Professional Documents
Culture Documents
2014
ICU
BED 2
ABD. RAUF
1/7/1956
677206
MRS: 25/8/14
AAI
S: O: KU: Lemah
GCS 7x(E2M5Vx)
tracheostomy
Pupil isokor 2.0/2.0
RCL +/+
A: POH XX Craniotomy
e.c SDH Frontobasal D
+ ICH
Lab (6/9/2014) :
HGB 10.2
WBC
24.3
RBC
3.37
PLT
879000
GDS
170
Ur
46
CR
0.50
GOT
116
GPT
201
Alb
2.9
Na
140
K
4.2
Kl
100
Foto thoraks AP (27/8/14) :
Pulmo normal
Dilatatio et elongatio aortae
CT-Kepala:
Pendarahan intracerebri
bilateral
Pendarahan subarachnoid
Bed 3
TASWIAH
10/5/1938
679928
MRS : 11/9/2014
WA
S : Kel (-)
O : Ku Lemah
GCS 9 (E2M5V2)
Pupil anisokor 2.5/2.0
RCL +/+
A : POH III
Craniectomy ec. ICH
Parietal Dextra
LAB 11/9/2014 :
HB
9.9
WBC 17.8
RBC 3.14
PLT 593000
GDS 132
GOT 40
GPT 44
Ur
19
Cr
0.40
Na
128
Ka
2.8
Cl
83
CT Scan Kepala Tanpa Kontras
11/9/2014
Perdarahan intracerebri
regio temporal Dextra
Hematosinus ethmoidalis
dan frontalis Dextra
Sinusitis sphenoidalis
Dextra
Foto Thoraks AP 11/9/2014
Cardiomegaly disertai
dilatatio, elongatio et
atherosclerosis aortae
Bed 5
SHADIQUL MUBIN
3-7-2000
678615
MRS : 2-9-2014
WA
S : (-)
O : Ku Lemah
GCS 10x (E4M6Vx)
Pupil isokor 2.5/2.5
RCL +/+
A : POH XI
Craniectomy ec. Fr.
Depressed Os. Frontal
Lab 6/9/2014:
HGB 9.8
RBC 3.18
WBC 6.4
PLT 103000
GDS 127
Ur
40
Cr
0.4
GOT 48
GPT 33
Na
139
K
4.5
Kl
110
Foto Thoraks AP 6/9/2014 :
Suspek kontusio paru sinistra
Foto
Cervical
(7/9/2014) :
Muscle Spam
AP/Lateral
BED 6
NATSIR KADIR
12/6/1980
676380
MRS: 23/8/14
WA
S: O: KU: Lemah
GCS 5x(E1M4Vx)
Pupil Isokor 2,5/2,5
RCL +/+
A: POH XXII
Craniectomy e.c SDH
Temporobasal S
Lab (9/9/2014) :
HGB 12.5
WBC 16.1
RBC
4.15
PLT
354000
GDS
169
Ur
36
CR
0.50
GOT
43
GPT
108
Na
129
K
3.3
Kl
103
Foto thoraks PA (18/8/14) :
Tidak tampak kelainan radiologik
pada foto thoraks ini
CT-Kepala (18/8/14) :
BED 10
IRAWATI
7/6/1971
678103
MRS: 29/8/14
NS
S: Kes.menurun
O: KU: Lemah
GCS 7x (E2M5Vx)
Pupil anisokor 3.0/2.5
RCL +/+
A: POH XV Craniotomy
e.c SDH
Temporoparietal dextra
Lab (8/9/2014) :
HGB 9.0
WBC 17.40
RBC 3.25
PLT 389000
GDS 91
Ur
28
CR
0.3
GOT 58
GPT 66
144
4.6
99
CT-Kepala (30/8/14) :
Herniasi Subfalcine
Hematosinus sphenoidalis
bilateral
Pneumonia Dextra
BED VIP 2
Sirajuddin
30/12/1993
S: Kel (-)
O: KU: Lemah
GCS 9x (E3M6Vx)
DW
679477
MRS: 9/9/14
BED VIP 3
Musfira
5/10/1998
678612
MRS: 2/9/2014
WA
S: (-)
O: KU: Lemah
GCS 3x (E1M2Vx)
Pupil isokor 4.0/4.0
RCL +/+
A: POH-IX
Craniotomy e.c EDH
regio frontal kiri
IVFD RL 28 TPM
Ceftriaxone 1 gr/12 jam
Ranitidin 1 amp/8 jam
Ketorolac 1 amp/8 jam
Head up 300
IVFD RL : DX (2:1) 20 tpm
Inj.Meropenem 1 gr/ 8 jam
Inj.Omeprazole 40 mg / 24
jam
GV + rawat luka / 2 hari
Terapi lain sesuai TS
Anastesi
LAB (9/9/2014)
HGB 12,9
WBC 10.3
RBC 4,16
PLT 77000
GDS 63
Ur
35
Cr
1.2
GOT 98
GPT 39
Na
153
K
3.3
Kl 116
Lab (10/9/2014):
Hb
8.8
RBC 3.24
WBC 13.46
PLT 39000
GDS 118
GOT 130
GPT 35
Alb 3.0
Ur
23
Cr
0.30
Na
163
K
2.9
Cl
115
Foto Thoraks AP (7/9/2104)
Cor dan pulmo dalam batas
normal
BED 2
Hamria
03-06-1966
521630
MRS: 06-09-2014
BED 8
Hawasia
NS
AAI
S: nyeri kepala
O: KU Sedang
A:post op tumor
intracranial
S: kel (-)
O: KU: Lemah
Lab (07-09-2014):
WBC 17,7 RBC 4,47 HGB 13,4
HCT 38,9 PLT 238 Na 144 K
4,1 Cl 96
Lab 12-9-2014
31-12-1960
472731
MRS: 10-9-2014
GCS 5x(E1M4Vx)
Pupil Isokor 2,5/2,5
RCL +/+
A: TCB GCS 6 + ICH
regio temporooccipital
kanan+prolonged
intubation
Post op tracheostomi dan
craniotomi
Hb 10.5
RBC 3.75
WBC 14,8
PLT 210
GDS 77
GOT 36
GPT 34
Albumin 2.1
Na 134
K 2.9
Cl 97