KORAN BEDAH SARAF SABTU 03 JANUARI 2015

LONTARA 3 BEDAH SARAF KAMAR 1

Bed 1
GRACE
VERONICA
PASHA

Dr. A.
ikhwanSp.Bs

694798
07-04-1958

S: pusing
O: KU: baik, sadar
A: - Focal brain injury
- Intracerebral
hemorrhage
- SOL
Intracranial

MRS :
30-12-2014

Cefadroxil
500mg/12jam/o
ral
Ranitidine 150
mg/ 8 jam/oral
Asammefenama
t 500mg/ 8
jam/oral
Piracetam 3x
850 mg/ oral
Mlodipin 10
mg/24 jam/ oral
Diazepam
5mg/24jam/oral

LONTARA 3 BEDAH SARAF KAMAR 2

-

LONTARA 3 BEDAH SARAF KAMAR 3

Bed 2
Muhammad
Gusly
25/08/1990
694852
MRS
20/12/14

Prof. DR. dr.

Andi Assadul,
Sp.BS

S: ematom pada kedua

kelopak mata

O: KU = sedang, sadar

A: Focal Brain Injury

Infus RL 28tpm
Ranitidine
50mg/8jam/iv
Ceftriaxone
1gr/12jam/iv
Ketorolac
30mg/8jam/iv
Konsul Bedah
Plastik

Laboratorium
(30/12/14)
RBC 4,28
HGB 10,2
HCT 30,6
PLT 2
WBC 14,5
CT 7`00``
BT 200
GOT/GPT 19/26
Ur/Cr 20/0.80
Na 144
K 4,2
Cl 108

Bed 4
ILHAM
SAPUTRA

DR. dr. Djoko

Widodo,
Sp.BS

30/04/83 31 thn
690151

S : Nyeri luka operasi

O : Keadaan umum:
sedang, sadar
Kekuatan otot
Sensorik
A : POH 9
laminektomi dekompresi
ec Paraplegi ec
syringomyelia

MRS :
18/12/2014

-IVFD RL 18 tpm
-Ceftriaxone 1
gr/12jam/iv
-Ketorolac
30mg/8j/iv
-Ranitidin
50mg/8j/iv
-Methylprednisolon
1 amp/8j/iv

Laboratorium
(22/12/14)
RBC 3.25
HGB 10.5
HCT 39.7
PLT 148
WBC 8.9
GDS 139
Albumin 3.2
Bil tot 0.42
Bil direk 0.16
GOT/GPT 25/17
Ur/Cr 16/0.50
Na/K/Cl 144/4.7/123

LONTARA 3 BEDAH SARAF KAMAR 4

Bed 3
REHAN
FEBRIAVAN

dr. Andi
Ikhwan,
Sp.BS

S : Nyeri kepala
O: Keadaan sedang
GCS 15, pupil isokor

27/02/2008
694593
A : Closed fraktur
depresi regio temporal
sinistra

MRS :
30/12/2014

Bed 2
EVI YUNI
ASTUTI

DR.dr.
Nasrullah,
Sp.BS

S : Nyeri kepala
O: Keadaan sedang
GCS 15, pupil isokor

04/06/2001
686687
MRS :
30/12/2014

A : SOL intrakranial
Hidrochepalus

- Aff drain
- Infus Kaen 3B 14
tpm
- Ceftriaxon 1g/12
jam/ intravena
- Ranitidin 3x 150
mg/ oral
- Paracetamol 3x 500
mg/ oral

- Fenitoin 45
mg/8jam/ oral
- Paracetamol sirup
500mg/ 8jam/
oral

Laboratorium
(30/12/14)
RBC 4,44
HGB 12. 9
HCT 39
PLT 273
WBC 11,8
GDS 119
GOT/GPT 37/10
Ur/Cr 16/0.50
Na/K/Cl 148/3,9/110
CT 800
BT 300
PT 11,2 c 10,8
INR 0,98
CT scan kepala
(29/12/14)
- Depressed fraktur
os temporal sinistra
- Perdarahan region
occipital dextra
sugestif perdarahan
subdural
- Mega cysterna
magna
LAB: 30/12/2014
RBC: 4,46
HGB: 13,7
HCT : 39
PLT: 329
WBC: 6,4
GDS: 69
Na/K/Cl: 139/3,5/104
PT 11,2 C 10,7
INR 0,91
APTT 31,2 C 25,7
GDS 69
Ur 17

Cr 0,40
GOT 19
GPT 7
ALB 3,9

Bed 5
NURBAYA

DR.dr. Nasrullah,
Sp.BS

01/07/1970
694385

O:KU: sedang,
sadar
Motorik 5 5
00
Sensorik N N

MRS :
25/12/2014

Bed 1
HASMANI

S : Kelemahan
kedua tungkai

Dr. Andi
Ikhwan,
SP.BS

17/8/1981
694659

- Ranitidin 150 mg/ 8

jam/ oral
- Paracetamol 500
mg/ 8 jam/ oral
- Neurodex tab/ 12
jam/ oral
- Rencana foto MRI
hari senin
5/1/2015

A : paraplegia ec
susp fracture
vertebra thoracalis
S:
- Tunggu jadwal
operasi
O: Keadaan umu m baik
A : Skull defek ec
fraktur sinistra

Foto Lumbosakral
AP + Lateral 25-122014
- Spondylosis
Lumbalis
Foto Thoraks
PA/AP
- Suspek
atelektasis paru
dextra
- Dilatatio aortae

MRS :
2/1/2015

LONTARA 3 BEDAH SARAF KAMAR 5

Bed 2
Darwis

Dr.dr.Djoko
Widodo,Sp.BS

- Infus RL 28 tpm
- Ceftriaxone 1 gr/12
jam/iv
O : KU : baik,sadar
Ranitidin
GCS 14 E3M6V5
50mg/8jam/iv
Ketorolac
A:
30mg/8jam/iv
- Focal brain injur
- Intracerebral
Haemorrhage

dr. Willy A,
Sp.BS

S : tidak ada keluhan - Infus RL 28 tpm

- Ceftriaxone 1 gr/12
jam/iv
O : KU : sakit
Ranitidin
sedang, sadar, pupil
50mg/8jam/iv
isokor 2, 5mm/2,
Ketorolac
5mm
30mg/8jam/iv
- Aspirasi hematom
A : Focal Brain
region occipital 60
injury
cc

31/12/1985
694577
MRS
29-12-2014

Bed 3
Aldy
Muhammad
20/06//2001
694425
MRS :
25/12/2014

S : nyeri kepala

Darah rutin
WBC : 14,8 10^3/ul
RBC : 4,28 10^6/uL
HBG : 14.2 gr/dl
HCT : 40.2%
PLT : 237 10^3/ul
GDS : 111
GOT/GPT : 20/13
Ur/Cr :30/0.70
Na:140
K:4.0
Cl:106
Darah rutin 31-12-2014
WBC : 7, 9 10^3/ul
RBC :3,50 10^6/uL
HBG : 9.9 gr/dl
HCT : 29%
PLT : 623 10^3/ul

Bed 4
NURUL
FAJRI
10-12-1999
681270
MRS :
16-12-2014

Bed 5
Muhammad
Agus
10/06/1989
694573
MRS :
29/12/2014

Dr.dr.Djoko
Widodo,Sp.BS

S : Nyeri luka
operasi

- Infuse RL 28 tpm
- Ceftriaxone 1 gr/12
jam/iv
- Ranitidin
50mg/8jam/iv
- Ketorolac
30mg/8jam/iv
- Diet Biasa

Lab
16-12-2014
WBC : 9.6 10^3/ul
O : KU : baik,
RBC : 5.37 10^6/uL
compos mentis
HBG : 14.9 gr/dl
HCT : 44.7%
A : Post Op
PLT : 33610^3/ul
Cranioplasty hari 5
GDS : 109
GOT/GPT : 21/12
Ur/Cr :14/0.70
Na:146
K:4.2
Cl:107
Dr.dr.Djoko
S: tidak ada keluhan - Infus NaCl 0, 9%
Darah rutin
Widodo,Sp.BS O: KU :baik/ sadar
- WBC 25,0 10^3/ul
28tpm
- Ceftriaxone 1 gr/12 - RBC 4,39 10^6/uL
GCS 15 E4M6V5
jam/iv
- HGB 13 gr/dl
A:
- Ranitidin
- HCT 37,20%
- Focal Brain
50mg/18jam/iv
- PLT 211 10^3/ul
injury
- Ketorolac
- Subdural
Kimia Darah
30mg/8jam/iv
hematom region
(26-12-2014)
temporal dextra
CT 7`00

BT 200
PT 11,4 C10,8
APTT 31,1C25,7
GDS 12
Ur 17
Cr : 0, 90
GOT: 28
GPT : 12
Na:140
K:3,3
Cl:108
Urinalisis :
Warna : kuning
pH :6,
Bj : 1,010
Protein :negative
Glukosa : negative
Blood, lekosit, bilirubin,
urobilinogen : negative
Sedimen leukosit : 0
Sedimen eritrosit 2
Sedimen epitel sel :3
CTScan kepala tanpa kontras :
Ftraktur os parietalis sinistra
dan os zygomaticum sinistra
Perdarahan subdural refio
frontotemporoparietal
sinistra disertai herniasi
subfalcine
Edema cerebri
Soft tissue swelling
Hematosinus ethmoidalis
bilateral

LONTARA 3 BEDAH SARAF KAMAR 6

BED 4
SAMSU

Dr.dr.Djoko
Widodo,Sp.BS

17-07-1984
694541

S: nyeri luka operasi - Cefadroxil 2x500

mg/oral
- Paracetamol 3x500
O:
mg/oral
KU : baik /sadar/luka
operasi kering

MRS:
28-12-2014

A: POH V
craniotomy ec EDH

Lab (25-12-2014)
WBC : 18,3
RBC : 4,36
HBG : 13,5
HCT : 39,6
PLT : 261
CT : 630
BT : 200
PT : 11,8 (k 11,4)
APTT : 30 (k 27,6)
GDS : 132
Ureum : 31
Kreatinin : 0,8
GOT : 48
GPT : 32
HBsAg : Non reactive
Na:140
K:4,3
Cl:106

CT-Scan (28-12-2014)
Pendarahan epidural region
frontotemporoparietal
dextra disertai herniasi
subfalcine
Pendarahan intracerebri
lobus parietalis dextra
Pneumocephal
Hematom subgaleal region
frontotemporoparietal
dextra disertai
emphysema subkutis
Multiple fraktur disertai
multihematosinus

TITIPAN
LONTARA 2 BAWAH BELAKANG
LONTARA 3 NEURO
K1B3
MUH. SIBOLE
6-3-1942
694517
MRS :28-122014

S: nyeri bekas operasi

O: GCS15
A: post op craniotomi
Hari 6 ec EDH
temporoparietal sinistra

Asam
mefenamat
3x500mg
Cefadroxyl
2x500mg
Ranitidine
3x150mg

Lab (28/12/2014)
PT/APTT: 12.4/32.3
CT/BT : 7.00/3.00
INR : 1.00

CT
kepalatanpakontras
(27/11/2014)
-perdarahan epidural
subakut regio
frontotemporoparieocci
pital sinistra disertai
herniasi subfalcine
Foto thorax AP

(27/11/2014)
Kesan :
-pulmo normal
-cardiomegali disertai
dilatatio aortae
K3B5
ILHAM

S: tidak ada keluhan

O : GCS15/sakit
sedang/gizi cukup

5-1-1960
693495
L3 HCU B 2
HARTINA

Tunggu jadwal
operasi

Foto Thorax AP
(18/12/14)
-tidak tampak kelainan
radiologik pd foto thorax
ini

POH 2 VP shunt
urgent

Lab (18-12-14)
WBC: 8.1
RBC : 4.72
HCT : 41.1
Hb: 13.9
PLT: 388
CT/BT : 8.00/3.00
PT: 10.3 ctrl 10.0
APTT : 28.0 ctrl 24.0
INR : 0.90
GDS : 102
Ur/Cr: 17/0.60

A/ Tu. Fossa posterior

dr. A. Ihwan,
Sp. BS

18/1/1973
693393

S: nyeri bekas operasi

O : GCS15/sakit
sedang/gizi cukup
A/ tumor intrcranial +
hisrocefalus

- -Ceftriaxone
1gr/12j/iv
- -ketorolac
30mg/8j/iv
- -ranitidine
50mg/8j/iv
- -gv/hari
- Asam traneksamat
1gr/12jam/iv

Thorax PA (18/12/14)
-Cor dan pulmo normal
-tidak tampak tandatanda metastasis pada
kedua paru
CT kepala (19/12/14)
-massa hiperdens
sugestif berasal dari
pinel body
-hydrocephalus
K3B2
Tn. Antonius
Arifin
693741
31/03/1980

dr. A. Ihwan,
Sp.BS

S:
O:
A: Hidrosefalus non
communicans + parese
N.VI sinistra ec Tu.
Intracranial

Post op VP Shunt
hari 3

LONTARA 4 ATAS BELAKANG

K6 B3
Qafiya Nurul
Jannah
685775
20/06/2014

A:Meningocele
Lumbalis

Rencana operasi
anestesi belum
setuju
Perbaiki KU

Lab (25/12/2014)
RBC: 5.13
WBC: 11.8
PLT: 285
HGB: 12.1

HCT: 35.1
GDS:72
Na/K/Cl : 141/ 5.0/ 108

HCU
Bed 1
MUSFIRA

Dr. Willy
Adhimarta, Sp
BS

S: Kesadaran menurun
O:KU: lemah GCS 10x
(E4M6Vx),
Pupil isokor, reflex
cahaya +/+
A :Post operasi
craniotomy ec. EDH
temporoparietal sinistra

Dr. Willy
Adhimarta, Sp
BS

S: Penurunankesadaran
O:KU: lemah
GCS 10x (E4M5Vx),
Pupil isokor, reflex
cahaya +/+
A :Post operasi
craniotomy subdural
hematom

05/10/1998
678612
MRS :
02/09/2014

Bed 2
NATSIR
KADIRI
12/06/1980
676380
MRS :
18/08/2014

- Oksigen 6lpm
- Head up 30o
- Paracetamol 500
mg/NGT (k/p)
- Ventolin 2,5
mg/8jam/nebulize
r
- Ambroxol 1 sdk/8
jam/NGT
- Neurodex 1
tab/12jam/NGT
- Rawat tracheostomy
- Fisioterapi
- Mobilisasi
- Tutup kanal
tracheostomy
- Terapi gizi sesuai TS
gizi klinik
- Phenytoin
100mg/8jam/drip
s dalam Nacl
100ml
- Dulcolax supp I
rectal
- Head up 30o
- IVFD RL 28 tpm
- O2 8 L/menit via
kanul
tracheostomy
- Paracetamol 1000
mg/8jam/IV (k/p)
- Bisolvon syr
1sdk/8jam/NGT
- Fisioterapi
- Mobilisasi
- Terapi gizi sesuai
Ts`gizi klinik

Lab 8/12/2014
RBC : 3,43
WBC : 11,7
HGB : 9,6
HCT : 28,4
PLT: 563
UR/CR: 17/0,30
GDS: 100
GOT/GPT: 62/93
Na/K/Cl: 138/3,7/107

Lab 01/12/2014
RBC: 4,99
WBC: 12,16
HGB: 13,9
HCT: 40,0
PLT: 423
NA/K/Cl: 138/4,5/101
GOT/GPT: 43/75

Bed 3
EKA SAGITA
PUTRA

Dr. Willy
Adhimarta, Sp
BS

S: Kejang tidak
O:KU: lemah
GCS 10x (E4M6Vx),
Pupil isokor 3,5/3,5,
reflex cahaya +/+
A :Post operasi external
drainage bilateral hari 28

- Head up 30o
- IVFD RL 28 tpm
- O2 6 L/menit via
kanul
tracheostomy
- IVFD RL 20 tpm
- Levofloxacin
500mg/12jam/IV
- Ranitidine 50 mg/12
jam/iv
- Phenytoin 100 mg/8
jam/iv
- Mobilisasikiridanka
nantiap 4 jam
- Farbion 5000
mg/24jam/iv
- Fisioterapi
- Rawat luka/2 hari
- Vancomycin

DR.dr.Djoko
Widodo,Sp.B
S

S: kesadaran menurun
O: Ku= lemah
GCS 10x (E4M6Vx)
pupil isokor 2,0/2,0mm
RCL +/+
Luka operasi kering
A: Post craniotomy ec
ICH hari ke24

- Aff infuse
- Cefadroxyil
500mg/12jam/ora
l
- Ranitidin
150mg/8jam/oral
- Asam mefenamat
500mg/8jam/oral
- Tutup tracheostomy

IKH

S :Nyeri kepala
O: ku: sakit sedang,
GCS15(E4V5M6), Pupil
isokor
A : Intracerebral
hemmorage temporal
dextra
Subdural hemmorage
temporal dextra

05/12/1995
686204
MRS :
25/10/2014

Bed 4
RACHMAT
4/6/1999
691982
MRS: 8/12/14

Bed 5
YAHYA
25/02/2004
694538
MRS :
28/12/2014

- O2 8 liter/menit
- Kaen 3B 28 tpm
- Ceftriaxone 1
gr/12jam/iv
-Ranitidine
50mg/12jam/iv
-Ketorolac 30
mg/8jam/IV
Paracetamol 250
mg/8jam.IV
Boleh pindah
perawatan biasa

Lab 10/12/2014
RBC : 4,20
HGB : 12,8
HCT: 36,4
PLT: 643
WBC: 17,4
GDS : 102
Ur/cr: 22/0,70
GOT/GPT: 37/45
Na/K/Cl: 143/3,4/103

Lab: 28/12/2014
RBC: 3,88
HGB: 12,3
HCT: 35,2
PLT: 273
WBC: 8,5
Ur/Cr: 35/1,00
GOT/GPT: 1278/994
Na/K/Cl: 142/4,2/109

Bed 6
YOSAFAT

DR.dr.
Nasrullah,
Sp.BS

17/7/91
684160
MRS:

Bed 7
ARSYAD ALLO

DR.dr.
Nasrullah,
Sp.BS

31/12/1946
682887
MRS :
01/10/2014

Bed 8
MARTHEN
BIDANGAN
14/03/1959
683291
MRS :
14/10/2014

DR.dr.Djoko
Widodo,Sp.B
S

- Oksigen 6lpm
- ceftriaxone
1gr/12jam/IV
- Ranitidin 1
amp/8jam/IV
- Ambroxol syr 1
sdk/8jam/NGT
- Farbion
5000/24jam/drips
- Terapi sesuai TS
anestesi
- Mobilisasi
Fisioterapi
- Boleh pindah
perawatan
biasa
S: kesadaran menurun
- Head up 30o
- IVFD RL 28 tpm
O:KU: Lemah,
- O2 8 L/menit via
tidaksadar, GCS 10x
kanul
(E4M6Vx),Pupil isokor,
tracheostomy
reflex cahaya +/+
Ranitidine
50 mg/12
A : ICH region
jam/iv
temporoparietalsinistra
- Ceftriaxon 1 gr/12
(post op craniotomy)
jam/iv
- Farmadol 100 mg/8
jam/drips/KP
- Bisolvon syrup 1
sendok/8
jam/NGT
- Ventilasi nebulizer
2,5 mg/8 jam/via
nebu
- Mobilisasikiridanka
nantiap 4 jam
- Rawat tracheostomy
S: emah anggota gerak,
sesak (-)
O: keadaan umum, sakit
sedang
GCS 10 (E4M6X5)
pupil isokor
A:Fraktur V-VI
post op stabilisasi
cervical ec fraktur
cervical

S: Penurunankesadaran
O:KU: Sakitsedang,
gizikurang, GCS 10x
(E4M6Vx),
Pupil isokor, reflex
cahaya +/+
A :ICH post pemasangan
VP-Shunt

- Head up 30o
- IVFD RL 28 tpm
- O2 8 L/menit/via
kanul
tracheostomy
- Ranitidine 50 mg/12
jam/iv
- Ventilasi nebulizer
2.5 mg/8 jam/via
nebu
- Ceftriaxone
1gr/12jam/iv
- Paracetamol 1000
mg/8jam/kp
- Ambroxol 1
sdk/8jam/NGT
- Rawatluka
tracheostomy
- Mobilisasikiridanka

Lab : 11/12/2014
RBC: 2,66
HGB: 7,8
HCT: 22,9
PLT: 465
WBC: 6,2
Na/K/Cl: 138/2,4/108
Ur/Cr: 26/0,50
GOT/GPT: 68/86
2-1-2015
HB : 6,8
RBC : 2,39
Albumin : 2,4
Na : 158
K : 2,3
Cl : 122

Lab : 10/12/2014
RBC: 3,33
HGB: 8,9
HCT: 28,4
PLT: 495
WBC: 10,6
Ur/cr: 13/0,51
GDS: 92
GOT/GPT: 39/53
Na/K/Cl: 142/3,8/102

nantiap 4 jam
- rawat luka/hari

ICU
Bed 2
ABD RAUF

- Terapisesuai TS
anestesi
- Mobilisasi
- Fisioterapi
- Nutrisi via NGT

Prof DR. dr.

AndiAsadul
Islam, Sp.BS

S :Penurunankesadaran
O:KU: sedang, GCS 7x
(E3M4Vx) pupil isokor
A :Post op craniotomy
ec ICH HARI 81

Prof.Dr.dr.An
diAsadul
Islam, Sp. BS

S :Kesadaranmenurun
- terapilanjutsesuai TS
O:KU: lemah,GCS 10x
anestesidanneurol
(E4M6Vx)
ogi
rawat
tracheostomy
A: Post op harike 23
- mobilisasi
craniotomy ec ICH
region
temporoparietalsinistrae
c HS

Dr.dr.
DjokoWidodo,
Sp.BS

S: kesadaranmenurun
O: KU tidaksadar
GCS tersedasi
Luka operasikering
Drain 100ml/hari
A: post op
hari5kraniotomiec. ICH
temporoparietal +
Fraktyurdepresi

01/07/1959
677206
MRS :
25/10/2014
Craniotomi
25/02/2014
Tracheotomi
29/10/2014

Bed 3
MAHATMA
GADHI
31/12/1960
690992
MRS :
29/11/2014
Bed 4
MUH IQBAR
23-05-2003
694559

Oksigen 8lpm
Ceftriaxon
1gr/12j/IV
50mg/8j/IV
Paracetamol
1000mg/8jam/I
V
Omeprazole
40mg/24jam/I
V
Mannitol
100ml/6jam/dri
ps
Terapi lain
sesuai TS
Anestesi

Bed 5
SYARIFUDDIN

Prof DR. dr.

AndiAsadul
Islam, Sp.BS

31-12-59
693769
MRS :
21/12/2014
Bed 6
MUHAMMAD
SUNUSI

Dr. Willy
Adhimarta, Sp
BS

31/12/1937
691516
MRS :

BED 7
Muh.
AshabulKahfi

Dr. Nasrullah,
Sp.BS

25/05/2001
694390

Bed 8
DEWI ARYUNI

Dr. Willy
Adhimarta, Sp
BS

S: Kesadaranmenurun
O: lemah. GCS
8x(E3M6Vx)
Pupil anisokor 3,5/3,0
mm
A:
Intraventrikelhemoragik

dr. Ikhwan,
Sp.BS

S: Kesadaranmenurun
O: KU lemas
GCS tersedasi
Pupil isokor 3,5/3,5 mm,
RC +/+
Luka operasikering
Drain 200cc/ post
operasi
A: post op hari
6craniotomiec ICH
frontalis + open fracture
depresifrontalis + SAH

24/4/2001
692754
MRS:
15/12/2014
VIP 1
Pajar
694486
9/05/1997
MRS :
27/12/2014

S: kesadaranmenurun
Kejang (-)
O: KU: tidaksadar GCS
10 (E2M5V2) pupil
isokor
Luka operasikering
A: POH
13Craniectomyec ICH +
SDH + SAH
S :Sesak
O:KU: Lemah,GCS 7x
(E2M5Vx)
Luka operasikering
T:172/110 mmhg
N: 104x/menit
P:26x/menit
A: Post op craniotomy
ec ICH pariotemporal
basal sinistrahari 26
S: Kesadaranmenurun
O: Keadaanumumlemah
GCS 7x (E2M5Vx)
Pupil anisokor 3,0/2,0
mm
Reflekscahaya +/+
Luka Operasikering
Drain 50cc/post operasi
A: Post op craniotomy
hari 8ec. ICH frontal

- Oksigen 8lpm
- Ceftriaxon
1gr/12j/IV
- 50mg/8j/IV
- Paracetamol
1000mg/8jam/IV
- Terapi lain sesuai TS
Anestesi
- Terapilanjut TS
Anestesi
- Rawat tracheostomy
- mobilisasi

- Ceftriaxone
1gr/12jam/IV
- Ranitidin 1
amp/8jam/IV
- Paracetamol
1gr/8jam/IV
- Mannitol
100ml/6jam
- Drain/hari
- Terapi lain sesuai TS
Anestesi
- Aff drain besok
- Terapi TS
Anestesilanjut
- Mobilisasi
- Rencana
tracheostomy
besok

-Terapisesuai TS
anestesi
-drain/hari
-mobilisasi

Lab: 21/12/2014
RBC: 4.55
HGB: 13.6
HCT: 38.0
PLT: 141
WBC: 12.6
Ur/Cr: 24/0.8
GOT/GPT: 28/17
Na/K/Cl: 142/3.9/106

VIP IV
IBRAHIM
BAYUPAH

DR.dr.
Nasrullah,
Sp.BS

061096
29/10/
MRS :
07/11/2014

S: Kesadaranmenurun
O:KU: Lemah, GCS 8x
(E3M5Vx)
Drain 250cc/hari
Luka operasikering
A: Post op
ventrikuloperitoneal
shunt ec tumor
intracranial + Post
tracheostomi
POH 17 repair extrernal
drainage

-Terapisesuai TS
anestesi
- Rawat
tracheostomy
- Mobilisasi
-produksi drain/ hari

PICU
Bed 1
Muh.
NaufalUlyaFokr
a

dr. Nasrullah
Sp.BS

S: KesadaranMenurun
- Cefotaxime
- Novalgin amp / 8
O: Lemah, tersedasi
jam/ intravena
A: Post op Vp Shunt Hr
Usulextubasi
1
e.cHidrocephalusComm
unicans

dr. Nasrullah
Sp.BS

S: kejang

O: KU :sedang

21-04-2000
396999
MRS:
29-12-2014
Bed 5
Athaya
693631
7-11-2013
Mrs:

A: status epileptikus

Terapi lanjut TS
anak
Cek kadar
phenintoin dalam
darah

Lab 15-12-14
WBC : 9.56
RBC : 4.39
HGB : 11.7
HCT : 37.0
PLT : 136
GDS : 94
GOT/GPT :372/352
Albumin :4.5
Na/K/CL : 140/4.4/105
MSCT Kepala non
kontras
Gambaran Dandy

Walker Variant

Bed 7
STANISLAOS
692099
22-9-2003

DR.dr.Djoko
S :kesadaranmenurun
Widodo,Sp.BS O : KU : sedang/
sadarGCS 13 E4M6V3
A : POH 15 VP shunt
echidrocepalus

- Terapisesuai TS
Pediatrik
- optimalisasi

MRS :
8-12-2014

CT scan kepalakontras
19-12-2014
Kesan :
- VP shunt
terpasangmelaluidefekp
ada parietal
kanandenganujung
distal
padaventrikellateraliska
nan
-massaintraaxial
ganglia
basaliskirisugestiflowgr
ade astrocytoma dengan
hydrocephalus noncommunicansdantandatandaherniasisubfalcine
multiplelesihiperdensda
nhipodenspadakeduahe
misfercerebridanhemisf
er cerebella kirisugestif
post infeksi
Foto thorax 8-12-2014
Kesan
:cordanpulmodalambata
sa normal

Bed 9
AISYAH
3-4-2006
695087

Dr. ikhwan
Sp.Bs

MRS :
31-12-2014

S: nyeri kepala
O: KU sedang, GCS 15
(E4,M6,V5)
A: Post VP shunt H-1 e,c
hypertensive
hydrocephalus non
communicans + sus.
epindimoma

Terapi lanjut dari TS

anak

PALEM BAWAH
PALEM ATAS
B2/8 bed 2
MUH. HELI
ZAINAL
07/09/1949
692392

dr.,Willy A,
Sp.BS

S :NyeriKepala
O: lemah
A: hydrocephaluse.c
tumor intrakranial

- Terapilanjutdari TS
Neurologi
- Optimalisasi KU
untukrencanaoper
asi

MRS :
11/12/2014

RSUH
411
Hayyong
028142
01/07/78
30/09/14

Prof
DrdrAndiAs
adul Islam
Sp.BS

S: (-)
O:KuSedang/GC/CM
Pupil isokor
GCS 15
PA:Pylositic
astrocytoma
A:POH 7 removal
tumor

406
Fadly
Muhammad
13/1/94
031221
MRS:03/12/14

Prof
DrdrAndiAs
adul Islam
Sp.BS

S:NyeriTungkaibaw
ah
O:KUsedang/GC/Sa
qdar pupil isokor
Kekuatan
55
22
Sensibilitas
NN

Pro operasi
removal tumor
tgl 24/12/14
-Sesuaiterapi TS
Gizi
-RL 20 tpm
ceftriaxone/12ja
m
-ranitidin/8jam
-ketorolac/8jam
-dexamethasone
1amp/8jam
-Aff drain
Ondansetron
3x1 tab
Ranitidine 2x1
tab
Pro radioterapi
Sesuaitsradiolog
i

LAB 26/12/14
Wbc: 8.94
Rbc: 4.02
HB; 11.6
HCT; 32.9
PLT ; 284
NA/K/CL ;
133/4.2/9.6
SGOT/SGPT: 20/25
UR/CR: 18/0.4
GDS 117

Perawatan post
op
NaCl 20 tpm
Cefadroxil
2x500
Ranitidine 2x1
As mefenamat
3x1
Terapi lain
sesuaits.HOM
Fisioterapi

LAB 25/12
WBC:11.91
RBC:3.67
SGOT:20
Hb:10.6
Sgpt:25
Hct:32,6
Ur:14
Plt:335
Pt/apt :13.7/29.2
18/12/14
elektrolit:
140/2.9/104
got/gpt: 39/52
prot total:5.4

A:tumor sacrum

319
Andy Abdul
Majid
027961
15/12/73
MRS
26/9/14

Prof
DrdrAndiAs
adul Islam
Sp.BS

S:O:KUSedang
A:POH XIV removal
tumor

LAB 19/12/14
WBC:3,97
RBC:4,69
Hb:10,9
Hct:33,7
Plt:173
22/12/14
NA/K/CL :
132/3.8/98
GOT/GPT: 15/9
ALB 3.7
PROT TOTAL 5.9
GDS 125
UR/CR 21.3/0.5

alb: 4.0
ur/cr: 40/0.9
MSCT 6/11/14
Tumor metastase
intracranial dan
tanda2 hernia
cerebri
MSCT 13/11/14
Massa extra axial
parietal
sinistrasuggestif
meningioma
dengandestruksios
parietal
sinistraherniasisubfalci
ne

403
Hasnah
17/11/54
637355

DrNasrullah
Sp.BS

S: nyerikepala (-)
O:Kusedang/gizicuk
up/sadar
Pupil isokor
GCS 15
A:POH VI
Debridement
Fr.Clavicula

RL 28 TPM
Ceftriaxone
1gr/12jam
Ranitidin/8jam/i
v
Ketorolac/8jam/i
v
AffInfus

LAB
WBC:19.32
RBC:3.62
Hb:9.9
Hct:30.2
PLT 216
GDS 313
Ur/Cr 24/0.8
GOT/GPT 22/21
CT/BT 7/3
PT/APTT 15.8/24
INR 1,35
Elektrolit:
137/4.3/203

425
Hasnah

DrdrDjoko
WidodoSp
BS

S:Luka
O:Kusedang/GC/sad
ar
Pupil isokor
GCS 15
N:88x
P:20x
S:36,8
Post Debridement
Aff Implant

IVFD RL 28 tpm
Ceftriaxone
1g/12j/Iv
Metronidazole
0.5mg/8jam
PCT 500/8jam
Ranitidine
1amp/8j
Rawatluka/harid
enganprontosan
Konsulendodank
ardio

Lab 23/12/14
WBC:8,52
RBC:4,92
Hb:14,7
Hct:43,6
Sgpt:14
SGOT:26
Ur:26
Cr:0,8
GDS:71
Plt:201
Na/K/Cl
140/4.0/105
PT/APTT 15,7/36.7
CT/BT 8/3
Alb 5.6

426
Michael
Hanny
032379
16/3/96
MRS 27/12/14

Dr.Nasrulla
h,Sp.BS

S: nyerikepala
KU: sedang
GCS 15
Pupil isokor
A: Trauma
capitisringan

412
031268
JOHN KALVIN
2/3/1990
MRS:
15/12/14

Dr.Nasrulla
h,Sp.BS

A: Tumor
KepalaKondroma
metastasis keotak

424
Drg.Wahdania
31/12/77
020155
MRS:
30/12/14

DrNasrullah
,Sp.BS

S:Nyeritulangbelak
ang
O:Sedang/GC/CM
GCS 15
Pupil Isokor
A: Frakturkompresi
L1

PCC

RL 20 tpm
Ceftriaxone
1gr/12jam
Ranitidin
50mg/8jam
Ketorolac 30
mg/8jam
Aff Infus

WBC: 12.21
RBC: 5.3
HGB: 15
HCT: 44.5
PLT: 300
PT/APTT: 13.5/30.7
GDS: 82
Ur/Cr: 25/1
GOT/GPT: 24/9
MSCT kepala 27/12
Sugestifmultisinusi
tisddhematosinusit
is ?
WBC: 14.48
RBC: 4.28
HGB: 10.5
HCT: 32
PLT: 675
GOT/GPT: 34/16
Prot Total: 6.9
Alb: 3.9
Ur/Cr: 26/0.7
Elektrolit:
126/4.5/92

Lab 29/12/14
Elektrolit
133/4.3/106
CT/BT 8/3
PT/APTT 14.4/27.9
HBsAg (-)
GDS 170
Ur/Cr 34/0.6
GOT/GPT 46/22
Alb 4.8
WBC 9.42
RBC 4.22
HB 11.1
HCT 34.1
PLT 172
Foto Pelvis
Tidaktampakkelain
an
MSCT Lumbosakral
-Fraktur CV L1

425
SonycaManga
nde
02/06/1997
22/12/14

DrdrDjoko
WidodoSp
BS

S:
O:keadaanumumba
ik GCS E4M6V5
A:Tumor
Intracranial
VP shunt insitu

303
Bunging
Renggina
24/8/48
694553

Dr.Nasrulla
h Sp.BS

S:Nyerikepala
O: KU
Sedang/Sadar
55
55
A: Brain concussion
without decrease of
conciousness

Ranitidine
50mg/8j/iv
Progestrol
1000mg/iv
Phentoin
100mg/8j/iv
Neurobion
5000mg/iv
Mobilisasi
Gantikateter per
minggu

WBC:8,21
RBC:2,88
Hb9,5
HCT:27,7
PLT:389

28/12/14
WBC 20.9
RBC 4.61
HGB 13.7
HCT 40
PLT 204
GDS 110
Ur/Cr 34/1.10
GOT/GPT 51/29
Elektrolit 145/4.2/113
HBsAg Non Reaktif
CT/BT 8/3
PT/APTT 12.1/26.0
INR 1.00
CT Kepala 28/12/14
Tidaktampak lei
hipodensdanhipe
rdens
intracranial
Focal brain
athrophylovusfro
ntalis
Hiperostosisospa
rietaliskiri
FotoLeher AP Lat
Spondilosisservik
alis
Osteoporosis
FotoLumbosakral
Spondilosislumba
lis
Osteoporosis
Foto Pelvis
Osteoporosis
Foto Thorax
Cardiomegaly
disertai dilatation
aortae
Spondilosisthora
calis

Suspekfraktur
costa VIII
kananbelakang

320
Nurdin Salam
694951
8-4-1955

DR.Nasrulla
h,Sp.BS

S: Nyerikepala
O: KU :Baik
GCS 15
A: FBI

RL 28 tpm
Ceftriaxone
1gr/12jam
Ranitidin
1amp/8jam
Ketorolac
1amp/8jam

CT Scan Kepala
Frakturoszygomaticusdext
ra
-Multihematosinus
LAB 30-12-14
CT/BT : 7.00/3.00
PT/APTT 12.1/24.6
GDS 115
UR/CR 19/0.9
GOT/GPT 37/33
HBsAgReaktif
Elektrolit 145/3.9/110
RBC 4.4
HGB 13.3
HCT 38.4
PLT 182
WBC 11.6