28 maret 2015

HCU Bed 4
ST. Nurnaini
703931
28/12/1952
MRS :
07/03/2015

kamar titipan

DPJP
Dr. dr.
Djoko
Widodo,
Sp.BS

LONTARA 3 BAWAH BELAKANG

S:kesadaran menurun Infus RL 28tpm
O: KU:
Ceftriaxone 1gr/12j/IV
GCS 5 (E1M5V2)
Ketorolac 30mg/8j/IV
Ranitidin 50mg/8j/IV
A: post op H2 ec
Headup 300
meningioma
Ganti Verban /2hari

Lab 15/03/2015
RBC : 3,73
WBC : 28,300
HGB : 11,3
HCT : 33
PLT : 308,000
Ur/Cr : 22/0,30
Na/K/Cl : 137/2,8/102
Lab 13/03/2015
RBC : 3,44
WBC : 20, 300
HGB : 10,4
HCT : 31
PLT : 182,000
PT/APTT : 10,8/31
Ur/Cr : 37/0,40
SGOT/SGPT : 22/26
GDS : 100
Alb : 2,5
Na/K/Cl : 140/ 2,7/107
CT-Scan Kepala (tanpa
kontras) 07/03/2015
-Massa extraaxil regio
frontotemporalis suspek
meningioma disertai brain
swelling dan tanda-tanda
herniasi subfalcine dan trans
tentorial
- Hydrocephalus obstruktif
- Encephalomalacia pons sisi
kanan

K3B5
Sampara Dg
Sibali
RM : 705407
Tgl lahir
01/07/1963
Tgl MRS
19/03/2015

K4B4
Karmila

S:
O: Ku = Baik
A : Multiple Abses
Cerebri dan
Cerebellum

DPJP:
Dr.dr.Djoko

S: nyeri kepala,
penglihatan kabur

Terapi sesuai TS Saraf

Tunggu Konfirmasi
bagian saraf

POH 2 Lobectomy

Lab 19/03/2015
WBC: 24.6
RBC: 4.07
HGB: 11.9
HCT: 35.7
PLT: 341000
CT/BT:
PT/APTT:
GDS: 95
Ur/Cr: 29/0.9
SGOT/SGPT: 24/1.1
Na/K/Cl: 140/3.6/102
HBsAg: nonreactive
MSCT Kepala
20/03/2015
Multiple Abses Cerebri dan
Cerebelum
Lab 09-3-2015
HB: 15.9

28 maret 2015

kamar titipan

RM: 699522
Tanngal lahir:
20-10-1966
Tanggal
konsul:09-032015

widodo,Sp.
BS

K1B3
Sartiani
MR: 705635
Tanggal lahir:
1-5-1963

DPJP:
Dr. Willy
Adhimarta,
Sp. BS

Simon Seda
705167
01-01-1945

DPJP:

MRS:
17-03-2015

Rukka
Lindung
659418
24-4-1959
MRS:
24-3-2015

Simon Seda
705167
01/01/1945
MRS
17/03-2015

DPJP

O: status generalisata
sakit sedang/ gizi
cukup
GCS15
Pupil isokor
A: POH 2 Lobectomy

HCT: 45.4
WBC : 9.9
RBC : 5.04
PLT : 234
GDS: 102
Ur/cr : 23/0.60
GOT/GPT : 26/57
Elektrolit: Na/K/Cl:
141/4.3/105

LONTARA 3 THT ATAS DEPAN

S: Nyeri kepala
- RL 10 tpm
O: GCS 15
- Ceftriaxone 1gr/12j/iv
Region occipital
- Ketorolac 30mg/8j/iv
sinistra: tampak luka
- Ranitidine 50mg/8j/iv
terjahit untuk 5x2 cm,
hematoma tidak ada
A: Trauma kapitis
ringan GCS 15
S: keluhan :
Instruksi post OP
Kesadaran Menurun
IVFD RL 28 tpm
O: Sakit Sedang
Ceftriaxone 1gr/12j/iv
GCS 11(E3M5V3)
Ranitidin ampl/8j/iv
A:
Ketorolac amp/8j/iv
Post craniektomi hari Feniton 100mg dalam
ke-1 SDH
Nacl piggy bag/8j
tempoparietal sinistra Cek HB post op
ICH temporal sinistra Asam traneksamat
amp/8j

S: Nyeri kepala
O: Status generalis
KU: Lemah
A: Tumor intrakranial

Infus RL: dextrose 5%

2:1
Mannitol 100cc/6 jam

S:
O: status generalisata
sakit sedang/ gizi
cukup
GCS15
Pupil isokor
A: POH craniectomy

Ceftriaxone
1gr/12jam/iv
Ranitidin 50mg/8jam/iv
Neurobion
5000iu/24jam/iv

Lab (22-3-2015)
WBC: 18,8
RBC: 4,86
HGB: 14,9
HCT: 43
PLT: 223
GDS: 185
Ur/Cr: 23/ 0,6
Lab 17-03-2015
RBC : 4.88
HGB: 12.6
HCT: 37.7
PLT:242
PT : 10.5
APPT: 28.5
GDS:190
UR/CR: 25/1.10
SGOT: 31
SGPT: 19
NA/KA/KL:140/4.3/103
Lab 16/03/2015
WBC 8750
RBC 3.35
HGB 10,6
HCT 31.1
PLT 364
GDS 90
Ur/Cr 28/0,80
SGOT/SGPT 21/18
Na/K/Cl 134/4.6/99
Lab 1403/2015
WBC 20.61
RBC 5.27
HGB 10.3
HCT 33.9
PLT 228000
GDS 164
Ur/Cr 26/1.0
SGOT/SGPT 26/13
Na/K/Cl 138/4.6/105

28 maret 2015

kamar titipan
LONTARA 3 ATAS BELAKANG
S: Tidak ada batok
Rencana Cranioplasty
kepala
hari Selasa 24/03/2015
O: : status
generalisata :
SS/GC/CM
GCS 15 pupil
isokor2mm/2mm,RC
+/+
A: Skull Defect
Regio Frontal Dextra

K2B6
N. Zulkarnaen
687335
31/12/1962
MRS
!9/03/2015

DPJP
dr.
Nasrullah
Sp.BS

K3B4
Rizaldi Winata
705995
27/12/1997
MRS:
24/03/2015

DPJP
Dr. dr.
Nasrullah,
Sp.BS

S: Nyeri kepala
O: Status generalis:
SS/GC/CM
GCS 15
A: TCR GCS 15

- RL 10 tpm
- Ketorolac 30mg/8j/iv
- Ranitidine 50mg/8j/iv
- Mannitol

K4B4
Anggun
Febriyani
705459
27/2/2000
MRS:
20/03/2015

DPJP: Prof
Dr. dr. Andi
Asadul I,
Sp.BS

S: Nyeri kepala
O: Status generalis:
SS/GC/CM
GCS 15
A: TCR GCS 15

- RL 10 tpm
- Ketorolac 30mg/8j/iv
- Ranitidine 50mg/8j/iv

Fauzan M N
706124
09/06-2006
25-03-2015

S: Nyeri luka operasi

O :KU baik GCS 15
A: POH 2
Craniectomy

RL 20 tpm
Ceftriaxone
1gr/12jam/iv
Ketorolac
30mg/8jam/iv
Burnazin Zalf

K7B6
Ayu Andini
22/11/2003
704797
MRS:
14/03/2015

Putra Ansar

LONTARA 4 ATAS BELAKANG

S: Lemah kedua
Tunggu hasil kultur
tangan dan kaki
O: : status
generalisata :
SS/GC/CM
GCS 15 pupil
isokor3mm/2mm,RC
+/+
A: Tetraparese ec
SOL
DPJP:

S: Demam ada,

- RL 10 tpm

Lab 1403/2015
WBC 7300
RBC 5.27
HGB 15.3
HCT 46
PLT 297000
CT/BT 800/230
GDS 108
Ur/Cr 30/0.90
SGOT/SGPT 24/28
Na/K/Cl 146/4.4/109
Lab 2403/2015
WBC 10,1
RBC 3,88
HGB 11,7
HCT 35,0
PLT 678
GDS 85
Ur/Cr 14/0,60
SGOT/SGPT 53/80
Lab 20/03/2015
WBC 9,9
RBC 5,07
HGB 14,7
HCT 43,2
PLT 403
GDS 131
Na/K/Cl: 141/5,2/106
Lab 25/03/2015
WBC 13.5
RBC 4.46
HGB 13.3
HCT 35.5
PLT 844
GDS 120
Ur/Cr 24/0,38
SGOT/SGPT 53/80
Na/K/Cl 143/4,5/109
Lab 14/03/2015
WBC 7600
RBC 4,76
HGB 13,2
HCT 39,3
PLT 500
GDS 90
Ur/Cr 20/0,40
SGOT/SGPT 15/21
Na/K/Cl 144/4,4/113

28 maret 2015
10/05/2014
701432
MRS:

kamar titipan
spastik ada
O: status
generalisata :
SS/GC/CM
GCS 15 pupil
isokor3mm/2mm,RC
+/+
A: Post VP shunt

- Ketorolac 30mg/8j/iv
- Ranitidine 50mg/8j/iv