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Ward Report
Wednesday , May 3nd 2018

A. Patient transferred to other hospital : (-)

B. Patient died (-)
C. Patient treated in ICU :(8)
1. Amrina /Female/ 45 years old/ Day 1
S: (-)
O: A: ETT
B: SIMV PEEP 5 FiO2 50 % RR: 16 x/m SpO2 : 99%
C: TD: 106/70 mmHg HR: 90 x/m
D: GCS :DPO Isochoric pupil, Light Reflex +/+
E : Sinus Rhytm
F: Fluid Balance :
I : 1489 cc
O : 1817 cc
IWL : 319 cc
Total : - 647 cc/ 24 hour

Cranium Region:
I : Dry Gauze
Drain : 150cc/ 14 hours

A : SOL intracranium Post Craniotomy Tumor Removal POD I

P: - IVFD asering xx/minute

- Inj. Ceftriaxone 2 gr/24 hour IV
- Inj. Omeprazole 40 mg/24 hour IV
- Inj. Dexamethasone 10mg/24hours
- Morfin 10 mg/KgBB continous
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2. Nurdin/ Male / 73 Years old/Day 1

S: (-)
O: A: clear
B: O2 nasal kanule 5lpm RR: 18 x/m SpO2 : 99%
C: TD: 107/84 mmHg HR: 80 x/m
D: GCS : E4M6V5 15 Isochoric pupil, Light reflex+/+
E : Sinus rhytm
F: Fluid Balance :
I : 1675 cc
O : 1782 cc
IWL : 318 cc
Total : - 425 cc/24 Hour

Abdominal Region :
I: Dry Gauze

A : Aortic Abdominal Aneurism Post EVAR POD I

P :- IVFD Ringer fiundin gtt xx/m
- Ceftriaxone 2 g / 24 hour
- Omeprazole 40 mg/24 Hour IV
- Paracetamol 500mg / 8 hours IV

3. Ridwan bin yanir/ Male / 22 Years old/Day 5 (no improvement)

S: (-)
O: A: ETT
B: TPIECE 6L/m RR: 22 x/m SpO2 : 99%
C: TD: 124/75 mmHg HR: 70 x/m
D: GCS : E1M5VT 6T Isochoric pupil, Light reflex+/+
E : Sinus rhytm

F: Fluid Balance :
I : 3985 cc
O : 4356 cc
IWL : 520 cc
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Total : -891 cc/24 Hour

Left thorax region:

I :dry gauze (+)
Chest tube : production 10 cc/24 hour
Undulaion +
Air Buble –
Expiratory buble –

A : Bilateral pneumothorax post chest tube bilateral POD 3

P : - IVFD Asering gtt xx/m

- Ceftriaxone 2 g / 24 hour
- Omeprazole 40 mg/24 Hour IV
- Paracetamol 500 mg k/p
- Manitol 150 mg/8 Hour
- Sucralfat syr 30cc/8 hour PO
- Aff Right Chest tube

4. Rinto tornando/Male/ 20 years old/ Day 3 (Improvement)

S: (-)
O: A: ETT
B:Spont PEEP 5 FiO2 40% RR: 28 x/m SpO2 : 99%
C: TD: 136/82 mmHg HR: 106 x/m
D: GCS :E4M6VT Isochoric pupil, Light Reflex +/+
E : Sinus Takikardi
Lab 2-5-2018
Hb : 19,3
F: Fluid Balance : Leukosit : 29.000
Tromb : 390.000
I : 3845 cc Ht :39
O : 4231 cc Albumin :2,6
GDS : 80
IWL : 473 cc Ureum : 47
Kreatinin: 0.42
Total : -859 cc/ 24 hour
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A : Fire burn injury grade II AB TBSA 58% + susp. Traumatic inhalation

Post Debridement POD III

P: - IVFD asering xx/minute

- Ceftriaxon 2gr/24 hour
- Omeprazole 40 mg/24 hour IV
- Morfin 5 mg/KgBB continous

5. Sortio bin Karso/Male/69 years old/ Day 6 (No Improvement)

S: (-)
O: A: ETT
B: SIMV PEEP 5 FiO2 40 % RR: 24 x/m SpO2 : 99%
C: TD: 115/82 mmHg HR: 86 x/m
D: GCS :E4 M6 VT Isochoric pupil, light reflex +/+
E : Sinus Rhytm
F: Fluid Balance : Lab 29-4-2018
Hb : 12,3
I : 133 cc
Leuko : 12.600
O : 3184cc HT : 39
Trombo: 153.000
IWL : 196 cc BSS : 170
Ht : 39
Total : - 191 cc/24 hour
Na :160
K : 6,1
Cl :8
NGT : Greenish Ur : 220
Abdominal region: Cr : 3,39

I : Wet gauze
P: Soft
P: Tympani
A: Bowel sounds (+)

A : Gastric perforation post exploration laparotomy POD 7 + sepsis + AKI Rifle F +

hipoalbuminemia + hiperkalemia

P: - IVFD RL : aminofluid 1:1 gtt XXX/mnt

- Noradrenalin 0,2 mg/Kg BB
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- Morfin 10 mg/KgBB continous

- Dexmetomidin 0,4 mg / Kg BB cc
- Amiodaron 200 mg / 8 hour
- Paracetamol 1 g / 8 hour
- Insulin 20 IU / 30 cc
- Meropenem 2 gr/8 hour IV
- Omeprazole 40 mg/24 hour IV

6. Hermanto / Male / 45Years old / Day 2 (No Improvement)

S: (-)
O: A: ETT
B: SIMV PEEP 10 FiO2 40 % RR: 19 x/m SpO2 : 99%
C: TD; 133/63 mmHg HR: 70 x/m
D: GCS : DPO Isochoric pupil, Light reflex+/+
E : Sinus takikardia
F: Lab 2-5-2018
I : 1722 cc Hb : 11.7
Leuko : 22.900
O : 2404 cc Tromb : 270.000
Ht : 37
IWL : 325 cc Na :145
Total : -1007 cc/24 Hour K : 4.3

Colli region :
I :Dry gauze (+)

A : Medulla Spinalis Tumor V. Cervical 1-2 Post Laminectomy Tumor Removal

POD 2

P: - IVFD Asering gtt xx/m

- Meropenem 1gr/ 8 Hours IV
- Omeprazole 40 mg/24 HourIV
- Paracetamol 500 mg k/p
- Metyl Prednisolone 125 mg/ 8 Hours IV
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7. M. Korib /Male/ 35 years old/ Day 2 (No Improvement)

S: (-)
O: A: ETT
B: SIMV PEEP 5 FiO2 50 % RR: 16 x/m SpO2 : 99%
C: TD: 100/58 mmHg HR: 67 x/m
D: GCS :DPO Isochoric pupil, Light Reflex +/+
E : Sinus Rhytm
F: Fluid Balance :
I : 1489 cc
O : 1817 cc
IWL : 319 cc
Total : - 647 cc/ 24 hour

Cranium Region:
I : Dry Gauze

A : SOL intracranium Post Craniotomy Tumor Removal POD II

P: - IVFD asering xx/minute

- Inj Dexmetedomidin 0,2 mcgr/Kgbb/hours Continue
- Inj. Meropenem 1 gr/8 hour IV
- Inj. Omeprazole 40 mg/24 hour IV
- Inj. Dexamethasone 10mg/24hours

8. Tenti Komalasari / Female / 58Years old / Day 44 (No improvement)

S: (-)
O: A: ETT
B: SIMV PEEP 10 FiO2 80 % RR: 22 x/m SpO2 : 99%
C: TD; 134/79 mmHg HR: 114 x/m
D: GCS :E4MxVT : 4xT Isochoric pupil, Light reflex+/+
E : Sinus takikardia
F: Lab 23-4-2018
I : 1722 cc Hb : 10.0
Leuko : 13.00
O : 2404 cc Tromb : 422.000
Ht :28
Na :127
K : 3.3
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IWL : 325 cc
Total : -1007 cc/24 Hour

Colli region :
I :Dry gauze (+)

A : -Spinal Cord Stenosis V.Cervical 4-5

-Post Anterior Cervical Corpectomy Fusion POD 41

P: - IVFD Asering gtt xx/m

- Cotrimoxazole 960 mg/12 Hour via NGT
- Omeprazole 40 mg/24 HourIV
- Paracetamol 500 mg k/p
- Mecobalamin 500 mg/8 Hour via NGT
- Vit C 200 mg /12 hour
- N- asetilsistein 200 mg/ 8hour NGT

D. Patient treated in PICU : (3)

1. Muhammad Farid /Male/ 3 years old / Day 6 (Improvement)

S: (-)
O: A: Cleared , nasal kanul / 2 Lm
B:RR: 26 x/m SpO2 : 99%
C: HR : 112 x / m
D: GCS :E4M6V5: 15 Isochoric pupil, Light reflex+/+
E : Sinus takikardia
F:
I : 1321 cc
O : 1553 cc
IWL : 50 cc
Total : - 282 cc/24 Hour
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Cranium region:
I : dry gauze

A : ALL + ICH post craniotomy POD 6

P: - IVFD NaCl 0,9 % kecepatan : 50 cc / hour

- NS 3 % kecepatan 40 cc/8 hour
- Drip Midazolam kec 1 cc / hour
- Diet cair 3 x 100 cc
- Fenitoin 50 mg / 12 hour IV
- Curcuma 1 cth / 12 hour PO
- Zinc kids 20 mg / 24 hour PO
- Paracetamol 180 mg
- Ceftriaxone 1,5 gram / 24 hour IV
- Ampicilin 1 gram / 8 hour IV

2. Annisa Shiza Khaysa /8 months old / Day 2

S: (-)
O: A: Clear
B:RR: 22 x/m SpO2 : 99%
C: HR : 116 x / m
D: GCS :E4M6V5: 15 Isochoric pupil, Light reflex+/+
E : Sinus takikardia
F:
I : 672 cc
O : 786 cc
IWL : -164 cc
Total : - 282 cc/24 Hour

Cranium region:
I : dry gauze

A : PDA post PDA Ligation per thoracotomy

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P : - Ampicilin 250mg/8jam
- Cerftazidime 250mg/8hours
- Furosemid 4mg/8hours
- Captopril 5mg/24 hours
- Paracetamol 70mg/8hours

3. Satria Putra / 11 years old / Day 1

S: (-)
O: A: Clear
B:RR: 20 x/m SpO2 : 99%
C: BP: 101/67mmhg HR : 109 x / m
D: GCS :E4M6V5: 15 Isochoric pupil, Light reflex+/+
E : Sinus takikardia
F:
I : 475cc
O : 100 cc
IWL : -835cc
Total : - 282 cc/13Hour

Thorax region:
I : Dry gauze
Drain production 90 cc/13 hour

A : Ventricel Septal Defect Post Sternotomy + VSD closure + Repair ventricular

defect with prothese POD I

P : - IVFD D5 ¼ NS + KCL 25cc/ Hours Gtt X/m

- Morfine 28mg + Midazolam 84mg inside Dextrose 5%
- Cefuroxim 500mg/8hours
- Furosemid 20mg/12hours
- Captopril 2,5mg/12 hours
- Paracetamol 500mg/6hours
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H. Pasien dirawat di NICU: (-)