SENSUS BEDAH SARAF

Minggu, 08 September 2019

R U A N G B E D A H W A N I T A
( 4 P a s i e n )
N o

N a m a
D M
Ruangan
M R S
D i a g n o s i s
T i n d a k a n
L a b
R e n c a n a
1 .
An. Seria Kmur
Umur 9 Tahun
BB 22kg
463371
R B W
03/09/19
Susp spondilostesis cervical
- I V F D N a c l 2 0 t p m
- Inj mekobalamin 3x150mg
- Drip pct 3x250mg
- Lacak TB sesuai dr.spA
H b 11 , 0
WBC 12,97
Konservatif
2 .
Ny.Grace lano
Umur 36 tahun
462770
R B W
28/8/19
- F r l u m b a l 4
- Other injury of lumbal spinal cord
- Canal stenosis
- IVFD RL+tramadol 1amp 20tp m
- inj ranitidin 2x1amp
- inj mekobalamin 2x1amp
- Pct 3x500mg (po)
- OAT FDC 4 tab (H3)
- Lactulosa syr 3x1C
H b 1 0 , 8
WBC 7,84
Prolaminectomy dekompresi
3 .
N y. S i m p e n
Umur 61 tahun
463431
R B W
2 / 8 / 1 9
Riw hidrosefalus post VP Shunt
- IVFD clinimix 1500cc+clinolic/24ja m
- inj Ranitidin 2x1amp
- inj ondansentron 3x1amp (k/p)
Pro revisivp shunt
- inj piracetam 2x1gr
4 .
- pct 3x500mg/NGT (k/p)
Ny.Antoneita Raweyai
- Vit B6 1x1
Umur 46 tahun
- Darplex 1x3tab (slma 3hari) H3
001266
- MLP 6x100cc
-cek DDR
 R B W
03/9/201 9
Contusio temporooksipital bilateral + encephalopatyKraniotomy dekompresi H3
Inj.Manitol 3x125cc H3
Clinimiks 1000cc/24jam + RL 500cc/24j
Tutofusin 1000cc/12jam
Nebulizer+combiven/8j
Inj.Phenytoin 3x100mg
Ceftriaxone 1x2gr
Kalneks 3x500mg
Inj.Ranitidin 2x50mg
Pct 4x500mg
Antrain 3x500
Piracetam 2x1gr iv
Semaks 4x6 tetes
Balance cairan

Post Craniotomy

R U A N G B E D A H P R I A ( 7
p a s i e n )
N o
N a m a
D M
Ruangan
M R S
D i a g n o s i s
T i n d a k a n
L a b
R e n c a n a
1 .
T n . A g us D a s t r a
 4 6 8 1 7 1
R B P
06/09/19
LBP ecfr.kompresi L2

Retensio urin
IVFDNacl0,9%20tpmmakro
Inj.Antrain3x1ampIV
Inj.Mecobalamin2x1ampIV
Inj.Ranitidin2x1ampIV
Pasangkorsetlumbal

H b 1 2 . 6
WBC9.92
Senin CT scan tulang belakang non contras
RBC4.93 Rencana naik ok
GDS76 2 .

Tn.AbrahamWaicang
Umur 19 tahun

4 6 0 5 3 4
R B P
21/08/19
- Difus Axonal injury
- Encephalopaty

- Venflon (+)
- Ranitidin 2x150mg (po)
- Piracetam 2x1200mg (po)
- Citicolin 2x500mg (po)
- Nebulizer combivent:Nacl 1cc/12jam
- Semax 3x4tts NDS
- Mobilisasi di kursi roda
- Fisioterapi

Konservatif
4 .
Tn. Khosum
Umur 37 tahun
4 6 6 7 7 0
R B P
30/08/19
Post Craniotomy ec EDH (H9)+fr basis cranii
- IVFD RL 1500cc:clinimix 1000cc/24jam
- Manitol 1X125cc (H5)
- inj ceftriaxon 2x1gr (H10)
- inj ranitidin 2x1amp
- - inj ketorolac 3x1amp
- inj piracetam 2x3gr (H10)
- inj metronidazole 3x500mg (H3)
- halloperidole+THP 2x1caps
- Diamox 2x250mg (po)
- KSR 2X600mg (po)
Hb 13,6
WBC 21,66
RBC 4,71
PLT 284
Post craniotomy
6 .
Tn. Adi Nurcahyo
Umur41 thn
4 6 8 7 3 9
R B P
04/8/2019
Hidrosefalus ec ensefalitis dan Vasculitis TB, post EVD H1
- IVFD D5 ½ NS 2000cc/24jam
- inj ranitidin 2x1amp
- inj fenitoin 3x100mg
- Inj.Ceftriaxon 2 x 1 gr
- inj paracetamol 3x500mg
-injondansentron 3x1amp k/p
-inj MZ 2x1vial (pagi)
- OAT 1x3tab

Hb 13.0
WBC 8.26
RBC 4.47
GDS 94
P o s t E V D
Pro VP Shunt
7 .
Tn. Yulius Pangkata
Umur19 thn
4 6 5 1 7 1
R B P
4/8/2019
SOL regio occipital dd GBS dd Tuberculoma
- IVFD RL+tramadol 1amp 20tpm makro
- inj ranitidin 2x1amp
- inj fenitoin 3x100mg
- inj omz 2x1vial
- Inj.Ceftriaxon 2 x 2 gr
- inj ketorolac 3x1amp
- injondansentron 3x1amp
- inj dexamethasone 4x5mg (H2)
Hb 12,9
WBC 4.86
RBC 4.53
GDS 93
Pro Craniotomy removal tumor
8 .
Tn. Hans Sobolim
Umur 40 tahun
4 6 7 8 8 7
R B P
6/9/2019
Hidrosefalusobstruksiecsusp meningioma ddtuberkuloma
- IVFD Nacl 0,9% 1500cc/24jam
- Inj dexamethasone 4x5mg (H2)
- Injomz 2x1vial
- Injantrain 3x1amp
- Diamox 2x500mg
- KSR 2x600mg
Hb 15,8
WBC 6,40
RBC 5,34
PLT 175
CT scan kepaladengankontras, Thorax PA
Pro VPShunt

R U A N G S A R A F ( p a s i e n )
N a m D i a g n o sT i n d a L a R e n c a n
N o Ruangan M R S
a i s k a n b a
R K K ( p a s i e n )

N oN a m a Ruangan M R SD i a g n o s i sT i n d a k a nL a bR e n c a n a

R u a n g O r t h o p e d i

N oN a m aR u a n g a nM R SD i a g n o s i sT i n d a k a L a bR e n c a n a

R U A N G V I P

N oN a m a Ruangan M R SD i a g n o s i sT i n d a k a nL a bR e n c a n a

R U A N G K E L A S 1

N oN a m a Ruangan M R SD i a g n o s i sT i n d a k a nL a bR e n c a n a
1 .T n . L a s u k i K e l a s 1 0 1 / 0 8 / 1 SDHakut+EDH+Kontusiolobusteporoparietalkiri+encephalopaty+fr.depressedostemporal+fr.maksilofacial+ IVFDDS½NS->2000cc/24jam
9 PostkraniotomydekompresiH3 Inj.Ceftriaxone2x2
gr
Inj.Manitol4x125m
 g
Inj.Phenytoin3x100
mg
Inj.Kalnex2x500m
g
Inj.Ranitidin2x1amp

I G D

N oN a m aD MRuanganM R SD i a g n o s i sT i n d a k a nL a bR e n c a n a
IVFD NS 0,9% 20 tpm makro
Inj.Ranitidin 2x1 Iv
Inj.Ceftriaxon 2x1 gr IV
Tn. Zakarias sokoy
1 . 4 6 0 4 7 2I G D 0 7 / 0 9 / 1 9Open fr.frontalis sinistra+MVL+EDH Inj. ATS IM Cek DL,GDS,Elektrolit,HbsAg, HIV,PT/APTT, Crosmetch, Konservatif
Umur 25 thn
Inj.Piracetam 2x3 gr
Manitol 4x125 cc
I C U

N oN a m aD M Ruangan M R SD i a g n o s i sT i n d a k a nL a bR e n c a n a

- I V F D
- inj ceftriaxon 2x1gr
Tn.Jhon Loupatty
1 . I C U 3 1 / 8 / 2 0 1 9 Spontaneus ICH thalamus dengan hidrosefalus+encephalopat, post VP Shunt (H1) - inj kalnex 3x500mg Post VP shunt
Umur 51tahun
- inj paracetamol 3x500mg
- inj ranitidin 2x1amp
2 .

R E S

N o N a m aR u a n g a nM R SD i a g n o s i sT i n d a k a nL a bR e n c a n a

D A F T A R P A S I E N K O N S U L

N oN a m aRuanganM R SD i a g n o s i sT i n d a k a nL a bR e n c a n a
P O L I

N oN a m aR u a n g a nM R SD i a g n o s i sT i n d a k a nL a bR e n c a n a

Pasien pulang :

N oN a m aD MR u a n g a nM R S D i a g n o s
TTn.Paulus Mangru
1 . 0 9 8 5 0 3R B P 3 1 / 0 8 / 1 9T r a u m a t i c S A H
Umur 46 thn
Tn. Hermon Mayakori
2 . 4 6 6 3 7 0R B P3 0 / 8 / 1 9 Open depressedfr.osFrontal, ICH Lobus frontal + Pneumocephalus + ensefalopaty
Umur 17 thn
T n . E s r a
3 . 4 6 2 4 7 5R B P0 1 / 0 9 / 1 9 P o s t c r a n i o t o m y d e k o m p r e s i
Umur 27 thn

Pasien meninggal:

N o N a m aR u a n g a nM R SD i a g n o s i s