KORAN BEDAH SARAF SENIN 29 DESEMBER 2014

RSUH
411
Hayyong
028142
01/07/78
30/09/14

Prof
DrdrAndiAsad
ul Islam Sp.BS

S: (-)
O:Ku Sedang/GC/CM
Pupil isokor
GCS 15
PA:Pylositic astrocytoma
A:POH 5 removal tumor

406
Fadly
Muhammad
13/1/94
031221
MRS:03/12/14

Prof
DrdrAndiAsad
ul Islam Sp.BS

S:Nyeri Tungkaibawah
O:KU sedang/GC/Saqdar
pupil isokor
Kekuatan
55
22
Sensibilitas
NN

Pro operasi removal

tumor tgl 24/12/14
-Sesuaiterapi TS Gizi
-RL 20 tpm
-ceftriaxone/12jam
-ranitidin/8jam
-ketorolac/8jam
-dexamethasone
1amp/8jam

LAB 26/12/14
Wbc: 8.94
Rbc: 4.02
HB; 11.6
HCT; 32.9
PLT ; 284
NA/K/CL ; 133/4.2/9.6
SGOT/SGPT: 20/25
UR/CR: 18/0.4
GDS 117

Ondansetron 3x1
tab
Ranitidine 2x1 tab
Pro radioterapi
Sesuaitsradiologi

LAB 19/12/14
WBC:3,97
RBC:4,69
Hb:10,9
Hct:33,7
Plt:173
22/12/14
NA/K/CL : 132/3.8/98
GOT/GPT: 15/9
ALB 3.7
PROT TOTAL 5.9
GDS 125
UR/CR 21.3/0.5

Perawatan post op
NaCl 20 tpm
Cefadroxil 2x500
Ranitidine 2x1
As mefenamat 3x1
Terapi lain sesuai
ts.HOM

LAB 25/12
WBC:11.91
RBC:3.67
SGOT:20
Hb:10.6
Sgpt:25
Hct:32,6
Ur:14
Plt:335
Pt/apt :13.7/29.2
18/12/14
elektrolit: 140/2.9/104
got/gpt: 39/52
prot total:5.4
alb: 4.0
ur/cr: 40/0.9
MSCT 6/11/14
Tumor metastase
intracranial dan tanda2
hernia cerebri

A:tumor sacrum

319
Andy Abdul
Majid
027961
15/12/73
MRS
26/9/14

Prof
DrdrAndiAsad
ul Islam Sp.BS

S:O:KU Sedang
A:POH XVII removal
tumor

MSCT 13/11/14
Massa extra axial parietal
sinistrasuggestif
meningioma
dengandestruksios parietal
sinistraherniasisubfalcine

403
Hasnah
17/11/54
637355

DrNasrullah
Sp.BS

S: nyeri kepala (-)

O:Ku
sedang/gizicukup/sadar
Pupil isokor
GCS 15
A:POH IV Debridement
Fr.Clavicula

RL 28 TPM
Ceftriaxone
1gr/12jam
Ranitidin/8jam/iv
Ketorolac/8jam/iv

LAB
WBC:19.32
RBC:3.62
Hb:9.9
Hct:30.2
PLT 216
GDS 313
Ur/Cr 24/0.8
GOT/GPT 22/21
CT/BT 7/3
PT/APTT 15.8/24
INR 1,35
Elektrolit: 137/4.3/203

425
Hasnah

DrdrDjokoWid
odoSp BS

S:Luka
O:Ku sedang/GC/sadar
Pupil isokor
GCS 15
N:88x
P:20x
S:36,8
Post Debridement
Aff Implant

IVFD RL 28 tpm
Ceftriaxone
1g/12j/Iv
Metronidazole
0.5mg/8jam
PCT 500/8jam
Ranitidine 1amp/8j
Rawatluka/hari
dengan prontosan

Lab 23/12/14
WBC:8,52
RBC:4,92
Hb:14,7
Hct:43,6
Sgpt:14
SGOT:26
Ur:26
Cr:0,8
GDS:71
Plt:201
Na/K/Cl 140/4.0/105
PT/APTT 15,7/36.7
CT/BT 8/3
Alb 5.6

426
Michael Hanny
032379
16/3/96
MRS 27/12/14

Dr.Nasrullah,S
p.BS

S: nyeri kepala
KU: sedang
GCS 15
Pupil isokor
A: Trauma capitis ringan

RL 20 tpm
Ceftriaxone
1gr/12jam
Ranitidin
50mg/8jam
Ketorolac 30
mg/8jam

WBC: 12.21
RBC: 5.3
HGB: 15
HCT: 44.5
PLT: 300
PT/APTT: 13.5/30.7
GDS: 82
Ur/Cr: 25/1
GOT/GPT: 24/9
MSCT kepala 27/12
Sugestif multisinusitis
dd hematosinusitis ?

216
A RatuHandayani
16/12/14
8/11/2007
693029

Dr Ikhwan
Sp.BS

S:Nyeri kepala
Nyeribahukanan
O:Kesadaran
umumbaik/GCS 15
VAS 4/10
A:FBI

Ceftriaxone
Ranitidine
15mg/8j/iv
Ketolorac
10mg/8j/iv
Mannitol
25cc/12j/iv

LAB 23/12/14
WBC:9,2
RBC:4,73
Hb:13,5
PLT:521
HCT:39,6
GDS:103
Ur/Cr:32/0,48
SGOT/SGPT:27/22
ALBUMIN:4,2

407
IndrawatiMuchta

Dr.dr.Djoko
Widodo Sp BS

S:Susahtidur/nyerilukao
perasi.

IVFD Ringer Lactate

20 tpm

PCC

LAB 22/12/14

r
681282
13/08/76
MRS:21/12/14

O:SK/GC/CMgcs 15
Verbankering,pupilisoko
r
A:POH 5 vp shunt ec
hydrocephalus due to
tumor intracranial
(ventrikel IV)

425
SonycaMangand
e
02/06/1997
22/12/14

Dr dr Djoko
WidodoSp BS

S:
O:keadaan umum baik
GCS E4M6V5
A:Tumor Intracranial
VP shunt insiv

303
Bunging
Renggina
24/8/48
694553

Dr.Nasrullah
Sp.BS

S:Nyeri kepala
O: KU Sedang/Sadar
55
55
A: Brain concussion
without decrease of
conciousness

Cetriaxone 1g/12j/iv
Ranitidine
50mg/8j/iv
Ketolorac
30mg/8j/iv
Mobilisasiduduk
Diet biasa
(pasienalergidaginga
yamdantelur)
Ranitidine
50mg/8j/iv
Progestrol
1000mg/iv
Phentoin
100mg/8j/iv
Neurobion
5000mg/iv
mobilisasi

WBC:8,9
RBC:4,43
Hb:12,4
PLT:339
HCT:36,0
GDS:102
Ur/Cr:24/0,70
SGOT/SGPT:12/11
WBC:8,21
RBC:2,88
Hb9,5
HCT:27,7
PLT:389

28/12/14
WBC 20.9
RBC 4.61
HGB 13.7
HCT 40
PLT 204
GDS 110
Ur/Cr 34/1.10
GOT/GPT 51/29
Elektrolit 145/4.2/113
HBsAg Non Reaktif
CT/BT 8/3
PT/APTT 12.1/26.0
INR 1.00
CT Kepala 28/12/14
Tidak tampak lei
hipodens dan
hiperdens
intracranial
Focal brain athrophy
lovus frontalis
Hiperostosis os
parietalis kiri
Foto Leher AP Lat
Spondilosis servikalis
Osteoporosis
Foto Lumbosakral
Spondilosis lumbalis
Osteoporosis
Foto Pelvis
Osteoporosis
Foto Thorax
Cardiomegaly
disertai dilatation
aortae
Spondilosis thoracalis

Suspek fraktur costa

VIII kanan belakang