ASSALAMUALAIKUM WARAHMATULLAHI WABARAKATUH

SELAMAT MALAM DOKTER

MENYAMPAIKAN KONDISI RUANGAN BEDAH SARAF :

RABU, 10 AGUSTUS 2022

ICU

BED 4

TN. ABDUN/L/38TH/11546232

MRS : 5/08/2022

DX : + CVA ICH BASAL LOBARIS FP D VOL. 35CC + IVH + HYDROCEPHALUS NON COMMUNICANS
+SUSP DAVF ( TN. ABDUN/L/38TH/11546232)

TX : + POST TDE ICH + ICP KOCHER S (07/08/2022)

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

BED 10

TN. HARI MULYADI/L/61TH/11546207

MRS : 5/08/2022

DX : DOC DT CVA ICH PONS + HYDROCEPHALUS + EDEM CEREBRI + HT ST II ( TN. HARI

MULYADI/L/61TH/11546207)

TX : POST EVD KOCHER D (6/8/2022)

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

BED 11

TN. SUTRISNO/L/46TH/11472492

MRS : 6/08/2022

DX : + DOC DT CVA ICH SUBORTEX S + BRAINSTEM + IVH + MALPOSISI VP SHUNT KOCHER D + HT

STAGE II + EDEMA CEREBRI + HIDROCEPHALUS ( TN. SUTRISNO/L/46TH/11472492)

TX : POST CITO REVISI VP SHUNT KOCHER D + TDE ICH (07/08/2022)

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

CISADANE (AKut)

BED 6

TN M. YAZID/L/55TH/11546250

MRS : 6/8/2022

DX : + OBS. TTT + MONOPARESE EXTREMITAS INFERIOR D EC SUSP SCI ASIA D DD LUMBOSACRAL

PLEXUS INJURY + CKR + SDH TIPIS REGIO PARIETAL D + CH FRONTAL D + EDEM CEREBRI + OPEN
WOUND REGIO SUPRAORBITA + MULTIPLE ABRASIO REGIO FASIALIS( TN M.
YAZID/L/55TH/11546250)

TX : + POST DEBRIDEMENT + PRIMARY CLOSURE LA (06/08/2022) + URGENT MRI LUMBOSACRAL

TANPA KONTRAS (11/08/2022)

DPJP : DR.MED.DR.TAL, SPBS(K)

BED 10

TN. SALI/L/62TH/11546258

MRS : 6/08/2022

DX : + CKR 356 + FRAKTUR BASIS CRANII + BURST LOBE PARIETAL S 10 CC + CH REGIO FRONTAL
BILATERAL + SAH + EDEM CEREBRI + FR. LINIER TEMPOROOCCIPITAL S (TN. SALI/L/62TH/11546258)

TX : + NON OPERATIVE MANAGEMENT + CT SCAN BILA TERJADI PENURUNAN GCS > 2 POINT

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

BED 13

TN. RAGIA GUNAWAN/L/48TH/11546450

DX : + CKR 456 TANPA PERDARAHAN INTRAKRANIAL + SUBDURAL HYGROMA FRONTOTEMPORAL

D/S + MULTIPLE FRACTURE COSTAE 3,4,5 POSTERIOR S + MULTIPLE FRACTURE COSTAE 3,4,5,6
POSTERIOR D + CONTUSIO PULMONUM S + MILD ARDS (TN. RAGIA GUNAWAN/L/48TH/11546450)

TX :

BS : + NON OPERATIVE MANAGEMENT + CT SCAN KONTROL BILA GCS TURUN >2POINT

BED 19

NY. SANI/P/67TH/11542123

MRS 8/8/2022
DX : CKR 456 TANPA PERDARAHAN INTRAKRANIAL + STITCHES WOUND REGIO OCCIPITAL + TOTAL
BOWEL OBSTRUCTION DT SUSP ADHESI POST HEMICOLECTOMY D DT CA CAECUM T4BN1M1 (PARU)
+ HIPONATREMIA + ANEMIA (NY. SANI/P/67TH/11542123)

TX : + NON OPERATIVE MANAGEMENT

DPJP : DR.DR.MED.TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

7HCU(akut)

BED 3

BY. FATIMATUZ ZAHRO/P/1BULAN 20HARI/11546233

MRS : 5/08/2022

DX : + SEIZURE DT ICH FRONTOPARIETAL S + SDH FRONTOTEMPORAL S + SAH + HYDROCEPHALUS

NON COMMUNICANS + EDEM CEREBRI ( BY. FATIMATUZ ZAHRO/P/1BULAN 20HARI/11546233)

TX : + EVD KOCHER D + CRANIOTOMY EVAKUASI ICH + DEKOMPRESI (BONE FLAP SUBGALEA)

(07/08/2022)

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

BED 5

AN. ALMEERA CETTA ZEVANNA/P/8TH/28KG/11536009

DX : + VENTRIKULITIS DD SEVERE HYDROCEPHALUS ON PATENT VP SHUNT KOCHER D ET S + RIW

TREPANASI DT ABSES CEREBRI + GLOMERULAR DISORDER IN SYSTEMIC CONNECTIVE TISSUE
DISORDER (LUPUS NEFRITIS) + HIPERTENSI STAGE II ON TREATMENT + OBSERVASI SEIZURE +
PNEUMONIA + POST ENDOSCOPIC EXPLORATION + IRIGASI + SEPTOSTOMY SEPTUM PELUSIDUM +
REVISI SHUNT KOCHER DEXTRA (19/05/2022) + POST EVD KOCHER D/S (03/08/2022) + POST
INFECTION MULTILOBULATED HYDROCEPHALUS (AN. ALMEERA CETTA
ZEVANNA/P/8TH/28KG/11536009)

PLAN : ENDOSCOPIC SEPTOSTOMY DAN VP SHUNT KOCHER DEXTRA

DPJP : DR. DR. FAR, SPBS-PED(K), FICS

BED 8

AN M IRWANSYAH/L/1 TH/8,5 KG/11514547

KONSULAN : 30/7/2022

DX: + OBS VOMMITING DT HIDROCEPHALUS ON UNPATENT VP SHUNT KEEN S + PNEUMONIA +

GLOBAL DEVELOPMENT DELAY + HIDROCEPHALUS( AN M IRWANSYAH/L/1 TH/8,5 KG/11514547)
TX + POST ENDOSCOPIC SEPTOSTOMY DAN VP SHUNT KEEN DEXTRA, AFF SEMUA SHUNT LAMA
(09/08/2022)

DPJP : DR. DR. FAR, SPBS-PED(K), FICS

CILIWUNG (AKUT)

BED 8

SDR. ROHMAD NUR CAHYO/L/25TH/11546446

DX : + COB 223 + EDEMA CEREBRI + SUBDURAL HYGROMA FRONTOTEMPORAL S + SAH + FR MAXILLA

S NON LEFORT + FR SPHENOZYGOMA S + FR FRONTOZYGOMA S + FR SPHENOID S + FR OS NASAL +
MULTIPLE ABRATIO REGIO FASCIALIS (SDR. ROHMAD NUR CAHYO/L/25TH/11546446)

TX : + NON OPERATIVE MANAGEMENT + CT SCAN EVALUASI 2X24 JAM ATAU BILA GCS TURUN >2
POIN

DPJP : DR.DR.MED.TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

MAHAKAM (AKUT)

BED 6

TN SANDI DWI KURNIAWAN/L/24TH/11544111

DX : + PNEUMONIA HAP + COB 224 + ICH BURST LOBE REGIO FRONTOBASAL + FR ANTERIOR ET
POSTERIOR WALL SINUS FRONTAL + FR. DEPRESSED OS FRONTAL S + FR. LINIER OS PARIETAL S +
DIASTASIS SUTURA CORONARIUS S + FR. MAXILLA NON LEFORT D ET S + FR. NOE D TIPE 1 + FR. ZMC
S + PNEUMONIA ( TN SANDI DWI KURNIAWAN/L/24TH/11544111)

TX :

TDE ICH BURSTLOBE + ICP + DEKORTIKASI+ CRANIALISASI + DEKOMPRESI (17/07/2022)

DPJP : DR. DR. FAR, SPBS (K)-PED, FICS.

BED 8

NY. MISNATI/P/57TH/11545723

MRS : 02/8/2022

DX : +DOC DT CVA ICH CAPSULA INTERNA S VOL. 9 CC +IVH +HHD +MODERATE HYDROCEPHALUS
+SEVERE HIPONATREMIA + POST EVD KOCHER D/S (03/08/2022)( NY. MISNATI/P/57TH/11545723)

PLAN : PRO AFF EVD SWITCH TO VP SHUNT KOCHER D ( 11/08/2022)

DR.MED.DR. TOMMY A. NAZWAR, SP-SPINE(K), FINSS, FINPS, FICS.

NICU(AKUT)

BY. NY. WIWIK/P/50HARI/1455GR/11543301

KONSUL : 1/08/2022

DX : + PRETERM/ BBLSR + NEONATAL PNEUMONIA + MEDICAL NEC + AKI ST RISK + LATE ONSET
SEPSIS + DE : PJB ASIANOTIK + DA : SUSPEK ASD + DF : KOMPENSATA + PERIVENTRIKULAR
LEUCOMALACIA + SEVERE COMMUNICATING HYDROCEPHALUS + NEONATAL SEIZURE( BY. NY.
WIWIK/P/50HARI/1455GR/11543301)

TX : POST ETV ( 10/08/2022)

DPJP : DR. DR. FAR, SPBS(K)

RINJANI (15)

BED 8

AN.ERLANGGA BAGUS/L/3,5TH/11KG/11439301

MRS : 05/08/2022

DX : TETHERED CORD IDIM T9 - T12 + TUMOR IDEM L1-L4--> POST EKSISI LIPOMYELOCELE + RELEASE
TETHERED CORD (08/08/2022)( AN.ERLANGGA BAGUS/L/3,5TH/11KG/11439301)

TX : POST EKSISI LIPOMYELOCELE + RELEASE TETHERED CORD (08/08/2022)

DPJP : DR.DR.MED.TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

BED 13

AN. AKBAR/5BULAN/5.3 KG/115333214/RINJANI

DX : + HYDROCEPHALUS NON COMMUNICANS EC STENOSIS AQUEDUCT POST SHUNT KOCHER D +

INFECTED SHUNT + VENTRICULITIS + RIWAYAT LOW LEVEL BOWEL OBSTRUCTION DT SUSP. ADHESI
DT SUSP. SHUNT INFECTION + POST AFF SHUNT SWITCH TO EVD (27/7/2022) + POST AFF EVD + ETV
DOUBLE SET UP VP SHUNT KOCHER D--> PRO VP SHUNT KOCHER D (11/08/2022)( AN.
AKBAR/5BULAN/5.3 KG/115333214/RINJANI

TX : PRO VP SHUNT KOCHER D (11/08/2022)

DPJP : DR. DR. FAR, SPBS (K)-PED, FICS.

GALUNGGUNG 18

BED 15

NY SUMIATI/P/52TH/10758915

MRS : 3/08/2022

DX : + CKR 456 + CHRONIC CEPHALGIA + SDH SUBAKUT FRONTOTEMPOROPARIETAL D +

CONTUSIONAL HAEMORRHAGE FRONTAL D + SAH + EDEMA CEREBRI--> POST BURHOLLE DRAINAGE
2 LUBANG 1 SISI (09/08/2022)( NY SUMIATI/P/52TH/10758915)

TX : POST BURHOLLE DRAINAGE 2 LUBANG 1 SISI (09/08/2022)

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

LAWU 19

BED 8

TN. PUJIONO/L/42TH/11541680

MRS : 4/08/2022

DX : + CARCINOMA NASOFARING T4N2CMX + MILD HYDROCEPHALUS + SOFT TISSUE TUMOR REGIO

PARIETAL S + HIPOALBUMINEMIA--> PRO URGENT VP SHUNT KOCHER D + NE BNF GA JOIN OP THT +
DEBRIDEMENT + BIOPSI TUMOR JOIN OP PLASTIK(TN. PUJIONO/L/42TH/11541680)

TX : + PRO URGENT VP SHUNT KOCHER D + NE BNF GA JOIN OP THT + DEBRIDEMENT + BIOPSI

TUMOR JOIN OP PLASTIK

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

BED 20

TN. SI'I/L/81TH/11546270

DX : + DOC DT SOP CEREBRI + HEMIPARESE D--> NON OPERATIVE MANAGEMENT + MRI KEPALA
KONTRAS(TN. SI'I/L/81TH/11546270)

TX : + NON OPERATIVE MANAGEMENT + MRI KEPALA KONTRAS

DPJP : DR. DR. MED. TOMMY A NAZWAR, SPBS-SPINE (K),FINNS,FINPS,FICS

MENINGGAL
SDR. HANDRI OKTA/L/17TH/11545716

MRS : 02/8/2022

DX : + OBS TTT + COB 213 + SDH FRONTOPARIETAL D + CONTUSIONAL HEMORRHAGE FRONTAL S +

DURRET HEMORRHAGE + CEREBRAL EDEMA + STITCHED WOUND REGIO FRONTAL D + STITCHED
WOUND REGIO LABIALIS ORIS SUPERIOR + CLOSE DEGLOVING REGIO SHOULDER D + CF R SCAPULAR
BODY + R AC & CC JOINT DISRUPTION + CF PROXIMAL SHAFT R RADIUS ULNA + OF MIDDLE SHAFT R
FEMUR GR. IIIA + OPEN DEGLOVING R THIGH + OF HEAD R 2ND METATARSAL + OF HEAD R 3RD
METATARSAL + CF BASE R 4TH METATARSAL + OF PROXIMAL PHALANX R 3RD TOE

TX : + POST ICP KONTRALATERAL (02/08/2022)

DPJP : DR. MED. DR. TOMMY A. NAZWAR, SP-SPINE(K), FINSS, FINPS, FICS

PAPS

TN. ABDUL ROCHMAN/L/37TH/11546271

DX : + CKR 456 + EDH OCCIPITAL D + FR LINIER OCCIPITAL D

TX : + NON OPERATIVE MANAGEMENT

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

POLIKLINIS

TN. NURALIM/L/61TH/10635406

MRS : 9/08/2022

DX : + DOC DT CVA THALAMUS S VOL. 60CC + IVH

TX : + TDE ICH + ICP KONTRALATERAL (KELUARGA MENOLAK)

DPJP : DR. DR. FAR, SPBS-PED(K), FICS.

BED 30

MR. ZAINUR ROZIKIN/L/33TH/11546469

MRS : 9/08/2022

DX : + OBS TTT + CKR 456 + OPEN WOUND LABIA ORIS INFERIOR S + OPEN WOUND GINGGIVA
SUPERIOR + DENTAL AVULSI INCISIVUS 1 KIRI ATAS + SUSP. CLOSED DEGLOVING REGIO FEMUR D/S
POSTERIOR + OBS. TTA + R PEDICLE FRACTURE VERT THORACAL 12 + CF R PROXIMAL HUMERUS
NEER TYPE III + VULNUS LACERATUM POSTERIOR SIDE L ELBOW + OPEN WOUND ANTERIOR SIDE R
KNEE WITH SUSP. PARTIAL PATELLAR TENDON RUPTURE + CF SUPERIOR INFERIOR R RAMI PUBIS +
OPEN DEGLOVING WOUND DORSAL SIDE R FOOT WITH SUSP. TOTAL RUPTURE EDL & EDB 2,3,4,5 &
PERONEUS TERTIUS TENDON + MULTIPLE VULNUS LACERATUM LATERAL SIDE L FOOT + MULTIPLE
VULNUS ABRASION ANTERIOR SIDE R LOWER LEG & L FOOT

TX : + NON OPERATIVE MANAGEMENT

DPJP : DR. DR. FAR, SPBS-PED(K), FICS.

NY. MARIATIN/ P/67TH/ 11545732

MRS : 07/08/2022

DX : + DOC DT CVA SAH + IVH + SDH + ANEURISMA FUSIFORM ACM M1 D + HT ST II +

HYDROCEPHALUS + HIPOKALEMIA

TX : + POST VP SHUNT KOCHER D (08/08/2022)

DPJP : DR. DR. MED. TOMMY A NAZWAR, SPBS-SPINE (K),FINNS,FINPS,FICS

TN. GIGIH PRASETYO/L/33TH/11546317

DX : + CKR 456 TANPA PERDARAHAN INTRAKRANIAL + INTERNAL BLEEDING HD STABIL + MULTIPLE

VULNUS ABRASIO REGIO FACIALIS + SUPERFICIAL MID DERMAL BURN INJURY REGIO EKSTREMITAS
SUPERIOR S 1% + R PROCESSUS TRANSVERSUS FRACTURE VERT LUMBAL 3,4,5

TX : + NON OPERATIVE MANAGEMENT

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

NY. AISYAH/P/74TH/11546551

MRS : 9/08/2022

DX : + CKR 456 TANPA PENDARAHAN INTRACRANIAL + OPEN WOUND REGIO NASAL

TX : + NON OPERATIF MANAGEMENT

DPJP : DR. DR. FAR, SPBS-PED(K), FICS.

TN. LUQMAN HAKIM/L/30TH/11546557

MRS : 9/08/2022

DX : + HEMATOM THORACOLUMBAL DD SUSP. CLOSED DEGLOVING REGIO TORAKOLUMBAL + OBS

TTT + OBS TTA + CKR 456 TANPA PERDARAHAN INTRAKRANIAL + FRACTURE DISLOCATION VERT
LUMBAL 4-5 ASIA B

TX : + NON OPERATIVE MANAGEMENT

DPJP : DR. DR. FAR, SPBS-PED(K), FICS.

SDR BAYU SAMUDRA/L/21TH/11546275

DX : + CKR 456 TANPA PERDARAHAN INTRAKRANIAL + ODEM CEREBRI + OPEN WOUND

FRONTOPARIETAL S + OPEN WOUND REGIO ORIS S

TX : + POST DEBRIDEMENT + PRIMARY HECTING PER GA (07/08/2022)

DPJP : DR. DR. MED. TOMMY A NAZWAR, SPBS-SPINE (K),FINNS,FINPS,FICS

KRS

NY. LIES WIDODO/P/88TH/11307680

MRS : 6/08/2022

DX : + CKR 456 TANPA PERDARAHAN INTRAKRANIAL + FR. RIMA ORBITA INFERIOR S + FR. ZMC S + CF
L BASE 4TH + 5TH METACARPAL + R ANKLE SPRAIN GRADE II

TX : + NON OPERATIVE MANAGEMENT

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

AN. ARSHAKA/L/2TH/15KG/11546272

MRS : 6/08/2022

DX : + CKR 356 TANPA PERDARAHAN INTRAKRANIAL + EDEMA CEREBRI

TX : NON OPERATIVE MANAGEMENT

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

NY. MELIANTI/P/56TH/11545507

MRS : 1/08/2022

DX : + OBS TTT + AXIAL PAIN EC INCOMPLETE BURST FRACTURE VL 4 AO SPINE A3 ASIA E

TX : NON OPERATIVE MANAGEMENT + PAIN MANAGAMENT + KONSUL REHAB MEDIK PEMASANGAN

TLSO

DPJP : DR.DR.MED.TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

AN. M. FATIH/L/4,5TH/14,6KG/11546449

DX : + CKR 456 TANPA PERDARAHAN INTRAKRANIAL + MULTIPLE OPEN WOUND REGIO PALPEBRA
INFERIOR D + OPEN WOUND REGIO PALPEBRA SUPERIOR D
TX : + NON OPERATIVE MANAGEMENT

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

SDR. EKO PRASETYA/L/28 TH/11546301

DX : + OBS TTA + CKR 456 TANPA PERDARAHAN INTRACRANIAL

TX :

DIGESTIF : + NON OPERATIVE MANAGEMENT

B. SARAF : + NON OPERATIVE MANAGEMENT

DPJP : DR. DR. MED. TAL,SPBS-SPINE (K),FINNS,FINPS,FICS

TERIMA KASIH DOKTER