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    Lontara 3 Bedah Saraf (Kamar 3)

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    Hudaedah'Udi'Mappeabang
    1. The document describes patients in the neurosurgery ward rooms 3 and 4. It lists each patient's name, age, medical record number, admission date, symptoms, observations, diagnosis and treatment plan. 2. The patients have various neurological conditions including brain tumors, head injuries from fractures or hematomas, and hydrocephalus. Their treatment plans involve medications, scans, and several scheduled for operations on Monday September 15th and Sunday September 14th. 3. Laboratory test results are provided for some patients showing blood counts, chemistries and imaging findings like hemorrhages and infarcts. The patients' conditions range from stable to severe with low hemoglobin and elevated liver enzymes in one case.

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    Lontara 3 Bedah Saraf (Kamar 3)

    Uploaded by

    Hudaedah'Udi'Mappeabang
    9 views2 pages
    1. The document describes patients in the neurosurgery ward rooms 3 and 4. It lists each patient's name, age, medical record number, admission date, symptoms, observations, diagnosis and treatment plan. 2. The patients have various neurological conditions including brain tumors, head injuries from fractures or hematomas, and hydrocephalus. Their treatment plans involve medications, scans, and several scheduled for operations on Monday September 15th and Sunday September 14th. 3. Laboratory test results are provided for some patients showing blood counts, chemistries and imaging findings like hemorrhages and infarcts. The patients' conditions range from stable to severe with low hemoglobin and elevated liver enzymes in one case.

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    1. The document describes patients in the neurosurgery ward rooms 3 and 4. It lists each patient's name, age, medical record number, admission date, symptoms, observations, diagnosis and treatment plan. 2. The patients have various neurological conditions including brain tumors, head injuries from fractures or hematomas, and hydrocephalus. Their treatment plans involve medications, scans, and several scheduled for operations on Monday September 15th and Sunday September 14th. 3. Laboratory test results are provided for some patients showing blood counts, chemistries and imaging findings like hemorrhages and infarcts. The patients' conditions range from stable to severe with low hemoglobin and elevated liver enzymes in one case.

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    © All Rights Reserved
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    Download as doc, pdf, or txt
    9 views2 pages

    Lontara 3 Bedah Saraf (Kamar 3)

    Uploaded by

    Hudaedah'Udi'Mappeabang
    1. The document describes patients in the neurosurgery ward rooms 3 and 4. It lists each patient's name, age, medical record number, admission date, symptoms, observations, diagnosis and treatment plan. 2. The patients have various neurological conditions including brain tumors, head injuries from fractures or hematomas, and hydrocephalus. Their treatment plans involve medications, scans, and several scheduled for operations on Monday September 15th and Sunday September 14th. 3. Laboratory test results are provided for some patients showing blood counts, chemistries and imaging findings like hemorrhages and infarcts. The patients' conditions range from stable to severe with low hemoglobin and elevated liver enzymes in one case.

    Copyright:

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    of 2

    Lontara 3 Bedah Saraf (Kamar 3)

    Bed 1
    Jumria
    19-4-1996
    679824
    MRS: 10/09/2014
    BED 3
    Mihsar
    25-02-1977
    678079
    MRS: 29-08-2014

    AAI

    S: (-)
    O: Ku sedang
    A: POH 4 kraniectomi
    ec fraktur depresi os
    frontal

    NS

    S: kel (-)
    O: KU sedang
    A: tumor intracranial

    Aff infuse ganti Conecta


    Ceftriaxone 1 gr/12j/iv

    R/ nyeri sesuai APS


    Rencana operasi senin
    15/09/2014

    Lab (29-08-2014):
    WBC 15,6 RBC 4,58 HGB14,0
    HCT39,8 PLT35,6 Na136 K3,7
    Cl96

    Lontara 3 Bedah Saraf Kamar 4

    1.

    2.

    3.

    BED 1
    J Dg Rannu
    643084
    01-12-1984
    MRS:08-09-2014

    BED 2
    AMRINA
    680060
    01-01-1988
    MRS : 12-09-2014

    BED 3
    Hawatunnisa
    01/12/2001
    679840
    MRS : 10/09/2014

    4.

    BED 4
    Sakina
    11-02-1975
    675188
    Konsul : 11-08-2014

    5.

    BED 5
    Fatmawati
    5/12/2007
    678738
    MRS: 3/9/2014

    6.

    BED 6
    St. Aisyah Ruman
    16-05-1999
    678529
    MRS: 08-09-2014

    DW

    WA

    AAI

    DW

    WA

    DW

    S: Nyeri kepala
    O: Ku sedang
    A: Tumor intracranial

    S : (-)
    O : Ku Baik
    A : Epidural Hematoma

    S : Nyeri Kepala
    O : KU baik
    D/ POH 3 craniotomy
    ec epidural hematom
    temporal sinistra

    S : (-)
    O : KU baik/ Compos
    mentis
    D/ tumor intracranial

    Asam Mefenamat 3 x 500mg


    Rencana CT Scan dengan
    kontras hari senin 15/9/2014

    IVFD RL 28 tetes/menit
    Ceftriaxone 1 gr/12 j/iv
    Ranitidin 50 mg/8 j/iv
    Ketorolac 30 mg/8 j/iv
    Nimotop 2,5 cc/jam
    Mannitol 100 cc/6 j/drips

    LAB 11/09/2014
    HB 12.3
    WBC 28.4
    RBC 4.06
    PLT 324000
    GDS 151
    Ur
    26
    Cr
    0.60
    GOT 29
    GPT 15
    Na
    143
    Ka
    3.2
    Cl
    106

    Aff infuse
    Cefadroxyl 2x300 mg
    Paracetamol 3x150 mg
    Aff drain
    Rencana pulang besok
    Aff catheter

    Rencana operasi hari senin


    15/09/2014

    S : (-)
    O : KU : sedang
    A: PO craniectomy e.c.
    fraktur depressed
    temporal D

    Paracetamol 3x250 mg
    Cefadroxyl 2x200 mg
    Aff hecting
    Rencana pulang besok

    S: (-)
    O: KU baik
    A: hydrocephalus

    Rencana cito operasi hari


    minggu 14/09/2014 pukul
    19.00
    Konsul anastesi
    Lapor ok
    Puasa lanjut
    Ab profilaksis ceftriaxone 1
    gr/iv pre op
    Cukur area operasi

    Lab (12-08-2014)
    WBC:10,55
    RBC:4,83
    HGB:11,4
    PLT:369
    Lab (08-09-2014)
    CT/BT:7.30/3.00
    PT/APTT:10.6/22.3
    GOT/GPT:60/96
    UR/CR:17/0.40
    GDS :182
    Na :145
    K :3.9
    Cl :103
    Lab: 3/9/2014
    HGB: 8,1 RBC: 2,88 WBC: 27,0
    PLT: 267
    GDS: 151 GOT: 39 GPT: 15 Na:
    135 K: 3,9 Cl: 103
    CT-Scan (01-09-2014):
    Pendarahan intracerebri yang
    meluas ke subarachnoid dan
    intraventricular
    Infarct cerebri parietal dextra
    Brain swelling
    Subgaleal hematoma dengan
    region temporoparietal sinistra

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