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KORAN BEDAH SARAF, JUMAT 12 JULI 2019

IGD

No IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN

1 Lalu Umar -Paraparese UNM ec Lab 09/07/2019 - Infus NaCl 0.9% 2000ml/24jam dr. Djoko Widodo,
canal stenosis SGOT : 28 - Ketorolac 30 mg/8jam/ iv Sp.BS(K)
Hadi/ L / 42
Thoracal SGPT : 17 - Ceftriaxone 1 gr/ 12 jam/ iv
tahun - Anemi WBC : 14.3 - Omeprazole 40 mg/ 24 jam/ iv
HGB : 7.3 - Transfusi PRC 3 Bag (2
885259
PLT : 442.000 bag/hari)
MRS: PT/APTT: 12,5/32.5
- Boleh Pindah Perawatan
UR/CR: 19/0.95
09/07/2019 - Paracetamol 500mg/ 8jam/iv
NA/KA/KL: 128/4.2/95
2 Jumardin/ L/ -Tumor Intracranial 09/07/2019 - Infus RL 20 tetes/menit Prof. Dr.dr Andi
-Hidrocephalus WBC: 8.12 - Ketorolacc 3o mg/ 8jam/iv Asadul Islam,
48 tahun
HB:12.6 - Ondancetron 40 mg/ 24 jam/iv Sp.BS(K)
887592 GOT/GPT:21/22
Na/K/Cl : 141/4.1/103
MRS:
Ur/cr: 24/1.08
09/07/2019 PLT : 146.000
3 Randy -TBI GCS 10 Lab /10/2019 - Infus NaCl 0.9% 28 tpm Cek Radiologi Prof.Dr. dr. A.Asadul
-ICH Frontal Sinistra SGOT :27 - Ceftriakson 1gr/12jam/iv islam M, SP.BS
Akbar/L/20
SGPT : 21 - Ketorolac 30 mg/ 8 jam/ iv
thn WBC : 19.4 - Kaateter urine
HGB : 15.4
888645
PLT : 284.000
09/07/2019 PT/APTT: 10./30.4
UR/CR: 19/0.73
NA/KA/KL:140/4.1/102

5 M.Irham/L/ -TBI gcs 15 - Infus NaCl 0.9% 28 tpm Prof.Dr. dr. A.Asadul
- Ranitidine 50mg/12jam/iv islam M, SP.BS
67 thun/
- Metamizole 1 gr/ 8 jam/ iv
888643
MS :
10/07/2019
6 Latifah Nur/ -HIdrocephalus Lab /11-07-2019 - Paracetamol 200 mg/12jam/iv Cek darah Lengkap Dr. dr. Nasrullah,
SGOT : 25 - Natrium 150 mg/nacl 105 cc Cek CT-Scan Sp.BS (K)
P/ 14thn SGPT : 29 habis dalam 15 menit Kepala
WBC : 6.2
72350
HGB : 12.6
MRS: PLT : 250..000
PT/APTT: 11.4/25.4
11/07/2019
UR/CR: 11/0.40
NA/KA/KL:135/3.9/101
GDS 154

7 Semma/ P / POH 1 Craniotomy Lab 11-07-2019 - Infus nacl 0,9 % 20 tpm Dr.Andi Ihwan
evakuasi SGOT :19 - Ceftriaxone 1 gr/12jam/iv Sp.BS(K)
34 Thun
Epidural hematoma SGPT : 19 - Ketorolac 30 mg/8jam/iv
888775 parietal dekstra + WBC : 9.3 - Omeprazole 40 mg/24 jam/iv
cranioplasty HGB : 11.9 - Takar produksi drain per 24 jam
MS :
PLT : 265.000
11/07/2019 PT/APTT: 10.6/22.4
UR/CR: 24/0.63
NA/KA/KL:138/4.3/105

PALEM ATAS

NO. IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN
1 Yudha Rahmadi Hemiparese (06-07-2019) X-Ray Thorax PA/AP (28- -Inf. NaCl 0.9% 28 tpm -Rencana kraniektomi Dr. dr. Djoko
Junus Dextra ec WBC : 13.5 06-2019) removal tumor (hari Widodo,
06-09-1975 Tumor HB : 11.3 -Tidak tampak kelainan -O2 3 liter/menit NRM jumat 12/07/2019) Sp.BS (K)
43 tahun Temporal HCT : 35 -Ceftriaxon 1 g/8 jam/iv -infome conset
878281 Sinistra PLT: 249.000 CT-Scan Kepala tanpa -Paracetamol 1 g/6 jam/iv -konsul Anastesi
MRS 18/06/2019 INR: 0.96 kontras (01-07-2019) -Dexamethasone 5 mg/8 -lapor Ok
B2/11 GDS: 194 -Gambaran butterfly Glioma jam/iv -strip PRC: 4 ambil, 2
Ur/Cr: 30/0.30 disertai pendarahan -Amlodipine tab 5mg 0-0-1 siap
SGOT/SGPT : 31/88 intratumoral dan -Omeprazole -puasa
menyebabkan herniasi 40mg/12jam/iv
(02-07-2019) subfalcine ked extra sejauh -
Na/K/Cl: 120/3.6/88 +/- 0.7 cm
-Pendarahan intraventrikel
sinistra cornu posterior
-Edema interstisial cornu
posterior ventrikel lateralis
sinistra
-Hydrocephalus Obstructive
-Skull defect os parietal
sinistra disertai herniasi
menings dan parenkim
cerebri

2 Muh. Nur salam Tumor (03/07/19) X-ray Thorax PA/AP (19-06- Rencana removal Dr. dr. Djoko
17-08-1965 retrobulbar Wbc : 8000 2019) tumor (Tunggu Widodo,
598901 sinstra Hb : 15.7 -Tidak tampak tanda-tanda konfirmasi jadwal) Sp.BS (K)
MRS 27-06-19 Hct: 47 metastasis
B2/11 INR: 1.06 -Slight cardiomegaly
Gds: 87
Ur/cr : 14/0.98 MSCT kepala dengan
Sgot/sgpt : 26/36 kontras (17/06/19)
Albumin: 3.8 Sugestif lymphangioma
Na/K/Cl: orbita sinistra
138/4.1/106

PALEM BAWAH

NO. IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN

LONTARA 1

NO. IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN

LONTARA 2 BAWAH DEPAN (URO)


NO. IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP
PASIEN

1. L2BD – K11-B3 -ICH Frontal Lab 09-07-2019 : CT Lumbal (Tanpa -NaCl 0,9% 20 tpm Dr.dr. Nasrullah
Andi Maryam Dextra WBC : 8.100 Kontras) 09-07-2019 : -Ranitidin 50 mg/12 Rencana Stabilisasi M, Sp.BS
888201 -Fraktur kompresi RBC : 2.910.000 -Spondylolisthesis CV jam/iv Posterior
01-01-1954 (65 Lumbal I HB : 9,0 L4-L5 ke anterior -Ketorolac 30 mg / 8
tahun) -Spondilolisthesis HCT : 27 disertai penyempitan jam/iv
MRS : 05-07-2019 Vertebra L3-L4 PLT : 473.000 discus intervertebralis -Paracetamol 1
-DM Tipe II PT/INR/APTT : CV L4-L5 dan L5-S1 gram/8jam/iv
-Anemia 10/0,07/27,1 -Fraktur kompresi CV
-Laxadine 15 ml/24 jam
GDS : 236 L1
-Transfusi PRC 1 bag
Ureum : 14 -Spondylosis lumbalis
Kreatinin : 0,44 -Osteoporosis senilis premedikasi
SGOT : 22 Usul : MRI Spine Difenhidramin 10 mg
SGPT : 18 lumbosacral
Na/K/Cl : Hasil konsul Endo :
134/4,1/100 USG Whole Abdomen DM Tipe II non obese
09-07-2019 : Terapi :
-Sludge Vesica Urinaria -Diet DM 1700 kkal/hari
-Efusi pleura dextra -Levemir 10
unit/subkutan
Foto lumbosacral -Novorapid 6 unit pagi ; 6
AP+Lateral 09-07-2019 unit siang ; 4 unit malam
:
-Spondylolisthesis CV
L4-L5 ke anterior
disertai penyempitan
discus intervertebralis
CV L4-L5 dan L5-S1
-Fraktur kompresi CV
L1
-Spondylosis lumbalis
-Osteoporosis senilis

Foto thoracal
AP+Lateral 05-07-2019
:
-Fraktur kompresi CV
L1
-Osteoporosis senilis
CT Kepala (Tanpa
kontras) 05-07-2019 :
-Pendarahan intracerebri
lobus frontalis dextra
-Subdural hematom
regio occipital dextra
-Brain swelling

LONTARA 2 BAWAH BELAKANG (ORTO)

NO. IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN

LONTARA 3

LONTARA 3 BAWAH DEPAN


ssss
KAMAR 1A

NO IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN
1 A.Alifa Tenri POH 11 Craniectomy Hasil Lab 27-6-2019 MSCT Scan Kepala Nacl 0.9 % 16 tpm Aff jahitan Dr. dr. Nasrullah
Azzahra drainase abses cerebri WBC : 15690 (17-06-2019) Sp.BS
884554 temporoparietal sinistra HB : 19.1 Suspek abses cerebri Omeprazole 20 mg/12jam/iv
19-04-2016 Hemiparese dextra HCT :55.3 Dexametason 20mg /12
3 tahun PLT : 343 Foto thorax (12-06-2019) jam/iv
BED 1 PT/APTT : 11.1/20.1 Dextrocardia
Ur/Cr : 49/0.37 Ceftriaxone 500mg/12jam/iv
SGOT/SGPT :39/17
Na/K/Cl 141/4.9/109 Ketorolac 15 mg/8 jam/iv
Sesuai terapi TS pediatric
Hasil Mikrobiologi
(05-06-2019)
Tidak ada
pertumbuhan bakteri
anaerob

2 Radeya Xhaka Spina Bifida post 2/7/2019 Foto thorax (4/3/2019) Paracetamol syr 1 cth /8 Aff infus Dr.dr. Djoko Widodo
Mahatma lipomylectomy +tutup Tidak tampak kelainan pada foto jam/oral Sp.BS
846237 defect WBC :21.7 radiologi Cefadroxi ½ tab/12jam/oral
27-08-2017 HGB:
01-07-2019
BED 2 RBC : 4.70
PLT : 541
GDS : 79
Ur//Cr :10/0.20
GOT/GPT : 69/26
PT/APTT : 11.3/34.3
Na/K/Cl: 139/4.9/104

KAMAR 1B

NO IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN
1 Pither Seru - tumor frontoparietal Hasil lab MSCT Kepala dengan kontras Infus NaCl 20 tpm DR.Dr. Djoko
Talendo sinistra 06-07-2019 (20/06/2019) Omeprazole 20 mg/12jam/iv Widodo, Sp.BS (K)
564618 -anemia WBC :11.57 - Gambaran astrocytoma lobus N-ace 200 mg/ 8jam/oral
31/12/1959(59 HGB:10.6 frontal sinistra yang menyebabkan Terapi lain sesuai GH
tahun) PLT: 117 herniasi subfalcine Paracetamol
BED 1 HCT :31.2 - Infark pons sisi dextra 500mg/8jam/oral
Ur/Cr : 80/1.52 -Brain edema
Na : 136
K: 4.8
Cl :105
GDP: 81

02-07-2019
WBC: 15,9
HGB: 9,8
PLT: 124
HCT : 29%
Ur/Cr : 85/1,45
Na: 131
K: 4.4
Cl: 101
SGOT:20
SGPT: 33
4/7/201
GDP :171
GD2PP : 353

2 AISYAH Tumor temporoparietal Lab 09/07/2019 Ceftriaxone 500mg/12 Rawat luka per 2 hari Dr. dr. Nasrullah
AQILAH sinistra post WBC : 6.42 jam/iv Sp.BS
874777 craniotomy removal RBC :4.55 Paracetamol 150mg/8 jam/iv
23/08/2014 tumor H-6 HGB : 12.0
4 TAHUN
HCT 35
BED 2
PLT 239

KAMAR 2
1

2 INDAH GITA - Paraplegia ec Lab 02/07/2019 Foto thorax ( 02/07/2019) : tulofusin 28 tpm - Rawat luka ulcus Dr.dr
syringomyelia WBC 13.92 decubitus Nasrullah,
CAHYANI/P/ 17 tahun Pneumonia dextra Omeprazole 40 mg/24 jam/iv
- Ulcus decubitus RBC 4.24 Rencana head ct scan M Sp. BS
887781 HGB 9.9 Ketorolac 30 mg/8 jam/iv dengan kontras (K)
PLT 610
MRS02/07/2019
PT 10.3 Dulcolax 1 tab/24jam/sup
BED 2 APTT 21.6
Ur/Cr 26/0.17
SGOT/SGPT 22/29
Na/K/Cl 138/4/102
3 Miftahul Khaera - Hemiparese 3/7/2019 Omeprazole 20 mg/12 jam/ Puasa 6-8 jam Dr.dr.Djo
08-03-1993/26 tahun/ dextra ec oral ko
MRS 2/7/2019 WBC: 5,3 Widodo,
Ependymoma
652944 Paracetamol 500mg/8jam/oral Sp.BS
Recurent HGB : 11,3 Infus Nacl 0.9% 20 tpm
temporoparietal Ranitidin 50
BED 3 sinistra PLT : 266
mg/12jam/intravena
HCT: 34 Ketorolac 30mg/ 8 jam/iv

Ur: 16
Cr: 0.69
GDS :84
Na/K/Cl: 137/3.9/105
GOT : 22
GPT:14

4.

5 RABATI/P - General Lab 02/07/2019 Foto thorax (02/07/2019) : Infus NaCl 0.9% 28 tpm Dr.dr
845194 weakness WBC: 4.9 - Terpasang shunt dengan tip Injeksi omeprazole 40 mg/12 Nasrullah,
15-08-1969 - Skull defect HGB: 6.0 cranial tidak tervisualisas jam/iv M Sp. BS
50 tahun regio HCT: 37 - Cor dan pulmo normal Ceftriaxone 1 gram/12 jam/iv (K)
MRS 01/07/2019 temporoparietal PLT: 300 - Dilatation et atherosclerosis Ketorolac 30mg/8jam/iv
BED 5 sinistra PT/APTT/INR: aorthae
10.5/1.01/26.3
- Post craniectomy - Elevasi diafragma dextra
GDS: 105
- Post vp shunting
Ur/Cr: 9/0.63
SGOT/SGPT: 18/10/4.2
Na/K/Cl: 141/3.9/99
6 HJ. SYAMSIDAR Post craniotomy Lab 02/07/2019 Rawat untuk craniotomy Dr.dr
830526 removal tumor WBC : 9.6 tunggu jadwal Nasrullah,
05-11-1976 RBC : 4.93 M Sp. BS
42 tahun HCT : 42
MRS 09/07/2019 PLT :401
PT/APTT/INR :
9.6/28.1/0.93
GDS : 190
Ur/Cr: 14/0.62
SGOT/SGPT : 13/25
Na/K/Cl : 138/5.0/106

KAMAR 3

NO IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN
1 Ardin -Meningioma Lab (8/07/2019) MSCT kepala (17/5/19) - Infus NaCl 0.9% 20 Rencana Prof. Dr.dr. Andi
883192 frontotemporal sinistra PT: 9.9 - meningioma regio tpm removal tumor Asadul Islam,
31-12-1979 / 39 +Hidrocephalus INR:0.96 frontotemporal sinistra sugestif - Omeprazole 40 Sp.BS(K)
th -Hari ke 15 APTT: 23.4 malignancy mg/12 jam/iv
25-06-2019 - Herniaci subfalcine - Ketorolac 30
K3/1 Lab (2/07/2019) - obstructive hydroccephalus mg/8jam/iv
WBC 11.29 ventrikel lateralis dextra
RBC 5.08
PLT 367
GDS 153
UR/CR 54/0.94
SGOT/SGPT 34/64
Na/k/Cl 138/4.6/103

Lab (17/06/2019)
WBC 7,8
RBC 5,01
PLT 341
GDS 90
UR/CR 12/0,92
SGOT/SGPT 12/22

2 By Ny.Dewi Meningoencephalocele Lab (03/07/2019) USG kepala - Paracetamol syr Dr. dr. Nasrullah M,
Purnama Hari ke 8 WBC 13.9 - Tampak dilatasi ventrikel 70mg/8jam/oral SP.BS
874540 RBC 4.49 lateral kanan-kiri , tidak tampak - Amoxicilin
09-02-2019 HB 10.8 hipervaskuler pada ventrikel. 10mg/8jam/oral
4 bulan 25 hari PLT 520 Parenkim cerehri terscan
03-07-2019 GDS 109 normal
K3/2 UR/CR 17/0.24 -meningocele+free fluid tidak
SGOT/SGPT 21/37 tampak struktur brain
NA/K/CL 127/5.5/103

3 NurAfiqah POH IV VP Shunt Lab (03/07/2019) Foto thorax(07/05/2019) - Infus asering Dr. Andi Ihwan
Azzahra Arifin Dandy Walker Syndrome WBC 11.29 -Pneumonia bilateral 500ml/24jam/iv Sp.BS
882355 Hari ke 8 RBC 4.08 -Ceftriaxone 300mg/12jam/iv
-dextrocardia
27-12-2018 HCT 32.4 -ranitidine 20
6 bulan PLT 378 mg/12jam/iv
02-07-2019 PT/APTT 10.6/32.5
K3/3 GDS 98 - Ketorolac
Ur/cr 9/0.07 15mg/8jam/intravena
SGOT/SGPT 51/52
Na/k/cl 136/4.7/107
Hasil laboratorium
(07/05/2019)
Wbc 11.5
Rbc 3.70
Hb 10.1
Hct 30
Plt 413
PT/APTT 10.2/29.6
Ur/cr 17/0.34
GOT/GPT 66/52

4. Tamrin -Paraparese ec Fraktur Lab (09/07/2019) MRI T SPINE DGN -infus NaCl 0.9 % -stabilisasi dr.Andi Ihwan,
12/06/1970 kompresi thorakal XII GDS 258 KONTRAS 24/05/19 -Ceftriaxone Sp.BS
49thn - DM tipe 2
posterior
-fraktur avulsi bagian aspek 1gr/12jam/intravena
884052 -hari ke 14 11-07-2019
Lab (28/06/2019) anterior dan fraktur kompresi -paracetamol
K3/4 GDP 366 ppada bagian posterior CV 500mg/24jam/iv
Thorakal 12 yang menekan
MRS
GD2PP 471
medulla spinalis - Terapi lain sesuai TS
HbA1c 11.8
27/06/2019 endokrin
-spondylolisthesis CV T11
Pemeriksaan lab 25/06/19 terhadap CV L1 grade I
Wbc 9700
Hb 13.6 -bone marrow edema T11, T12
Plt 345000 hingga vertebra arc
Gds 223
-suspek hematom paravertebra
setinggi CV T12-L1
-MR myelografi : tampak
stenosis canalis spinalis CV
T11 hingga L1

5 Andi Qairil Dg Post debridement Lab (30/6/2019) MSCT Scan kepala - Head up 30ͦ Dr. dr. Nasrullah M,
Puan Baso TBI GCS 15 E4M6V5 WBC 10.8 SP.BS
887045 Fraktur maxilofacial RBC 3.70 -multiple fraktur kompleks os - oksigen via nasal kanul 3
05-06-1998 Hari ke 13 HB 10.8 frontalis kiri, os temporalis kiri, lpm
MRS 26-06- PLT 170 os zygomaticus kiri, os maxilla,
sisi medial kiri os mandibula - infus nacl 0.9% 20 tpm
2019
K3/6 Lab(26/6/2019) dan os nasal sutura ftontonasal - cefixime 1 gr/12 jam/iv (2)
UR/CR 105/1.46 dan sutura nasomaxilla kanan
SGOT/SGPT 29/22 - ketorolac 30 mg/8jam/iv
- dislokasi temporomandibular
NA/K/CL 140/5.0/102 joint dextra -metamizole 1gr/8jam/iv
PT/APTT 10.6/30.8
INR 1.02 -terapi lain sesuai TS plastik
GDS 104

KAMAR 4
1 Edwis Nandang TBI GCS 15 Lab(08/07/2019) CCT Scan kepala - Head up 30ͦ Dr. dr. Nasrullah M,
888310 Paraplegia + fraktur GDS: 109 SP.BS
24-12-2004 vertebra thoracal VIII – UR/CR 48/0.65 -Suspek retention cyst sinus - oksigen via nasal kanul 3
MRS 08-07- IX SGOT/SGPT 58/46 sphenoid sinistra lpm
2019 Listesis VIII-IX NA/K/CL 140/4.6/104 -Dandy walker variant - infus nacl 0.9% 20 tpm
K4/1 PT/APTT 10.5/22.2
INR 1.02 - cefixime 1 gr/12 jam/iv
- ketorolac 30 mg/8jam/iv
- omeprazole 40mg/24jam/iv
- dulcolax susp

2 Mahmud/L/46 - Skull defek Lab 17/06/2019 - Infus NaCL 0.9% 28 tpm Rencana DR.Dr.Willy
tahun WBC 7.4 - Ceftriaxone 1 gr/12 jam/iv cranioplasty Adhimarta, Sp.BS
03-05-1973 HGB 14.9 (K)
885889 PLT 195
MRS PT/APTT 9.8/26.6
10/07/2019 GDS 110
K4/2 Ur/Cr 9/0.89
SGOT/SGPT 22/29
LONTARA 3 BAWAH BELAKANG
NO IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP
PASIEN

LONTARA 3 ATAS DEPAN

NO IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN

LONTARA 3 ATAS BELAKANG

NO IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN

1. Hendra TBI GCS 15+ICH Lab 4/7/19 CT Kepala (Tanpa kontras) - Infus natrium -Head 30 derajat Dr.Andi
888088 Frontal Sinistra + ICH Wbc : 18.1 chloride 0.9% 20 tpm Ihwan,Sp.BS
13/3/1989 interhemisphere Rbc :4,58 -tidak tampak lesi
(30 tahun) frontal sinistra Hb: 14,7 hipodens/iperdens patologik -Cefotaxim 1
Kamar 6 Bed 3 Plt :250.000 intrakranial gr/12jam/iv
Pt/aptt :11.8/21.8
Inr :1,14 -subgaleal hematom regio -ketorolac 30 mg/ 8
GDS : 94 temporal dextra jam/iv
Ureum/kreatinin : Foto thoraks PA/AP -Ranitidin 50 mg/12
22/0.69
30/06/19 jam/iv
SGOT/SGPT : 45/51
Na/K/Kl :140/3,6/110 -TB paru aktif lesi luas
disertai atelektasis

-efusi pleura sinistra

Foto thoraks PA/AP


29/06/19

-Atelektasis lobus superior


sinistra

-TB paru lesi luas disertai


multiple bullae

-efusi pleura sinistra

-tulang-tulang intak

2. Muh.Tang -TBI GCS 13 + Maxial LAB 05/7/2019 - - IVPD Nacl 0,9% 28 -TS bedah plastik -
888190 facial injury tpm
09-09-1992 HB : 12,7
Kamar 6 bed 5 -Cefriaxon 1 gr/12
RBC : 4,5 jam/iv
PLT :245 -ketorolac 30 mg/ 8
WBC : 15,1 jam / iv

PT/APTT :10,8/29.7 -Omeprazole 40


mg/12 jam/i
UREUM/KREATINI:26/
0,68

SGOT/SGPT:62/37

Na/K/Kl : 137/4,2/105
3. SUPRIYADI/L/ TBI GCS 15 Lab 06/07/2019 - - Collar neck - Terapi sesuai TS Dr. dr. Djoko
34 tahun
- Multiple vulnus WBC 20.1 - Head up 30o bedah plastic dan mata Widodo, Sp. BS
excoriatum HGB 15.8 - O2 3 lpm (K)
29-06-1985 - Multiple trauma PLT 274 - Ceftriaxone 1 gr/12
PT/APTT 11.2/30.7 jam/iv
888228
GDS 83
Kamar 6 bed 6 Ur/Cr 30/1.02 Omeprazole 40 mg/ 24
5 SGOP/SGPT 123/108 jam/ oral
Na/Ka/Cl 141/4.5/103

LONTARA 4

NO. IDENTITAS PASIEN DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP
HCU

No IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN

1 Dhea - Paraparese inferior Lab 05/07/2019 MSCT scan dgn kontras - Head up 300 - TS Obgyn rencana Dr. dr. Nasrullah M,
ec. Fraktur vertebra SGOT : 27 (02/07/2019) - Infus NaCl 0.9% 20 tpm biopsi tapi tidak SP.BS
Zulfia/P/15ta
thoracal VIII-IX SGPT : 47 - tampak multiple massa - Fenitoin 100 mg/dalam NaCl urgent :
hun hiperdens (42 HU) batas 100 cc optimalisasi KU
WBC : 26.100 tegas, permukaan regular, - Ceftriaxone 2 gr/24 jam/iv - Rencana TS Kulit
887670
RBC : 4.13 non kalsifikasi dengan - Omeprazole 40 mg/24 jam/iv & Kelamin : Terapi
26/02/2004 HGB : 10.6 ukuran terbesar 4.4x4.1x2.9
- Ketorolac 30 mg/8 jam/iv dermatitis lanjut
PLT : 327.000 yang menyengat kontras (74
HCU Bed 1 - Paracetamol infus 1 gr/6 jam/iv sesuai TS
MCV : 79 HU) pada region frontalis
MCH : 25.6 bilateral, region occipitalis,
MCHC : 32.5 dan regio temporalis dextra
MRS
yang telah meluas hingga ke
01/07/2019 Lab 02/07/2019 sinus sphenoidalis
PT/APTT 1.2/21.9 KESAN: gambaran multiple
UR/CR 20/0.39 meningioma
Masuk HCU SGOT/SGPT 27/105
NA/KA/KL 136/3.4/99 Foto Thorsx (01/07/2019)
06/07/2019
WBC 34.31 - Elevasi diafragma dextra
RBC4.33 (proses intrahepatic?)
HGB 10.2 - Cor normal
2 M.Said/L/55t Craniopharingioma Lab 05/07/2019 Foto thorax AP  Nasal kanuul O2 4-5 liter/menit  Observasi tanda DR.Dr.Djoko Widodo,
hn residif post omayo Na : 129 (10/06/2019):  Infus NaCl 0,9% 20 tpm vital Sp.BS (K)
880572 hari ke 55 K : 3.9 - Terpasang CVC pada  Citicholin 500 mg/8
12/11/1963 Cl : 96 hemithorax kanan dengan jam/oral/NGT
HCU bed 2 ujung pada paravertebral  Ceftriaxone 1 gr/12 jam/iv
Hasil Kultur (04/07/2019) setinggi costa VII kanan  Sanmol 1 gr/8 jam/iv
- Sensitif : belakang kesan pada vena  Ambroxol tab 3x1/8
MRS Benzylpenicilin, cava superior jam/oral/NGT
15/05/2019 Ampicilin, Linezolid, - Terpasang tracheostomy
Vancomycin, pada trachea dengan ujung
Nitrofurantoin, tip setinggi 4.8 cm diatas
Masuk HCU Tigecycline
15/06/2019 carina
Hasil lab 01/07/2019 - Tanda-tanda bendungan
Wbc : 11.88 paru
HB : 10.4 - Dilatation et elongation
PLT : 497 aortae
HCT 33
Ur/cr : 21/0.48
Protein total : 5.2
Albumin : 2.8
Globulin : 2.4
Na/k/cl : 132/3.1/100

Urinalisa 20/06/2019
UUN : 14

3 Fitrah - Hidrocephalus post Analisa Gas Darah CT Scan Kepala tanpa - Infus dextrose 12 tpm - Rawat luka/2 hari Prof.Dr.dr. Andi
Perdana VP Shunting (07/07/2019) kontras potongan axial - Paracetamol 100 mg/8 jam/iv Asadul Islam, Sp.B (K)
M/1thn craniosinostosis post pH : 7.457 (05/07/2019) - Antibiotic sesuai TS pediatric
850219 rekonstruksi cranial SO2 : 96.8 - Terpasang VP shunt - Fenobarbital 40 mg/12 jam/iv
hari ke 10 PO2 : 85.9 dengan tip pada cornu - Amikasin 18 mg/12 jam/iv
09/06/2018 ctO2 : 14.5 posterior ventrikel - Paracetamol syrup 1 cth/8
PCO2 : 45.4 lateralis dextra jam/oral
MRS: ctCO2 : 33.7 - Hydrocephalus non - Cefadroxil (?) syrup 1 cth/12
22/06/2019 HCO3 : 32.3
communicans disertai jam/oral
BE : 8.2
gambaran colpocephaly - Ventolin : NaCl 0,9% = 1 : 1 /8
HCU bed 3
- Meningocele orbita jam/inhalasi
Lab (05/07/2019)
Masuk HCU WBC : 6830 medial sinistra
08/06/2019 RBC : 3.55 - Suspek colloid cyst of
HGB : 9.6 the third ventricle
PLT : 189000 - Disgenesis corpus
MCV : 84.5 callosum
MCH : 27.0
MCHC : 32.0

Lab (25/06/2019)
Anti TOXO IgG : 0
Anti TOXO IgM : 0.08
Anti Rubella IgG : 82 ()
Anti Rubella IgM : 0.15
Anti CMV IgG : 39 ()
Anti CMV IgM : 0.21

4. Sultang POH 5 cramectomy Lab darah (07/7/19) CT Scan Kepala tanpa - Paracetamol 500 mg/8 jam/oral - Aff drain Dr.dr.Nasrullah,Sp.BS(
888275 evakuasi hematoma GDS: 135 kontras ( 07/07/2019) - Ranitidine 150 mg/12 jam/oral - Bladder training -> K)
17/09/2002 EDH temporal sinistra - Cefixime 200 mg/12 jam/oral Aff catheter
MRS: - Aff infus
sssssss
07/07/2019 Lab darah (07/07/2019) -pendarahan epidural regio - Bisa pulang (tgl
(22.15 wita) temporoparietal dextra 12/7/2019) ->
HCU Bed 4 dengan estimasi volume Kontrol di prakter
WBC: 15.880
pendarahan +/- 139,04cc Dr. dr. Nasrullah,
HB: 12,3
Masuk HCU disertai herniasi subfalcine Sp. BS(K)
PLT: 146000
10/07/2019 ke sinistra +/- 1,3 cm.
HCT: 36,2
Ureum : 22 -Fraktur os temporal pasrt
Kreatinin : 0,93 vertical dextra disertai
Albumin : 4,1 subglaeal region
Na/K/Cl : 140/4,4/106 temporoparietal dextra

-sinusitis sphenoidalis
sinistra

Foto Thorax -
5 Cici/ 887448/ - POH 11 Lab (3-7-19) MSCT Kepala 3 dimensi - Infus NaCl 0.9% 20 tpm -diet lunak Dr.dr. Willy
19 Tahun Craniectomy WBC: 8000 non kontras (02-07-2019) : - Ceftriaxone 1 gr/12 jam/iv Adhimarta, Sp.BS
segmen fraktur RBC: 3.60 - Omeprazole 40 mg/12 jam/iv
28/02/2000 HGB: 10.5 -tulang mandibula intak
frontal dextra - Ketorolac 30 mg/8 jam/iv
PLT: 178.000 - Metronidazole 500mg/8jam/iv
MRS : -fraktur depresi os frontalis
29/06/2019 Lab (1-7-19) dextra,os supra orbita
Wbc : 9.55 dextra,lamina papyracea
HB : 9.3 dextra,os temporal dextra,os
HCU Bed 5 PLT : 167.000 nasal,os maxillaris bilateral

- Multihematosinus
Lab (29-6-19)
PT/APTT : 11/22.1 -pneumocephal regio
Masuk HCU: INR : 1.06 frontalis dextra
02/07/2019 GDS : 118
Ur/Cr : 24/0.89 -soft tissue swelling regio
SGOT/SGPT : 20/17 frontotemporal kanan
Na/K/Cl : 141/3.8/108
CT KepalaTanpaKontras
(29-6-19)

-Perdarahan epidural region


frontalisdextradenganestima
si volume perdarahan +/-
4cc

-Pneumocephal region
frontalisdextra
- Brain edema

-Multihematosinus

Frakturdepresiosfrontalisdex
tra, frakturgreather wing
dextra, lamina
papyraceadextradanos
temporal dextra

-Frakturos mastoid
sinistradisertaihematomastoi
dsinistra

Subgaleal hematoma region


frontotemporaldextradisertai
emfisemasubcutis

Foto Thorax (29-6-19)

-Tidaktampakkelainan

6 LaniLiptiaiy - POH 2 VP shunt ec Lab 07/07/2019 FotoPolos abdomen (07- - Asering 12tpm Prof.Dr. dr. A.Asadul
hidrancephaly SGOT : 42 06-2019) - Ceftriaxone 200mg/12jam/iv islam M, Sp.BS
/P/7 bulan
SGPT : 26 - Terpasang VP - Ranitidine 20mg/12jam/iv
882146 WBC : 13,9 shunt - Pct 100mg/6jam/iv
HGB : 9,0 padahemitorakssini - Stesolid rectal rectal 5g
05/12/2018
PLT : 596.000 stra yang melewati - Observasi tanda vital
PT/APTT: 12,8/24.5
midline dengan tip - Terapi sesuai ts gizi klinik
UR/CR: 21,8/0.26
HCU BED 6 pada ICS VI lanjut
NA/K/CL:136/5,7/103
kanandepan
- Gambaranpeningka
MRS tantekananintraabd
07/07/2019 ominal

7 Sofyan, 21thn - Traumatic Brain Lab 03/07/2019 Foto skull AP/Lateral - acc rawat jalan Dr.dr.Djoko Widodo,
Injury GCS 15 Bilirubin total : 0.53 (02/07/2019) - aff ngt, infus, catheter Sp.BS(K)
887510 Bilirubin direk : 0.2 - Fraktur os maxillaris
- Maxillofacial injury - ceftriaxone 200mg/12 jam/oral
22/05/1998 fracture symphisis os Albumin : 3.7 sinistra - paracetamol 500mg/12 jam/oral
HBsAg : non reaktif - Fraktur kominutif os
mandila+fraktur Anti HCV : non reaktif mandibular
maxilla+fraktur - Terpasang NGT dengan
MRS : tip tidak tervisualisasi
orbita sinistra
01/07/2019 Lab 07/07/2019
Wbc : 11.17 CT-Scan kepala tanpa
HB : 810.6 kontras (01/07/2019)
HCU bed 8 PLT : 240.000 - Tidak nampak lesi
PT/APTT : 11.1/24.6 hipo/hiperdens patologik
INR : 1.08 intracranial
GDS : 147 - Fraktur os nasal et os
HCU
Ur/Cr : 27/0.92 zygomaticum sinistra
02/07/2019 SGOT/SGPT : 55/41 - multihematosinus
Na/K/Cl : 142/4.2/110

8 Muhammad - POH 4 craniectomi Lab 10-07-2019 CT-Scan Kepala (07-07- -aff infus Dr. dr. Nasrullah,
elevasi segmen fraktur SGOT : 31 2019): - paracetamol 250mg/8 jam/oral Sp.BS(K)
Algifary/ L /
+cranioplasty SGPT : 29 - Tampak Fraktur -clopidogrel 250mg/8jam/oral
8 tahun WBC : 8.61 depressed pada os -rawat jalan
HGB : 10.2 parietal kanan, fraktur
888272
PLT : 385 pada os frontal kanan.
MRS PT/APTT:11.8/32.1
Tulang tulang lainnya
UR/CR: 13/0.36
07/07/2019 terscan intak
NA/K/CL: 150/4.8/92
HCU BED 9 - lesi hiperdens pada soft
8/7/19 tissue regio parietal kanan, di
sertai soft tissue edema pada
regio frontao parietal dextra.

9 Yusandi Post external drainase Lab 05/07/2019 : CT kepalatanpakontras: -NaCl 0.9% 20tpm -Head up 30° Prof. Dr. dr. Asadul
883853 ec IVH+ICH frontal WBC : 17.500 Islam, sp.BS(k)
19 tahun dextra RGB :3,60 - Perdarahan epidural frontal - Azytromicin 1 gr/24 jam/NGT
16/7/1999 HB : 10,4 dextra
- multiple ICH frontal -ranitidin 50mg/12jam/NGT
PLT : 522
MRS 22/5/19 dextra
-observasi tanda vital
Lab urin (4/7/19) - IVH
HCU Bed 10 Ur/Cr: 29/0.11 - SAH -paracetamol 500mg/8jam/oral
Protein total/alb 6.9/3.3 - Brain swelling NGT
24/5/19 Na/k/cl 127/4.2/90 - Multihemotosinus
-Pneumoorbitadextra
- Frakturos frontal dextra
- Subgalealhematom frontal
dextra
- Persistent cavum septum
pellucidum
10 A.Hafsah TBI GCS 14 Hasil lab 6/07/2019 CT SCAN KONTROL -rawat sama mata, Dr.dr. willy adhimarta,
886721 Na/K/Cl: 131/4.5/100 KEPALA 3/07/19 -terapi TS gizi klinik dan TS gizi, gh Sp.BS
01-07-1947 ICH temporoparietal UUN : 9
-pendarahan intracerebral GH lanjut
72 tahun dextra Hasil lab 26/06/2019
UUN : 8 lobus frontal et parietal -NaCl 0.9% 20tpm
HCU Bed 12 HT stage II on dextra serta capsula interna -ranitidin 50mg /12
treatment Hasil lab 25/06/2019 bilateral jam/NGT
MRS Albumin : 3.2 (Dibandingkandengan CT -paracetamol
23/12/2019 Protein total : 5.9 Scan 23-6-19 500mg/8jam/NGT
Globulin : 2.7 terdapatperbaikan) -ceftriaxone 1gr/12 jam/iv
Hasil lab 23/06/19 -Suspek diffuse axonal -ondansetron bila muntah
Wbc 16.200 injury
Hb 12.1
Plt 171000 -Focal brain injury
Na/K/Cl 136/4.4/105
-hematosinus ethmoidalis
SGOT/SGPT: 83/70 dextra et
sphenoidalissinistra

-wing fraktur greater wingos


sphenoid dextra

-subgalealhematom regio
occipital dextra

FOTO THORAX

-Cardiomegaly disertai
dilatation et atherosclerosis
aortae

-Terpasang gastric tube

CT KEPALA 23/06/19

-pendarahan intracerebral
lobus frontal et parietal
dextra serta capsula interna
bilateral dengan estimasi
volume pendarahan +/- 10.7
cc

-hematosinus ethmoidalis
dextra et
sphenoidalissinistra
-fraktur greater wingos
sphenoid dextra

-subgalealhematom regio
occipital dextra

ICU

IDENTITAS TERAPI
NO. DIAGNOSIS HASIL LAB RADIOLOGI PLANNING DPJP
PASIEN

1. Ny. ST. Rafiah WH post caling Lab darah CT Scan Kepala Tanpa -Terapi lanjut Dr.dr.Nasrullah,Sp.BS(
745099 hr 13 (08/07/19) Kontras(23-06-2019) sesuai TS Neuro dan K)
15/06/1950 GDS: 110 Anastesi
-Perdarahan
MRS: 28/06/2019
subarachnoid -rawat luka
ICU VIP 3 Lab darah -Atrofi Cerebri -mannitol 100cc/ 4
(08/07/2019) jam
WBC: 11,69 -Suspek mastoiditis
HB: 7,4 kanan -acetazolamid 500
PLT: 390000 mg/ 8 jam
HCT: 21,0
Ureum : 54 Foto Thorax
Kreatinin : 0,50 (23/06/2019)
Sgot/sgpt : 43/46 -Pneumonia kiri
-Suspek aspergilloma
lapangan atas paru kiri
-Suspek massa paru
lapangan tengah paru kiri
-Cardiomegaly
-Eleveasi diafragma
kanan

2. Dhea Wulansari Post op hari 0 Lab darah CT Scan Kepala tanpa -infus ringer laktat dr.Willy
882445 kraniektomi (11/07/19)
23/01/2003 dekompresi GDS: 134 kontras 20 tts/menit Adhimarta,Sp.BS(K)
MRS: 03/07/2019
-ceftriaxone 1g/12
jam
ICU BED 1 Lab darah Foto Thorax -
(11/07/2019) -ranitidine 5g/12
WBC: 9,9 jam
HB: 13,5
PLT: 416000 -ketorolac 3 g/ 8
HCT: 39 jam
Ureum : 18 -asam treksamat
Kreatinin : 0,50 50g / 8 jam
Albumin : 4,0
Na/K/Cl : -klem drain sampai
139/4,7/108 besok

-bila pasien sadar


belum boleh makan
dan minum

-metil prednisolone
125g/ 12 jam

3. Masna POH 3 (09/07/19) X-ray Thorax PA/AP -Rl 20tpm Prof.Dr.dr.Andi Asadul
862774 WBC : 13,51 (28-05-2019) Islam,Sp.BS(K)
HB : 12,9 -Tidak tampak tanda- -ceftriaxone 1gr/12
01/07/1961 cramectomy
HCT : 38,8 tanda metastasis jam / iv
MRS: 26/07/2019 removal tumor
GDS : 253 -Dilatatio et
ec. Astrocytoma Ur/cr : 31/0,49 atherosclerosis aortae -ranitidine
ICU BED 10 temporo parietal SGOT/SGPT : 50mg/12 jam/iv
dextra residif. 16/19 Foto thorax PA/AP
Na/K/CL : 08/07/2019 -ketorolak 30mg/8
142/4,0/104 - tidak tampak tanda- jam/iv
Albumin : 3,4 tanda metastasis pada
foto thorax ini -asam trexamat
Patologi Anatomi -dilatatio et 50mg/8 jam/iv
(06-12-2018) atheroscletosis aortae -fenitoin 100g/8
Diffuse
jam/dalam nacl
astrocytoma grade 0,9% 100 cc 10-15
III menit

-takar drain / 24
jam

NICU

NO. IDENTITAS PASIEN DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP

1 Anisa Galla -kejang Hasil Lab (04-07- CT-scan kepala 26-06- -tatalaksana kejang dr. Andi Ihwan, Sp.BS
neonatorum 2019) 2019 sesuai TS pediatrik
887092 - communicans -rawat luka/2hari
post VP shunt WBC: 8.8 - Severe hydrocephalus
13-06-2019 hari 7
-hidrocefalus Hb: 13.6 X-ray thorax (02-07-2019)
MRS 26/6/2019
comminicans
Plt: 346.000 - Terpasang gastric tube
NICU IIB
- Cor dan pulmo normal
(03-07-2019)

PT: 13.9

APTT: 29.8

GOT/GPT: 21/20

Alb: 3.0

Na/K/cl: 159/4.5/128

GDS: 90
PICU

NO TERAPI
IDENTITAS PASIEN DIAGNOSIS HASIL LAB RADIOLOGI PLANNING DPJP
.

2 Muh. Vaudzhan -Traumatic Lab (08-07- CT-scan kepala (03-07- -rencana pindah Prof. Dr. dr. Andi Asadul
brain injury 2019) 2019) - IVFD nacl 0.9% HCU bedah saraf Islam, Sp.BS(K)
GCS15 E3V5M6 Wbc: 9.3 20tpm
887933 - Perdarahan intracerebri
-Intracranial Hb: 13.8 - ranitidine -tunggu hasil CT
hematom Plt: 229.000 lobus 50mg/ 12 jam/iv scan kepala
27-12-2008 frontotemporo Rbc 4.90 frontotemporoparietal -metamizol
parietal dextra Hct 40 500mg/8jam/iv
dextra disertai herniasi
post AGD 7.419 -antibiotik & gizi
PICU Bed 2 craniectomy Pco2 39.2 subfalcine dengan sesuai TS pediatri
evakuasi hari 8 Hco3 25.6 volume perdarahan ± -rawat luka/2
-Maksillofasial BE 0.9 hari
MRS 03/07/2019 75.6cc
injury
-Fractur radius Foto antebrachii AP’Lat Pediatric
+ ulna dextra DS - Cephazoline
- Fraktur shalter harris 460mg/8jam/iv
tipe 1 os radius dextra - Fentanyl
- Fraktur oblique 1/3 2mcg/kgbb/jam
distal os ulna - Midazolam
1mcg/kgbb/jam
x-ray thorax (04-07-2019) - Ranitidine 46mg/
-terpasang ETT pada 12 jam
trachea dengan tip ± 5.2 cm - Ketorolac
diatas carina 15mg/8jam/iv
-Terpasang gastric tube
-cor dan pulmo normal

3 ALENA NOVELIA -Spontan ICH Lab 10/07/2017 CT KEPALA (Tanpa -Terapi lain Manitol Dr.dr Nasrullah, M Sp. BS
886413 regio Wbc: 3.57 Kontras) sesuai TS 38cc/6jam/ivtravena (K)
parietoocipital Rbc 9.7 pediatrik
23/11/2013 07/07/2019
bilateral Hb: 29 -Terapi lain
MRS : 07/07/2019 -Acute Hct: 80 Perdarahan intracerebri sesuai TS
Plt: 13.7 pediatrik
Picu bed 4 Lymphoblastic parasagital lobis parietal
bilateral dan occipital
leukima Pediatric
bilateral terutama sinistra
-jamin oksigen 2lpm
dengan estimasi volume
-IVFD RL 20tpm
perdarahan +-30.1 cc
-Diazepam 10mg/
-Gambaran dendy walker
rectal
variant
-paracetamol
200/8jam/ml/Ivo

4 Muh. Ukasya - cystic - cystic Hasil lab: Foto Thorax -ceftriaxone - Perbaikan KU DR.Dr. Djoko Widodo,
886706 astrocytoma 04/07/2019) (27/06/2019) 500mg/12jam/iv Sp.BS (K)
post drainase -ranitidine
01-01-2017 -WBC: 9.42 -Terpasang gastric tube
intratumor hari 15mg/12 jam/iv
ke-9 -RBC 3.27 dengan tip kesan pada gaster -paracetamol
MRS 27/6/2019
-post syok susp -HGB: 9.0 - Cor dn pulmo dalam batas 120mg/ 6 jam/iv
septik syok - Rawat
PICU Bed 8 -Pneumonia -PLT: 545.000 normal luka/2hari
-susp. -terapi lain sesuai
Perdarahan TS pediatric
- PT/INR/APTT : CT-scan control (03-07-
tekanan cranial
bagian atas 9.8/0.95/24.6 2019) Pediatric
-Tonic seizure - CRP kuantitatif : -suspek intracranial - jamin oksigen
20.5 teratoma lobus 2lpm
- Prokalsitonin : temporoparietal sinistra - IVFD Ringer
0.13 disertai oerdarahan asetat 48.9ml/jam/iv
intratumoral, - gentamicin
(01-07-2019) pneumocephal dan herniasi 66mg/24 jam/iv
-Na/K/Cl : subfalcine ked extra - meropenem
136/5.2/104 sejaHypertensive 400mg/8jam/iv
-Albumin :3.3 hydrocephalus - Fenobarbital
- GDS : 69 communicans disertai 30mg/ 12 jam/
- Ur/cr: 17/0.15 perdarahan ventrikel dan sonde
- SGOT/SGPT: pneumoventrikel - Asam valproat
50/121 -terpasang drain dengan tip 1.65mg/ 12 jam/oral
-D Dimer: 0.58 kesan intratumor - piracetam
170mg/6jam/iv
- paracetamol 16
mg/8jam/iv
- vancomycin
180mg/24jam/iv
- susu formula
8x100ml via sondel
PCC

NO. IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN

Darmawi Skull defect (04-07-2019) CT Kepala (tanpa Terapi lain sesuai Ts GH


1. 283924 region WBC : 10.6 kontras) (04-07-2019) Cranioplasty Prof.Dr.dr Andi
Asadul
40 tahun/ 12-11-1978 temporoparietal HGB : 14.5 Kesan : Optimalisasi KU Islam,Sp.BS (K)
MRS 09-07-2019 sinistra HCT : 43.3 - Encephalomaiac
Kamar 310 Hipertensi grade PLT : 322 ia lobus Konsul GH
1 GDS : 91 temporo parietal
Ur/Cr : 21/0.93 sinistra disertai
SGOT/SGPT: ventriculomegal
28/25 y ex vacuo
Na/K/Cl:
- Defect os
136/4.0/104
temporoparietal
sinistra disertai
herniasi
menings dan
parenkim
cerebri

UNHAS

NO. IDENTITAS DIAGNOSIS HASIL LAB RADIOLOGI TERAPI PLANNING DPJP


PASIEN

1 Wafa Al-firdausy Hidrocephalus (02/07/2019) MSCT Scan Kepala tanpa Infus RL 16tpm dr. Andi Ihwan,
hardin post op hari w kontras (28-06-2019): Sp.BS
WBC : 12.43 Cefotaxime 200 mg/12
VP shunting
122600 - Communicating jam
HGB : 16.1 hydrocephalus
30-05-2019 disertai dengan Paracetamol 50 mg/8jam
HCT : 46.1
MRS 09-07-2019 suspek Ranitidine 50mg/12jam
Kamar 407 PLT : 520 transependymal Mobilisasi
edema DD/infesi
GDS: 82 Diet biasa
Ur/Cr : 10/0.6
GOT/GPT : 46/36
Na/K/Cl : 131/5.6/99

dr. Andi Ihwan,


2 Syahrir Baskit meningioma (04/07/2019) Infus NaCl 0.9% 1500 Sp.BS
suprasellar cc/24jam
112552 WBC : 5.14
Ceftriaxone 1gr/12jam
MRS 11-07-2019 HGB : 14.1
1 jam pre op
HCT : 40.7
Siap darah (2 ambil, 2
PLT : 286
siap)
Aptt : 24.1
GOT/GPT : 29/39
Na/K/Cl : 135/3.8/100