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DR DR SYAHRUL, SP.S (K)
DR DR SYAHRUL, SP.S (K)
DR DR SYAHRUL, SP.S (K)
S (K)
MINA 1
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K2B2 Mahmud Pakeh, Nyeri kepala E4 SDH Kronik 29/10/2021 IV Citicoline 1 gr/12jam
Lk 73 thn M6 IV Mecobalamin 500mg/8jam
V5 HT Stage II HB : 12.2 IV Omeprazole 40mg/12jam
Raber Tgl masuk HT : 37 PO Stalevo 3x1
Pulmo 29/10/2021 Bronkitis Leu : 7.9 PO Diovan 1x160mg
B.Saraf Trom : 380 PO Flumucyl 3x200mg
Post Op Burhole KGDS : 142 IV Ceftriaxone 1gr/12jam
UR : 11 (3/11/21)
CR : 0.90 IV Novalgin 1amp/8jam
NA/K/ CL
137/3.80/107
PT/APTT 14,2/36,2
DDimer 480
AU 5,4
Dr. dr. SYAHRUL, Sp.S (K)
MINA 1
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
D Dimer 910
Dr. dr. SYAHRUL, Sp.S (K)
MINA 1
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K4B4 Munazir Ishak, Kelemhan E4 hemiparese dextra ec susp HB : 16,9 IV Citicolin 500mg/12jam Cek Lab lengkap
Lk, 47 th anggota gerak M6 stroke HT : 47 IV Paracetamol 1000mg/8jam senin
kanan V5 Leuko 8,9 Drip Perdipin tetrasi dose
Tgl masuk DM Tipe 2 Trom 267 Clopidogrel 1x75mg
4/11/2021 KGDS 318
Hipertensi Encephalopathy UR 35
CR 1,1
NA/K/ CL
144/4,3/108
Dr. dr. SYAHRUL, Sp.S (K)
MINA 1
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K5B4 Ishak, Lk, 39 Nyeri kepala E4 Severe headache + HB : 10,4 IV Metilprednisolon 125mg/12jam
tahun M6 hidrosefalus post VP Shunt HT : 31 IV Mecobalamin 500mcg/12jam
V5 Leu : 16,9 IV Omeprazole 40mg/12jam
Tgl masuk Riwayat hidrosefalus ec susp. Trom : 522 IV Citicolin 500mg/12jam
DPJP 2/11/2021 SOL Intrakranial KGDS : 118 IV Ceftriaxone 1gr/12jam
dr SY UR : 16
Post Repare VP Shunt CR : 0,7
NA 137
K 102
Cl 102
Albumin
PT
APTT
INR
D Dimer
Dr. dr. SYAHRUL, Sp.S (K)
MINA 1
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K6B6 Sulaiman kelemahan E4 Hemiparesis sinistra + paresis HB : 15,7 IV Piracetam 1200mg/12jam 3 POST DSA
Arsyad, Lk, 53th angggota M6 N VII XII sinistra sentral ec HT : 43 hari
gerak V5 Stroke Iskemik Leu : 12,8 IV Mecobalamin 500mcg/12jam
Tgl masuk Trom : 281 IV Omeprazole 40mg/12jam
Raber 1/11/2021 DM Tipe 2 KGDS : 225 Sc Lantus 0-0-10iu
IPD UR : 39 PO Atorvastatin 1x20mg
CR : 0,6
NA 140
K 4,4
CL 105
Dr. dr. SYAHRUL, Sp.S (K)
MINA 2
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K3B2 Cut Zainab, Pr, Nyeri kepala E4 Cephalgia kronis progresif + 2/11/2021 IV Metilprednisolon 125mg/12jam Head Ct Kontras (+)
44thn M6 Paresis N VII XII dextra IV Mecobalamin 500mg/12jam Hasil (-)
pandangan V5 sentral ec SOL Intracranial HB : 10,9 IV Ceftriaxone 1gr/12jam
ganda HT : 34 (2/11/2021)
Tgl masuk Leu : 8,9 IV Paracetamol 1000mg/8jam
Raber 02/11/2021 Trom : 374 PO Keppra 2x500mg
dr ES KGDS : 115 IV Omeprazole 40mg/12jam
UR : 29
CR : 0,6
NA/K/ CL
142/4.3/105
Dr. dr. SYAHRUL, Sp.S (K)
MINA 2
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K1B2 Mu Inah, pr, 50 Pusing E4 Cephalgia Kronis progresif + HB : 12,3 IV Citicolin 500mg/12jam
th berputar M6 Obs seizure ec sol intracranial HT : 35 IV Dexametason 5mg/8jam
V5 (post removal tumor) Leuko 8,6 IV Paracetamol 1000mg/8jam
Tgl masuk Trom 393 IV Diazepam (KP)
4/11/2021 KGDS 162 PO Keppra 2x500mg
UR 15 PO Amlodipin 1x10mg
CR 0,8 PO Valsartan 1x160mg
NA/K/ CL
143/4,1/114
Dr. dr. SYAHRUL, Sp.S (K)
MINA 2
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K7B1 Marliah, pr, 63 penurunan E4 penurunan kesadaran + HB : 13,1 Drip Nimodipin 2,1cc/jam Cek lab lengkap
th kesadaran M6 hemiparese dextra ec stroke HT : 38 IV Ceftriaxone 1gr/12jamn senin
V5 Leuko 14,1 (5/11/21)
Tgl masuk Trom 290 IV Citicolin 500mg/12jam
4/11/2021 KGDS 130 IV Pantoprazole 40mg/24jam
UR 68 PO Amlodipin 1x10mg
CR 1,7 PO Diovan 1x160mg
NA/K/ CL
141/4,1/105
Dr. dr. SYAHRUL, Sp.S (K)
MINA 2
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K7B5 Raihanum Nyeri kepla E4 130/8 Severe Headache ec SOL HB : 12,3 IV Metilprednisolon 125mg/12jam Konsul Bedah Saraf
Jannah, pr, M6 0 Intracranial dd/ HT : 37 IV Mecobalamin 500mcg/12jam
33thn V5 kistasubarachnoid Leu : 11,2 IV Omeprazole 40mg/12jam
Raber Trom : 309 PO Depakote 2x500mg
dr. ES KGDS : 95 PO Clobazam 1x10mg
Tgl masuk UR : 14
Raber 3/11/2021 CR : 0,5
bedah NA/K/ CL
saraf 142/4,2/110
Dr. dr. SYAHRUL, Sp.S (K)
MINA 2
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
ISO 2 Raihana, pr, kelemahan E4 Hemiparesis dextra ec Stroke HB : 13,3 THREEWAY Lab Lengkap senin
39thn angggota M6 Iskemik HT : 38 IV Citicolin 500mg/12jam
gerak kanan V5 Leu : 9,3 IV Mecobalamin 500mcg/12jam
Hipertensi stage 1 Trom : 312 PO Atorvastatin 1x20mg
Tgl masuk KGDS : 113 PO Clobazam 1x10mg
3/11/2021 UR : 16 Clopidogrel 1x75mg
CR : 1,00
NA/K/ CL
144/4,1/110
Dr. dr. SYAHRUL, Sp.S (K)
ZAMZAM 1
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K11 Adja gusti, Pr, Pusing E4 Paresis N. VII XII dextra HB : 12,2 IV Piracetam 12g/12jam Lab lengkap Senin
71th berputar M6 sentral ec stroke iskemik HT : 36 IV Mecobalamin 500mcg/12jam
V5 - Hipertensi stage 2 Leuko 6,4 PO Diovan 1x160mg
Trom 286 Sc Lovenox 0.6cc/12jam
Tgl masuk KGDS 110 (4/11/21)
4/11/2021 UR 17 PO AMlodipin 1x10mg
CR 0,7 PO Atorvastatin 1x20mg
NA/K/ CL
144/3,5/110
Dr. dr. SYAHRUL, Sp.S (K)
ZAMZAM 1
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K16 Husnawati, Pr, Sulit Menelan E4 Hemiparesis Dextra + Paresis 29/10/2021 IV Citicoline 1000mg/12jam MRI Kepala tgl
47thn M6 N VII XII dextra, Paresis N IX X IV Mecobalamin 500mg/12jam 11/11/21
V5 ec Susp Stroke Batang Otak HB : 13,0
DPJP HT : 40 IPD
IPD Tgl konsul DM Tipe 2 Leu : 10,2 SC Levemir 0-0-16iu
2/11/2021 Trom : 335 PO Diovan 1x80mg
KGDS : 484 PO Bisoprolol 1x2,5mg
UR : 36 PO Amlodipin 1x10mg
CR :1.0 PO Fluexetin 1x10mg
NA/K/ CL
140/4.40/104
TSHs 1,180
Free T4 20,85
Dr. dr. SYAHRUL, Sp.S (K)
ZAMZAM 2
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K10 Baktiar Rusli, Lk Penurunan E4 Hemiplegi dextra + afasia 25/10/2021 PO Nimodipine 4x60mg
57 thn kesadaran M6 global + paresis N VII dan XII HB : 14.7 PO Citicoline 1000mg/12jam
Vaf dextra sentral ec stroke HT : 41 PO mecobalamin 500mg/ 12jam
Tgl masuk hemoragik (ICH ganglia Leu :10.6 PO Omperazole 40mg/12jam
25/10/2021 basalis hemisfer serebri Trom : 289 PO Amlodipin 1x10mg
sinistra) KGDS :131
UR: 21
CR : 1.00
NA/K/ CL
142/4.40/110
Dr. dr. SYAHRUL, Sp.S (K)
ICCU
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
B3 Marniati, Pr, Penurunan E4 80/60 Penurunan kesadaran ec susp 05/11/21 IV Piracetam12gram/ 24jam (5
68thn kesadaran M6 hypoxic ischemia Hb : 16 hari)
V5 encephalopathy+ Syok Ht : 42 Iv mecobalamin 500mg/12jam
Raber kardiogenik (perbaikan) Tr : 149
Dr. SY Tgl konsul Leu : 21,4
06/11/21 Gds : 203
DPJP Ur/cr : 93/3,1
Cardio Na/k/cl :
134/5,0/107
Dr. dr. SYAHRUL, Sp.S (K)
RAUDAH 4
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K5B4 Junaidi bin Nyeri di leher E4 170/1 Tetraparses tipe UMN ec Fr. 23/10/21 23/10/21
usman, Lk, 46 th M6 00 Cervical 3 post trauma Hb : 17,1 Iv mecobalamin 500mg/12jam
V5 Ht : 48 Iv omeprazole 40mg/24jam
Raber Post Stabilisasi Posterior Tr : 238 Iv paracetamol 1 gr/8jam
Dr. SY Tgl mrs : Leu : 10,4 Iv ceftriaxon 1gr/12jam
23/10/21 Gds : 146 Amlodipin 1x10mg
DPJP Ur/cr : 0,5/18 Diovan 1x160mg
Ortho Na/k/cl : Gabapentin 3x300mg
145/3,7/108
Dr. dr. SYAHRUL, Sp.S (K)
Raudah 6
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K4A Cut Cadin, Pr, kelemahan E Penuriunan Kesadaran + HB : 10,5 IV Citicolin 500mg/12jam Head Ct Scan(+)
75thn angggota M Hemiparesis dextra + Paresis HT : 31 IV Mecobalamin 500mcg/12jam hasil (-)
gerak kanan V N VII XII dextra sentral ec Leu : 21,8
Stroke Iskemik Trom : 275
Tgl konsul KGDS : 222
4/11/2021 DM Tipe 2 UR : 38
CR : 1,2
Close fr Humerus dextra Pro NA/K/ CL
ORIF 144/4,1/110
Pneumonia
Dr. dr. SYAHRUL, Sp.S (K)
AQSA 1
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K7B1 Adam Naja, Lk, Kejang (-) E4 Obs. General Seizure ec dd/ HB : 8,4 IV Citicolin 100mg/12jam
21thn M6 Uremic Encephalopathy HT : 25
V5 Leu : 17,5
Tgl masuk CKD stage V On HD Reguler Trom : 208
DPJP 1/11/2021 KGDS :
IPD Anemia Sedang ec PSMBA UR :
CR :
NA 135
Raber
K 5,8
dr SY Cl 102
Albumin 2,5
PT 23,7
APTT 42,7
INR 1,72
Dr. dr. SYAHRUL, Sp.S (K)
RICU
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
Hamdan Matt, Nyeri E4 Covid-19 confirmed case HB : 10,4 IV Meropenem 1gr/8jam
Lk, 67 th Pinggang M6 dengan gejala berat+ hipoksia HT : 31 IV Furosemid 20mg/24jam
V5 perifer Leu : 16,9 IV Metylprednisolon
Trom : 522 125mg/24jam
DPJP Tgl masuk LBP dengan Radikular pain KGDS : 118 IV Omeprazole 40mg/12jam
Pulmo 1/11/2021 L1-L2, L2-L3, L3-L4, L5-S1 UR : 16
bilateral ec susp foraminal CR : 0,7
Raber stenosis NA 137
K 102
dr SY
Cl 102
Albumin
PT
APTT
INR
D Dimer
Dr. dr. SYAHRUL, Sp.S (K)
HCU
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
albumin 3,2
Dr. dr. SYAHRUL, Sp.S (K)
ZAMZAM 4
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K15 Nanda Putri M. E4 - Polineuropathy perifer ec. HB : 14,5 - Gabapentin 3x100 mg EMG 4 ekstremitas
Pr. 32 thn M6 dd. HT : 43 - Alprazolam 1x0,5 mg (malam)
V5 1. Hipertiroid Leuko 6,5
dpjp 2. DM tipe 2 Trom 334
IPD Tgl Konsul - KIPI KGDS 79
6/11/2021 - Hipertiroid ec. Grave UR 16
Raber Diseases CR 1,1
dr SY - DM Tipe 2 NA/K/ CL
- Susp. SLE 145/4,1/110
Dr. dr. SYAHRUL, Sp.S (K)
RAUDAH 4
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K7B6 Ataillah, Lk, 28 Nyeri kepala E4 1. Cephalgia post trauma EC HB : 14,5 Iv. Piracetam 1gr/8jam Toleransi OP Ringan
th M6 oedema cerebri HT : 43 sedang
V5 2. Fr lefort 2 + fr ZMC Leuko 6,5
dpjp Tgl Konsul 5NRS Trom 334
BP-RE 6/11/2021 KGDS 79
UR 16
Raber CR 1,1
dr SY NA/K/ CL
145/4,1/110
Dr. dr. SYAHRUL, Sp.S (K)
AQSA 3
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K4B4 Mawardiati 61 Kelemahan E4 Hemiplegi sinistra + paresis n HB : IV. Citicholine 1gr/12 jam pasang ngt
th anggota gerak M6 VII XII sinistra sentral + HT :
V5 paresis N IX, X bilateral EC Leuko head CT scan non
dpjp Tgl Konsul suspek recurrent stroke Trom kontras
IPD 6/11/2021 5NRS KGDS
Gangguan kognitif EC UR speech terapi
Raber demensia vaskular CR
dr SY NA/K/ CL fisioterapi pasif
DM tipe 2
latihan menelan
Hipertensi St 2
Aki St 3
Dr. dr. SYAHRUL, Sp.S (K)
ICCU
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD
K1B1 Zainuddin bin kebas kebas E 1. Neuropatik pain post HB : IV Mecobalamin 500 mcg/12 jam
Ahmad 51 th M chemotherapy HT : PO Gabapentin 1x300 mg(malam)
V 2. Ca colon Leuko
dpjp 3. Post colostomy closure Trom
B Digest Tgl Konsul KGDS
6/11/2021 UR
Raber CR
dr SY NA/K/ CL
Dr. dr. SYAHRUL, Sp.S (K)
HCU Medical
SUBJEKTIF
NO KAMAR IDENTITAS DIAGNOSIS LABORATORIUM TERAPI PLANING
Keluhan GCS TD