List pasien 29/11/19

IRINA A ATAS
A1.2 Tumbol Jeremiah/L/25th/708910 Kista kongenital Lab : 23/11/2019 Oksigenasi
frontal dekstra
MRS: 24/11/219 Leu : 12,3 Elevasi kepala 30
Fr. Clavicula derajat
DPJP: Prof. Dr. dr. Eko Prasetyo SpBS(K) dekstra 1/3 media Eri : 5,31
Analgetik
Fr. Zygoma Hb: 15,8
dekstra Antibiotik
Ht: 45,3
Mobilisasi
Tro: 251
Rencana APS
MCH: 29,8

MCHC : 34,9

MCV : 85,2

SGOT : 23

SGPT : 11

CI : 101,7

K : 3,99

Na : 143

A8.5 Agow Sandy/L/ 19 th/1707346 Vulus skizum Lab : 25/11/2019 Mobilisasi

 MRS : servikal + Ruptur Leu : 15 belajar duduk
duramater + Fr.
DPJP: Dr.dr. Eko Prasetyo,SpBS(K) Servikal II + Eri : 4,88 Antibiotik

S : Kelemahan anggota gerak kanan Ulkus dekubitus Hb: 14,9 Analgetik

grade.I
O: KU Cukup Kes E4V5M6 Ht: 41,5 Rawat luka

Tro: 318 Aff drain

MCH: 30,5

MCHC : 30,5

MCV : 85,1

SGOT : 29

SGPT : 34

CI : 99,1

K : 4,68

Na : 138

A9.4 Tumbol Noel/ L/ 5 th/708922 Fraktur Os Lab 24/11/19 Observasi

Frontal Dextra kesadaran
MRS: 24/11/2019 Leukosit 20.5
Antibiotik
DPJP: Prof. Dr. dr. Eko Prasetyo SpBS(K) Eritrosit 4.37
Analgetik
Hb 12.4
 S: Nyeri kepala Ht 34.9 Rawat
lukandebgan
O: Trombosit 446 salep
KU Baik GCS E4V5M6 MCH 28.5

R Frontal: Luka terawat MCHC 35.6

MCV 80

SGOT 40

SGPT 14

Ureum 26

Cr 0.3

PT12.9/14.2

INT 1,03/1,17

APTT 29/34.5

Na 141

K 3.29

Cl 99

A11.1 Mamuaya Risca/P/4th/709551 EDH regio Lab 28/11/19 Observasi tanda

temporal Sinistra peningkayan
MRS:28/11/19 Leukosit 10 TIK
DPJP Dr. dr. Maximillian Oley , SpBS(K) Eritrosit 4,33 Head of bed 30

Hb 12 Antibiotik

S: Nyeri kepala + Ht 33,6 Analgetik

O: GCS E4V5M6 Trombosit 251

Kepala : CA(-), pupil bulat isokor o 3mm, RC MCH 27,7

(+)
MCHC 35,7

MCV 77,6

SGOT 59

SGPT 39

Ureum 20

Cr 0.3

PT 12.6/15,4

INT 0,94/1,15

APTT 38,1/36.0
 IRINA A BAWAH
1 B3.1 Korompot Feraldi/L/15th/709038 Fr.depressed temporo Lab:25/11/2019 Oksigenasi
occipital dextra
Dr.dr. Eko Prasetyo,SpBS(K) Leu: 15,5 Elevasi head of bed
Vulnus laserasi 30
r.temporoparietal dextra Eri: 5,00
Rawat luka
S: Penurunan kesadaran Hb: 14,4
Antibiotik
O: Ht: 41,2
Analgetik
KU Cukup Kes E2V2M5 Trombo : 238

Pupilbulat isokor 3/3mm MCH : 28,9

R.temporooccipital dextra : Hematoma uk MCHC: 35,0

5x6cm
MCV: 82,5

Cl : 98,6

K : 3,79

Na: 138

2 B3.2 Sobarik Ateng/L/25th/708516 EDH Parietal Sinistra Lab:20/11/2019 l Elevasi Head of Bed
30O
 MRS: 20/11/2019 Fr. Basis cranii media Leu: 19,8 Oksigenasi

DPJP : Dr. dr. Maximillian Oley , SpBS(K) Pneumatocele Eri: 4,64 Rawat luka

S: Nyeri Kepala – Hb: 14,9 Antibiotik

O: KU: Baik Ht: 42,5 Analgetik

Kes E3V5M6 Trombo : 313 Mobilisasi

Pupil bulat isokor 3mm/3mm, RC +/+ MCH : 32,1

Reg. auricula dextra : Luka terawat + MCHC: 35,0

MCV: 91,7

Cl : 97,4

K : 3,17

Na 130

3 B3.3 Hendrik Takalumang/ L/21th/ 705482 Post craniectomi ec Lab:28/11/2019 Elevasi Head of Bed
EDH temporoparietal 30O
MRS : Dextra Leu: 17,3 Cek Hasil
CT Scan Oksigenasi via
DPJP: Dr. dr. Maximillian Oley , SpBS(K) Multiple ICH Eri: 3.55 kontrol trakeostomi
Hb: 10,8 Rawat luka
S : Penurunan kesadaran, Ht: 31 Antibiotik
O: Trombo : 552 Analgetik
 KU: berat MCH : 30,,6

GCS: E2V1M3 MCHC: 35,0

Pupil bulat isokor 3mm/3mm, RC +/+ MCV: 87,3

Region temporoparietal D: luka terbuka +, Cl : 91,3

teraba tulang +
K : 4,36
Region colli: trakeostomy +
Na : 133

4 B3.4 Makalunsenge Muhammad EDH Temporaparietal Lab 22/11/19 Oksigenasi

Fahrul/L/9th/708709 Dekstra
Leukosit 19,2 Elevasi head of bed
MRS: 22/11/19 Fr. Os. Temporal 30°
Sinistra Eritrosit 4,11
Dpjp: Dr. dr. Eko Prasetyo SpBS (K) Antibiotik
Hb 10,3
Analgetik
Ht 30,6
S: Nyeri kepala + Rawat luka
O: KU: cukup, ks: CM, GCS : E4M5V6 Trombosit 349

Pupil bulat isokor 3-3mm, RC +/+ MCH 25,1

R, temporal dextra : Hematoma MCHC 33,8

MCV 74,3

SGOT 35

SGPT 11
 Ureum 23

Cr 05

GDS 158

PT 15/15,2

INT 1,26/1,28

APTT 30,5/35,2

Na 129

K 4,01

Cl 95,7

5 B7.2 Rumeen Wiliam/ L/ 84 tahun/708362 SDH temporoparietal Lab 23/11/19 Observasi kedadaean
occipital Dextra + Fr.
MRS: 19/11/2019 Collum femur sinistra Leukosit 8,1 Oksigenasi

DPJP: Prof. Dr. dr. Eko Prasetyo SpBS(K) + parkinson Eritrosit 3,9 Antibiotik

Hb 12,5 Analgetik

S: nyeri kepala Ht 33,8 Terapi sesuai TS

orthopedi
O: Trombosit 178

KU;Cukup Kes E4V5M6 MCH 32,1

Pupil bulat isokor 3/3mm MCHC 37,0

 R.Supraorbital : Luka terawat MCV 86,7

R.Frontoparietooccipital :Luka terawat SGOT 23

SGPT 21

Ureum 61

Cr 1,1

GDS 242

6 B7.4 Sarempang Jekrianto/17th/L/709736 CKR + Vulnus Lab 01/12/19 Oksigenasi

Laserasi Regio Frontal
MRS: 01/12019 Dextra Leukosit 6,5 Antibiotik

DPJP: Dr. dr. Maximillian Oley , SpBS(K) Eritrosit 4,25 Cuci jahit luka

S Hb 12,0

O Kes Somnolen GCS E5V5M6 pupil Ht 33,0

isokor o 3mm
Trombosit 145
Regio: frontalis dextra luka terjahit o 4cm
perdarahan efektif (-) MCH 28,2

- retroorbita dextra hematoma (+) MCHC 36,4

MCV 77,6

SGOT 27
 SGPT 10

Ureum 32

Cr 0,7

GDS 97

7 B7.6 Raden Virlan/L/15th/709525 Cedera otak Ringan Lab 28/11/19 Cegah secondary
brain injury
MRS: 28/11/2019 Multiple Vulnus Leukosit 18,0
Ekskoriasi Atasi nyeri
DPJP: Dr. dr. Maximillian Oley , SpBS(K) Eritrosit 5,01
Rawa luka
Hb 14,5

Ht 42,6

Trombosit 256

MCH 29

MCHC 34,3

MCV 84,4

SGOT 30

SGPT 22

Ureum 27
 Cr 0,7

GDS 99

PT 13,5/15,4

INT 1,00/1,15

APTT 32,4/36

Na 129

K 4,

8 B7.7 Mamonto Andre/L/23th/709471 EDH parietal sinistra, SDH Lab 28/11/19 Observas kesadaran
parietal dextra
MRS: 28/11/2019 Leukosit 17,2 Head of bed 30derajat
+fr os nasal- Fr rima
DPJP: Dr. dr. Maximillian Oley , SpBS(K) orbital superior sinistra Eritrosit 3,91 Rencana operasi elektif

S: nyeri kepala (+) Hb 12,5

O: Gcs E3V5M6 Ht 35,8

Kepala : CA (-), pupik bulat isokor o 3mm, Trombosit 127

RC (+)
MCH 32

MCHC 35
 MCV 91,4

SGOT 33

SGPT 17

Ureum 17

Cr 0,8

GDS 139

PT 13,4/13,4

INT 0,,99/1,00

APTT 29,0/33,5

Na 136

K 3,6

Cl 99,9

9 8.1 Laoh Nuordin/65th/L/709633 CKR + Vulnus Eksoriasis Lab 29/11/19 Rawat luka

MRS: 29/11/2019 Leukosit 12,9 Oksigenasi

DPJP: Prof. Dr. dr. Eko Prasetyo SpBS(K) Eritrosit 5,48 Antibiotik

Hb 16,4 Analgetik
 S: Penurunan Kesadaran ajibat terjatuh, Ht 49,5 Elevasi head of bed
riwayat hipertensi (+) 30°
Trombosit 302
O: Cegah cedera otak
MCH 30,0
KU;Cukup Kes somnolent GCS E3V5M6
MCHC 33,2
Pupil bulat isokor 3/3mm
MCV 90,3
Kepala: Luka lecet 2cm
SGOT 30

SGPT 15

Ureum 41

Cr 1,3

GDS 105

10 B8. Derek Tobias/L/65th/709530 Subdural Hygroma Lab 28/11/19 Perbaiki KU

3 Frontoparietal sinistra
MRS: 28/11/2019 Leukosit 9,,5 Oksigenasi

DPJP: Dr. dr. Maximillian Oley , SpBS(K) Eritrosit 3,02 Antipiretik

S: penurunan kesadaran akibat KLL Hb 8,5 Antibiotik

O: GCS E3V5M6 Ht 24,3 Operasi elektif

 TD: 120/70 N:73 R:20 SB: 36,5 Trombosit 164

Pupil bulat isokor 3/3mm MCH 28,3

R. Frontal sinistra : Hematom uk 5cm MCHC 35,2

Luka terjahit uk 4cm MCV 80,4

SGOT 52

SGPT 16

Ureum 22

Cr 0,9

11 B9.7 Wenur Hokta/ L/ 48 tahun/708902 SDH Frontotemporal Lab 23/11/19 Rawat luka
sinistra
MRS: 24/11/2019 +Pneumatocele + Leukosit 21,5 Oksigenasi

DPJP: Prof. Dr. dr. Eko Prasetyo SpBS(K) Fr.segmental os Eritrosit 4,58 Antibiotik
frontal + Fr.
Zygomamaxillary Hb 13,0 Analgetik
complex
S: nyeri kepala Ht 39,2 Elevasi head of bed
30°
O: Trombosit 337
Debridement
KU;Cukup Kes E4V5M6 MCH 28,4

Pupil bulat isokor 3/3mm MCHC 33,2

R.Supraorbital : Luka terawat MCV 85,6

R.Frontoparietooccipital :Luka terawat SGOT 30

SGPT 15

Ureum 30

Cr 0,8

GDS 101

PT 14,5/14,2

INT 1,21/1,17

APTT 29,7/34,5

Na : 137
 IRINA A TERATAI
1 2.14 Ivan Roti/L/ 15 th/708988 Fr.Lefort II PT 13.1/14.2 Oral hiegiene

MRS : 25/11/19 Fr. Mandibula INR 1,05/1.17 Oksigenasi

sinistra
DPJP: Dr.dr. Maximillian Oley, SpBS(K) APTT 27.2/34.5 Antibiotik

S : Nyeri kepala Analgetik

O: Ku baik , Kes : E4V5M6 Na 136 Elevasi head of

bed 30°
Pupil bulat isokor 3/3mm RC+ K 3.99

R.periorbital dextra : Hematoma + Cl 97.4

Leukosit 27

Eritrosit 5.94

Hb 14.8

Ht 43.6

Trombosit 302

MCH 24.9

MCHC 33.9
 MCV 73.4

SGOT 51

SGPT 44

Ureum 21

ICU BAWAH
1 ICU Bed Tampah Joseph/L/71 th/705266 Post craniectomy Lab 22/11/19 -analgesik
8 MRS: 18/09/19 decompresi ec Leu 17.7
SDH Eri 3.55 -antibiotic
Hb/Ht : 12.4/37.2 Mobilisasi
DPJP: Dr.dr. Eko Prasetyo,SpBS(K)
Netro.Bat : 5
Rawat luka
MCV 104.7
S: Penurunan kesadaran Elevasi head of bed
O: KU: sedang, GCS : E1M2V2 Trombosit 412 30°
MCH 34.8

MCHC 33.3
2 ICU bed Fano Rindengan /L/43th/707928 Post kraniektomi 25/11/2019 Observasi TIK
12 ec ICH Frontal + Leu : 18.9
MRS :16/11/2019 SDH regio Eri : 2.81 Antibiotik
temporal Hb : 8.9 Analgetik
Ht : 24,7
DPJP: Dr.dr. Maximillian Oley, SpBS(K)
Tro :480

S: - MCH 31,7

O : GCS :E2M3V5 MCHC 36,1

MCV 87,8

3 Bed 3 Egbert mansye/P/66thn/708887 Post craniectomi Leukosit 13,2 Rawat luka

dekompresi ec
MRS:23/11/2019 SDH Eritrosit 3,16 Antibiotik
frontoparietotemp Hb 10,2 Analgetik
oroocipital sinistra
Dpjp: Dr. dr. E. Prasetyo, SpBS (K) Ht 28 Oksigenasi

Tromboit 228

MCH32,1

MCHC 36.2
 MCV 88.7

SGOT 712

SGPT 638

Albumin2,77

PICU

Potabuga EDH 25/11/19

Ersa/L/16th/709022 Frontal
Dekstra Leukosit
MRS: 25/11/19 15,7
SAH
DPJP : Dr. dr. Eko Eritrosit
Prasetyo SpBS (K) Fr. Zygoma 4.14
D
Hb 11,6
Fr.
S: Penurunan Semental Ht 33
Kesadaran Mandibula Trombosit
O: E1M3B2R1 166
MCH 228

MCHC 35

MCV 79

SGOT 1,998

SGPT 1,035

Ureum 23

Cr 0,9,

GDS 187

PT 25,1/12,5

INT 2,5/0,99

APTT
27,1/35,4

Na 144

K 2,91

Cl 102,0
 HCU
1 2.14 Sondakh Joshua Wuisan/L/ 17 th/709099 Post Craniotomy Lab 28/11/19 Cek Lab lengkap
Decompression +AGD
MRS : 25/11/19 e.c Epidural Leuko: 10,3 (terlampir)
DPJP: Dr.dr. Eko Prasetyo,SpBS(K) Hematoma regio Eritrosit 3.08
frontoparietal Konsul rehab
S : On Sedasi sinistra hari ke-II Hb 9,0 medik

O: Regiofrontroparietal sinistra : Tampak luka Ht 25,3 Antibiotik

terawat Antipiretik
Trombosit 221
Drain: 75cc Hemorargik Ts lain sesuai ts
MCH 29.4
Kes : HCU
MCHC 35,7

MCV 82,2

SGOT 39

SGPT 18

Ur 33

Cr 0.9

Gds : 139

Cl : 100,1

K : 3,69
Na : 139