MAPPING BEDAH SARAF

Seni, 23 JANUARI 2017

TOTAL: 20PASIEN

Ruangan
Jeumpa 2
Jeumpa 3
Jeumpa 4
NABAWI 1
NABAWI 2
ISO
PJT

Dr. ISKANDAR, Sp.BS

1pasien
2 pasien
1 pasien
1 pasien
1 pasien
PICU
1 Pasien
ICU D
1 pasien
ICUC
JUMLAH
8 PASIEN
6 PASIEN
Kamar
K4B3

IdentitasPasien
Farid assyraf, 8 bulan, Lk
1088671

DPJP : dr.
1.

2.

ISKANDAR,
Sp. BS

Tgl masuk: 19/01/2017

AD 5
Tgl OP 21/1/2017
POD 3

K3B2

Khairul azmi, 6 tahun, LK

1116416

DPJP: dr.
BUSTAMI,
Sp.BS

Tgl masuk: 20/01/2017

AD 3

Dr. BUSTAMI, Sp.BS

1 pasien
2 Pasien
1 Pasien
1 pasien
1 Pasien
2 pasien
8 PASIEN

Dr. IMAM H, Sp.BS

1 pasien
2 Pasien
1 pasien
-

TOTAL
3 pasien
4 pasien
1 pasien
2 pasien
3 pasien
1 Pasien
1 pasien

1 Pasien
2 pasien
2 pasien
20 PASIEN

JEUMPA 2 TOTAL : 3 PASIEN

LAB
Lab 19/1/2017
Hb/Ht/Er/Leu/Tro
12,2/36/5,5/28,4/627
Diftell: 1/0/0/46/47/6
Na/K/Cl
141/5,5/107
Ur/cr
5/0,10
Lab 20/1/2017
Hb/Ht/Er/Leu/Tro
10,5/32/4,0/39,1/433
Diftell : 0/0/1/87/5/7
Ct/bt: 2/7
Ur/Cr: 34/0,50

Diagnosa

Treatment

Malfungsi shunt ec hidrocefalus non

komunikan

Elevasi Fraktur depress + Orif

-IVFD RL 20 gtt/i

Planning
-

Aff cateter
Pasang NGT

Observasi gcs
Rawat luka
GV hari ke 3

-inj.ceftriaxone 2 gr/hari
-inj.ranitidin 1 amp/12 jam
-diet 6x100cc

Tgl Op: 20/1/2017

POD 3
3

K4B4

DPJP : dr.
IMAM
HIDAYAT,
Sp. BS

Zahratul Syifa, 2 bulan, Pr

1106860
Tgl masuk: 16/1/2017
AD 7

Lab 16/1/2017
Hb/Ht/Er/Leu/Tro
10,5/32/4,2/26,9/562
Diftell : 0/0/1/75/20/4
Ct/bt: 2/8
Ur/Cr: 24/0,50

Post Vp shunt ec meningoenchefalocel

Tgl OP 17/1/2017
POD 6
-

Rawat luka
Observasi
USG Abdomen Senin

JEUMPA 3 TOTAL : 4 PASIEN

NO

Kamar

IdentitasPasien

LAB

Diagnosa

K2B2

Asmaul Husna, Pr, 21th

1-09-58-74

Lab 9/1/2017
Hb/Ht/Er/Leu/Tro
15,6/47/6,5/8,1/355
Diftell: 4/1/0/50/37/8
Ct/bt: 2/8
GDS: 102
Ur/ cr: 19/1,12
Na/K/Cl
143/4,0/106

Skull defect ar frontalis sinistra

Lab 12/1/2017
Hb/Ht/Er/Leu/Tro
15,6/47/6,5/8,1/355
Diftell: 4/1/0/50/37/8
Ct/bt: 2/8
GDS: 102
Ur/ cr: 19/1,12
Na/K/Cl
143/4,0/106
Lab 5/1/2017
Hb/Ht/Er/Leu/Tro
13,3/37,8/46,6/11,7/322
Diftell : 1/1/0/80/11/7

Skull defect ar frontalis

Lab 18/1/2017
Hb/Ht/Er/Leu/Tro
16,4/45/5,3/12,4/335
Diftell : 0/0/0/84/7/0
Ur/Cr: 58/0,70
Na/K/Cl
131/3,9/94

Stroke hemorage (ICH thalamus S +

IVH) + hidrocefalus non comunikan+
post Vp Shunt

1.
DPJP: dr.
BUSTAMI,
Sp.BS

Tgl masuk:17/1/2017
AD 5
Tgl OP: 18/1/2017
POD 5

K7B5
2.
DPJP: dr.
IMAM
HIDAYAT,
Sp.BS

Rizki Wahyu, Lk, 19th

1-08-92-67
Tgl masuk:17/1/2017
AD 5
Tgl OP: 18/1/2017
POD 5

3
K4b2

DPJP : dr.
IMAM
HIDAYAT,
Sp. BS
4

Nurlina, 38th, Pr
1116135

Planning
Terapi Oral
Senin PBJ

Terapi oral
Pasang stopper
Senin PBJ

Miningioma ar Frontal
-

GCS

IVFD RL 20 gtt/i
Inj. Ranitidin I amp/8jam
Inj. Ketorolac 1 amp/8jam

Operasi elektif
Konsul anestesi
Konsul kardio

Tgl masuk: 18/1/2017

AD 5

K5B1

DPJP :
BUSTAMI,
Sp. BS

Treatment

Trimo, 76th, Lk
1116254

Tgl Op : 19/1/17
POD 4

GCS
E2M3Vx

IVFD RL 20 gtt/menit
Inj. Cefixime 1gr/12jam
Inj.omeprazol 40mg/12 jam
Amlodipin 1x 10 mg
Valsartan 1x 10mg
Diet sonde 6x200cc

- Observasi GCS

JEUMPA 4 TOTAL: 1 PASIEN

NO

Kamar

IdentitasPasien

K5B1

Safrizal, 25th, LK
1116418

DPJP: dr.
BUSTAMI,
Sp.BS

Tgl masuk: 20/01/2017

AD 3

1.

LAB
Lab 20/1/2017
Hb/Ht/Er/Leu/Tro
15,4/5,31/43,5/12,9/257
ct/bt: 2/10
GDS: 106
Ur/cr: 21/0,9

Diagnosa

Treatment

CKR+EDH ar temporoparietal Sin + fr.

Linear ar temporal

Planning

-neurodex 2x1 tab

Rawat luka
Mobilisasi

Tgl op: 21/01/2017

POD2

NABAWI 1 TOTAL : 2 PASIEN

Kamar

IdentitasPasien

K1B5
1.
DPJP: dr.
ISKANDAR,
Sp. BS

Jafar M. Nur, Lk, 41th

1115219
Tgl masuk:9/1/2017
AD 14

LAB
Lab 17/1/2017
Hb/Ht/Er/Leu/Tro
10,4/29/3,5/8,6/404
Diftell: 5/0/0/65/20/10
Na/K/ClCa
138/4,0/112

Diagnosa

Treatment

Planning

SDHg bilateral + post debridement ai fr.

Femur

Sesuai Ts. Neurologi

Observasi
Selasa PBJ

Skull defect ar Frontalis Sinistra

Sesuai Ts. Neurologi

Op Cranioplasty acrilic
Senin PBJ

Tgl op: 12/01/2017

POD 11
2.

K6B3
DPJP: dr.
ISKANDAR,
Sp. BS

Fina, Pr, 27th

1094023
Tgl masuk:17/1/2017
AD 5

Lab 6/1/2017
Hb/Ht/Er/Leu/Tro
12,9/40/4,8/11,1/303
Diftell: 3/0/0/72/20/5
Pt/Aptt: 2/7
Na/K/Cl
142/4,7/108

Tgl op: 18/01/2017

POD 5
-

NABAWI 2 TOTAL : 3 PASIEN

Kamar
3.

IdentitasPasien

K4B2

DPJP : dr.
ISKANDAR,

Nazariah, 41th, Pr
1077544

LAB
Lab 14/1/2017
Hb/Ht/Er/Leu/Tro
14,5/42/5,3/14,9/241
Diftell: 2/1/0/69/16/12

Diagnosa
SOL intracranial + Hidrocefalus non
comunican + post op Vp Shunt

Treatment
-IVFD RL 20 gtt/i
-inj. Ondansetron 1 amp/ 8jam
-inj. Ranitidin 1 amp/ 8jam

Planning
-

Observasi
Konsul kardio (+)
Konsul anestesi (+)

Sp. BS

Tgl masuk: 15/01/2017

POD 8

K3B4

Hasyem Rusli, Lk, 38 thn

1114601

4.

DPJP : dr.
IMAM
HIDAYAT,
Sp. BS

Tgl masuk: 04/01/2017

AD 20

DPJP: dr.
BUSTAMI,
Sp.BS

-inj. Tramadol 1 amp/ 8jam

-drip PCT 1gr/ 12jam

Post removal tumor a.i Cephalgia ec

SOL Intracranial

Vestigo 2x1
Coditam 3x1
Ranitidin 3x1
Duragesic path 25 mg

Observasi gcs
Rawat luka
GV hari ke 3
Alih rawat neuro

- sesuai TS intensive
-inj.ceftriaxone 2 gr/hari
-inj.ranitidin 1 amp/12 jam
-inj.ketorolac 30mg/8jam
-diet 6x100cc

Rencana craniotomy
elevasi fr.depres
elektif
Konsul kardio
Konsil anestesi

Tgl Op: 12/1/2017

POD 13

K6B5
5.

Na/K/Cl
12/4,8/96
Ur/cr
42/0,70
Lab 4/1/2017
Hb/Ht/Er/Leu/Tro
14,4/42/5,0/13,7/286
Diftell : 0/1/0/75/17/7
Ct/bt: 2/7

Rustam, 24th , Lk
1116403
Tgl masuk: 19/1/2017
AD 4

Lab 19/1/2017
Hb/Ht/Er/Leu/Tro
14,5/41/4,8/10,0/246
Diftell : 2/0/0/73/18/7
Ct/Bt: 2/7
Na/K/Cl
143/3,6/121
Ur/cr: 20/0,80

Close fr.depres ar frontal Sin

PJT TOTAL: 1 PASIEN

NO

Kamar
K7B1

1.

DPJP : dr.
ISKANDAR,
Sp.BS

IdentitasPasien
Marlina abdullah, PR, 43 tahun
Tgl masuk: 17/01/2017
AD 6
Tgl op:
POD

LAB
Lab
Hb/Ht/Er/Leu/Tro
12,3/36/4,2/6,4/226
diftell: 1/0/0/70/24/5
ct/bt: 2/7
albumin: 4,37
Na/K/Cl
147/3,8/109
GDS: 224
Ur/cr: 32/0,80

Diagnosa

Treatment

Meningioma

Diet MB
PCT 3x1 tab
Ranitidine 2x1 tab

Planning
Persiapan operasi

ISO TOTAL: 1 PASIEN

NO

Kamar
3A

IdentitasPasien
Tri novanda, Lk, 32 thn
1112240

1.

DPJP : dr.
ISKANDAR,
Sp.BS

Tgl Op : 22/12/16
POD 27

LAB
Lab 5/1/2017
Hb/Ht/Er/Leu/Tro
9,9/31/3,5/9,7/553
Diftell : 1/1/0/80/11/7
Tgl 30/12/2016
Na/K/Cl
137/3,8/108
Ur/Cr : 22/0,78

Diagnosa
Post craniectomy removal meningioma +
re decompresi ai edema cerebri berat
GCS
E4M5Vafasia

Treatment
-

levofloxacine 2x500 mg
as.mefenamat 3x500 mg
phenitoin 3x1
dexamethasone 3x1
cloramfenocol slp 3x1
diet TKTP + ekstra putih telur
neurodex 2x1 tab
D

Planning
Fisioterapi
Rawat luka
Mobilisasi miring
kanan kiri

ICU D TOTAL :2PASIEN

Kamar
B4
1.
DPJP: dr.
ISKANDAR,
Sp. BS

2.

IdentitasPasien
Ridwan Arifin, lk, 51 tahun
Tgl Masuk: 13/1/2017
AD 2
Tg; Op: 13/1/2017
POD 10

LAB

Diagnosa

Lab 13/1/2017
Hb/Ht/Er/Leu/Tro
16,4/48/5,6/15,2/233
Diftell: 0/0/0/93/3/4
Ct/bt: 2/8
Na/K/Cl
144/3,2/105
GDS: 127
Ur/cr: 19/0,90
Na/K/Cl/Ca/Mg
144/3,5/112/7,6/1,5

Post Craniectomy evakuasi

ICH+Hipertensi

Lab 14/1/2017
Hb/Ht/Er/Leu/Tro
9,9/32/3,8/12,1/433
Diftell : 0/1/0/91/5/3
Pt/aptt: 11,0/36,6
d-dimer: 246,17
HbsAg: negatif
Sgot: 298
Na/K/Cl/Ca/Mg
140/4,5/103/9,3/1,9

Post vp shunt ec stroke hemoragik

(ICH+IVH) +Hidrocephalis non
communican

Treatment
-

Planning

Inj.ceftriaxon 1 gr/12 jam

Inj.ranitidin 1amp/12 jam
Inj.keterolak 1 amp/8 jam
Phenytoin 3x1 tab
Diet sonde 6x200cc

Observasi GCS
Rawat luka
Rawat traceostmi
ACC pindah
HCU

B2

DPJP :
BUSTAMI,
Sp. BS

Rosmaini, pr, 58 thn

1113678

Tgl Op : 26/12/16
POD 26

GCS
E3 M5 V2

Head up 30o
IVFD RL 20 gtt/menit
Inj. Cefixime 1gr/12jam
Inj.omeprazol 40mg/12 jam
Valsartan 1x80 mg
Drip pct 1 gr/ 8 jam
Amlodipin 1x 5 mg
Flumicil syr 3x1
Ventolin nebul / 8 jam
Diet Sonde 6 x 100 cc
Yang lain Sesuai TS

- Observasi GCS

PICU TOTAL : 1PASIEN

NO
1.

Kamar

IdentitasPasien

Bed 4

M. Farid Arsyad, 4 bulan

DPJP: dr.
ISKANDAR

Tgl op: 12/01/2017

POD 11

LAB
Lab 20/1/2017
Hb/Ht/Er/Leu/Tro
11,6/38/4,8/10,6/350
Diftell: 4/1/0/40/46/9
Pt/aptt: 9,9/42,7

Diagnosa
SDH kronik + infark serebri
Post burhoel drainase

Treatment
-

Inj.novalgin 50 mg/8 jam

Lanjut terapi sesuai SP.A

Planning
Observasi
Rawat luka

, Sp. BS

d-dimer: 739,38
Na/K/ClCa
131/5,2/98/8,9
-

ICUC TOTAL : 2 PASIEN

NO
1

Kamar

IdentitasPasien

Bed 1

Moh. amin, lk, 63 thn

1116582

DPJP :
BUSTAMI,
Sp. BS

Tgl OP 22/1/2017
POD 1

Bed 2

Fakhriah, 47th, pr
1116294

DPJP :
BUSTAMI,
Sp. BS

Tgl OP 20/1/2017
POD 3

LAB

Diagnosa

Treatment

Planning

Lab 22/1/2017
Hb/Ht/Er/Leu/Tro
15,6/46/5,7/20,9/244
Diftell:0/0/1/80/11/8
Pt/apt : 10,6/35,4
Na/K/Cl ; 146/2,9/113
Ur ; 40
Albumin ; 3,52

Stroke hemoragik (ICH +IVH) +

Hydrocephalus non communican

IVFD 20 gtt/i
Inj. Ceftriaxone 2 gr/24 jam
Inj. Novalgin 1 amp/8 jam
Inj. Ranitidine 1 amp/8 jam
Phenitoin 1 amp/8 jam
Diet sonde 6x100 cc

Lab 22/1/2017
Hb/Ht/Er/Leu/Tro
8,7/32/3,9/12,2/152/
Diftell:0/0/1/80/11/8
Ct/bt: 2/8
Na/K/Cl
154/4,0/129
Ur/cr: 37/1,00

Stroke Hemorage (ICH basal ganglia

Sin.) + craniectomi evakuasi ICH

IVFD 20 gtt/i
Inj. Ceftriaxone 100 mg/12
jam
Omeprazole 1 amp /8jam
Sucralfack syr 3xcth 1
Pyracetam 1gr /8jam
Phenitoin amp /8jam
Diet sonde

Rawat
luka
GV(+)
observasi