1 gr/12 jam/IVRanitidin 50 mg/8 jam/IVKetorolac 30 mg/8 jam/IVMannitol 100 cc/6 jam bila tensi > 100 mmHg

Lab 17/02/2015WBC: 26.5RBC: 3.82HGB: 11.1HCT: 33.7PLT: 339CT/BT: 7'00/3'00PT/APTT: 10.1/22.9GDS: 175Ur/Cr: 26/0.90SGOT/SGPT: 38/15Na/K/Cl: 143/3.1/106HBsAg: nonreactive

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

K2B4SartinaMR: 701860Tanggal Lahir:21/10/2000Tanggal MRS:18/02/2015

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

S: nyeri kepalaO: KU: sedangGCS 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 18/02/2015WBC: 13.1RBC: 4.20HGB: 11.4HCT: 34.5PLT: 345CT/BT: 7'00/2'00PT/APTT: 10.5/24.2GDS: 100Ur/Cr: 16/0.5SGOT/SGPT: 21/9Na/K/Cl: 142/3.6/107HBsAg: nonreactive