Ward Report

Tuesday, 30th on April 2019

A. Patient Referred to other hospital: (-)

B. Patient died (-):
C. Patient Treated in GICU (9) :

1. Adi Juliansyah / Male / 27 Years old /Days 3 / Bed 1 (improvement)

S: (-)

O A : Clear

B : Nasal canul 3l/m RR : 18 x/m SpO2: 99 %

C : BP : 106/75 mmHg HR : 102 x/m

D : E4V5M6 : 15

E : Sinus rhytm Isochoric Pupil, Light Reflex +/+

F : Fluid Balance: Lab 28-4-2019 Lab 28-4-2019

pH : 7,295 Hb : 11,5
I : 3923 cc pCO2 : 47,8 Leu : 25530
pO2 : 109,7 Ht : 32
O : 661 cc Plt :3
IWL : 125 cc Ur/Cr : 54/0,71

Total : 2692 cc/24 hours

Regio Abdomen
I : Dry gauze (+), Drain (+) produksi 20 cc/24 jam serous hemorrhage
P : Soft (+)
P: tympani
A : Bowel sound (+) n

A. Diffuse Peritonitis ec. Perforation of Colon transversum post laparotomy exploration +

colostomy POD 2 (28-4-2019)

P. IVFD RL gtt xx/min -Omeprazole 40 mg / 24 hours IV

Ceftriaxon 2g/12 hours IV -Ketorolac 30mg/8 hours IV

2. Mohd. Amin Daoed/Male/ 67 years old/ Day 1/ Bed 3

S: (-)

O A : Clear

B : Nasal Canul 3 l/m 100%

C : BP 106/65 mmHg 66x/m

D : GCS : E4M6V5=15 isochoric pupil, Light Reflex +/+

E : Sinus Rhytm Lab 30-4-2019

Hb: 12.7
F : Fluid Balance Leukosit: 18.740
Trombosit: 407000
I : 190cc pH: 7,358
pCO2 : 42,4
O : 100cc pO2: 129,5

IWL : 30cc

Total : 90cc/1 jam

Thorax Region:

I: Dry Gauze (+)

A: Post Decortication Thoracotomy ec Left Lung Abses POD 1

P: Ceftriaxon 1g/12 hour

Meropenem 1g/ 8 hours

Ciprofloxacin 200mg/ 12 hours

Omeprazole 40mg/ 24 hours

Paracetamol Inj. 1g/8 hours

Furosemide 20mg/ 12 hours

Nebulizer Ventolin/8 jam

3. Enny Safina/ Female / 49 years old / Day 6 / Bed 5 (improvement )

S: (-)

O A : Clear

B : NRM 10 Lpm RR : 26 SpO2: 100 %

C : BP : 147/90 mmhg HR: 80 x / menit

D : GCS : E4M6V5= 15 isochoric Pupil, Light reflex ++/+

E : Sinus rhytm Lab 30-4-2019

Lab 30-4-2019
Hb: 10.0
F : Fluid Balance pH : 7,358
Leu 6020
pCO2 : 42.4
Plt 407000
I : 1558 cc pO2 : 129.5

O : 1364 cc
IWL : 59cc
Total : - cc/24 hours
Femur Dextra Region :
I : Dry gauze (+ ()

A. Gangren Gruris dextra post amputatamu region femur dextra et femur dextra tGangren
crurus dextra et femur dextra post amputatum trans femoral POD 6 (24-4-19)

P : IVFD RL gtt xx/minute Asam tranexamat 1 mg/ 8 hours IV

Meropenem 1 gr/8 hours IV Metoclopramid 10 mg/8 hours IV

Paracetamol 1gr/8 hours IV Ca Gluconas 10 gr/ 8 hours

Omeprazole 40 mg/8 hours IV N Acetyl sistein 200 mg/8hours NGT

4. Ronaldoe/ Male/ 22 years old/ Day 1/ Bed 6
S : (-)

O : A: ETT

B: SIMP PEED 5 FiO2 50% SpO2: 100%

C: BP: 98/60 HR :18x/m

D: GCS E4M6VT=10T

E: Sinus Rhytm Lab 26-4-2019

Hb : 9.8
F: Fluid Balance Leu : 13880
Plt : 547000
I : 1550cc Ht : 29
Ur :9
O : 640 Cr: : 0.8
Na : 138
IWL : 460 K : 4.0

Total: 450cc/ 24 haours

Thorax Region Anterior et Posterior

I : Wet Gauze

A : Ulcus Granulosum Region Temporal Sinistra + Thorak Anterior et Posterior +

Post Debridement POD 1

P: Ceftriaxone 2g/24 hours

Omeprazole 40mg/ 24 hours

N Acetylsystein 200mg/8 hours

Vit C 1g/8 hours

5. Depit bin Nasir/ Male/ 53 years old /Days 3/ Bed 8 (Improvement)

S : (-)

O : A : Clear

B : Nasal Canul 3L/m RR : 15 x/ m, SpO2 : 100%

C : BP : 132/65 mmHg HR : 58 x/m

D : GCS: E4M6V5= 15 Isochoric Pupil, Light Reflex +/+

E : Sinus rythm Lab 30-4-2019 Lab 30-4-2019

pH : 7,454
F: Keseimbangan cairan Hb : 10,0 pCO2 : 30,7
Leu : 11990 pO2 : 281,8
I : 1750 cc Trombo: 171000 Laktat : 1,6
Ht : 27
O : 2462 cc

IWL : 151 cc

Total : -712 / 24 hours

Cranium Region :

I : Dry Gauze (+), Drain (+) production 30 cc / 24 hours

A : EDH Temporoparietal sinistra lobe + SDH Temporoparietal dextra lobe post

Craniotomy evacuation POD 4 (26-4-19)

P: IVFD RL gtt xx/ min IV

Morphin 10 mcg/kgBW/hour

Dexmedetomidin 0,2 mcg/ kgBW/8 hours IV

Ceftriaxone 2g/24 hours IV

N Acetyl Cisteine 200 mg / 8 hours PO

6. Ardiansyah Bin Abidin/Male/ 19 years /Days 6/ Bed 8 (Improvement)

S : (-)

O : A : Clear

B : Nasal canul 3 lpm RR : 12 x/ m, SpO2 :100%

C : BP : 110/80 mmHg HR : 93 x/m

D : GCS: E4M6V4 = 14 Isochoric Pupil, Light Reflex +/+

E : Sinus rythm Lab 28-4-2019 Lab 28-4-2019

Hb : 8,1 pH : 7,445
F: Fluid Balance Leu : 12.390 pCO2 : 29,3
Ht : 23 pO2 : 137,7
I : 2480 cc Trom : 238.000 HCO3 : 21,2
O : 2150 cc

IWL : 450 cc

Total :- 120 cc/ 24 hours

Cranium Region :

I : Dry Gauze (+), Drain (+) production 15 cc / 24 Jam

A : SDH Temporoparietal lobus dextra + cerebral edema + Post craniotomy

decompresi POD 6 (24-4-19)

P: IVFD RL gtt xx/ min IV

Morphin 10 mcg/ hour

Norephinefrin 0,1 mcg / hours

Ceftriaxone 2g/24 hours IV

Omeprazole 40 mg/24 hour

Paracetamol 1g/8 hous IV

N Acetyl Cisteine 200 mg / 8 hours PO

Manitol 150 mg / 8 hours IV

7. Syarifah/ Male / 58 years / Days 3 / Bed 11 (Improvement)

S :(-)

O A: ETT

B :SIMPV PEEP 5 FiO2 50% RR : 34x/m SpO2 98%

C : BP : 172/98 mmHg HR : 110 x / mnt

D : GCS : E4M6VT : 10T

Lab 28-4-2019
Hb :13,6
E : Sinus Rhythm Leu : 12.390
Ht :418
F: Fluid Balance Trom : 279.000

I :1650 cc

O :1350 cc

IWL l : 370 cc

Total : -70 cc/24 jam

Frontal region
I : Dry Gauze (+)

A ICH + SDH + edema cerebri post craniotomy evacuation POD 2 (28/4/19)

P: IVFD RL gttxx/m

Paracetamol 1 gr/8 hours

Ceftriaxon 1 gr/12 hoursIV

N asetilsistein 200mg/8 hours PO

Omeprazole 1 x 40 mg IV
8. Ayu Hastari / female / 23 years/ Day 2 / Bed 12 (improvement)

S :(-)

O A: ETT

B : SIMV + PEEP 5 FiO2 50% RR : 36x/m SpO2 98%

C : BP : 100/79 mmHg HR : 110 x / mnt

D : GCS : Under Drugs Effect

E : Sinus Rhythm
Lab 30-4-2019
Hb :9,2
F: Fluid Balance
Leu : 10430
Trom : 104.000
I : 2600 cc pH : 7,444
pCO2 : 28,1
O : 1350 cc pO2 : 176,7
IWL : 448 cc

Total : 802 cc/24 jam

Anterior colii region :

I : Dry Gauze (+)
A Tyroid Tumor Suspect Malignancy post debulking POD 1 (29/4/19)

P: IVFD RL gttxx

Cefriaxon 1 gr/12 hours IV

Paracetamol 1 gr/8 hours

Dexamethasone 0.3 mg / kgBB

Omeprazole 1 x 40 hours IV
8. Halwiyah bt D.G. Malimpo / Female/ 46 years old / Days 16 / Bed 13 (no
improvement)

S :(-)

O A: Tracheostomy

B :SPONT 5 FiO2 50% RR : 36x/m SpO2 98%

C : BP : 135/63 mmHg HR : 110 x / mnt

D : GCS : E4M3VT= 7T

E : Sinus Rhythm Lab 29-4-2019

Hb : 8,5
F: Fluid Balance Leu : 12200
Trom : 580000
pH : 7,451
I :1950 cc
pCO2 : 34,4
O :1820 cc pO2 : 38,5
Lactat :1,2
IWL : 52 cc

Total : -78 cc/24 hours

Frontal Region
I Dry gauge (+)
A Post Craniectomy Dekompresi for infra cerebral infarction POD 17 (13-4-2019) +
Merkell cell tumor OD post embolization + Anemia + Hipokalemia + Hipoalbumin

P: IVFD RL gttxx

Norepinefrin 0,3 mcg /minute

Paracetamol 1 gr/8 hours

Dexamethasone 0.3 mg / kgBB

Amikacin 1 gr/8 hours IV

N asetilsistein 200mg/8 hours PO

Omeprazole 1 x 40 hours IV
D. Patient treated in PICU (3) :

1. Dimas Faris Maulana /male/ 1 year / Days 1 / Bed 1

S : (-)

O : A : ETT

B : SIMV, PEEP 5, FiO2 40% RR: 15 x/m SpO2 : 99%

C : BP :129/758 mmHg N: 87 x/m

D : GCS E3M2VT = 5T Isochoric Pupil, Liight Reflex+/+

\ E : Sinus rythm Lab 30-4-2019

Hb : 10,2
Leu : 45.1
Fluid Balance Ht : 33
I : 986 cc Plt : 92
Ur : 124
O : 650 cc Cr : 1,08
Alb : 3,1
IWL : cc

Total : 336 cc/24 hours

Thorax Region

I : simetris, Chest tube (product-, undulation+, air bubble-)

P : sonor both hemothoraks

A : vesikuler both hemithoraks

A : Pleural Efussion Dextra + Emfisema Femoris sinistra + Tension Pneumothorax

sinistra Post WSD Sinistra POD 1

P : IVFD NaCL 88 cc/hour

Vancomycin 140 mg / 8 hours Fenitoin 2 x 100 mg
Ceftazidim 200mg / tiap 8 hours
Paracetamol. 70 mg /6 hours
Furosemide 5 mg / 4jam
2. Ganta Putra Aditama/male/ 6 years / Days 8 (Improvement)

S : (-)

O : A : ETT

B : NRM 6 LPM RR: 15 x/m SpO2 : 99%

C : BP : 125/75 mmHg N: 87 x/m

D : GCS E4M6V5 = 15 Isochoric Pupil, Light Reflex+/+

E : Sinus rythm

Fluid Balance Thorax region

I : 2765 cc Regio Thorax

O : 2019 cc I: Product WSD 100cc,undulation +, air bubble -

IWL : 469c P: Sonor +/+

Total : 277 cc/24 hours A: vesikuler +/+

Lab 30-4-2019
Hb : 9,9
Leu : 16270
Trom : 787.000
Alb : 3.3
Ur : 15
Cr : 0.38

A : Demam dengue + Pneumonia+ Pleural Effusion Dextra Post WSD Dx POD 1

P : IVFD NaCL gtt X /hour

Ceftazidim 650mg / 8 hours
Ampicillin 750mg / 6 hours
Paracetamol. 130 mg /6 hours
3. Farhan Muhammad hidayat/male/ 16 years / Days 11 / Bed 4
(No Improvement)

S : (-)

O : A : ETT

B : SIMV, PEEP 5, FiO2 40% RR: 15 x/m SpO2 : 99%

C : BP : 125/75 mmHg N: 87 x/m

D : GCS E1M2VT = 3T Isochoric Pupil, Liight Reflex+/+

E : Sinus rythm
Lab 19-4-2019
Fluid Balance Hb : 16.9
I : 2642 cc Leu : 17040
Trom : 386000
Ca :8
O : 1978 cc
Na : 145
K : 3.2
IWL : 400cc

Total : 264 cc/24 hours

Right Temporoparietal Region

I : Dry Gauze (+)

A : SOL lobus temporoparietal dextra Post conventional burrhole + Abses evacuation

POD 10 (20/4/19)

P : IVFD NaCL 88 cc/hour

Ceftriaxon 1 x 2 gr Fenitoin 2 x 100 mg
Metronidazole 3 x 360 mg
Ampicillin 3 x 2 gr
Paracetamol. 500 mg /6 hours
Manitol 3 x 250 mg
E. Pasien treated in NICU (4)
1. By Ny Ririn Amelia/ male / 1 month (8-3-2019)/ Days 29/ Bed 6 (No Improvement)

S : (-)

O : A : Nasal Prong

B : BCPAP PEEP 7 FiO2 30% RR: 48 x/m SpO2 : 100%

C : HR: 144x/m

D : Hipoactive Isochoric pupil, Light reflex +/+

E : Sinus Rhytm LAB

F: Fluid balance
Lab 29-4-2019
I : 420 cc Hb : 14.4
Leu : 10210
O : 130 cc Trom : 96000
Ht : 40
IWL : 45 cc
Total : 245 cc/24 hours
Abdominal Region
I : dry Gauze
P: Soft
P: Thympani
A: Bowel sound (+)

A : Perforastion of gaster pre pyloric + Divertikel Meckel Post Laparatomy

exploration + Repair Perforasi gaster POD 30 (30-3-19) + Trombositopenia

P : IVFD D10 1/5 + Kcl 7,5 speed 5,8cc/ hour

Metronidazole 12 mg/12 hours IV
Meropenem 60 mg/8 hours IV
Amikasin 12 mg/8 hours IV
Transfusi TC 3x15 cc
2. By Ny Murtasimah/Female/1 month (27-3-2019)/ Days 34/ Bed 6 (Improvement)

S : flatus+, defecation +

O : A : Nasal Prong

B : NIV PEEP 5 FiO2 50% RR: 44 x/m SpO2 : 100%

C : HR: 120x/m

D : Hipoactive Isochoporic pupil, Light Ref;ex +/+

E : Sinus Rhytm Lab 28-4-19

Hb : 13,6
F: Fluid Balance L : 17.46
I : 209 cc Tr : 388.000
Alb : 4.3
O : 204cc Na : 140
IWL : 301 cc K : 4.9
Total : -296 cc/24 Jam
Abdominal Regiom
I : Flat,
P: Soft
P: Thympani
A: sound bowel movement (+)

A : Bowel obstruction ec susp NEC

P : IVFD D10 1/5 NS + Ca Glukonas 20 cc + Kcl 4 cc kec 6.0 cc/ hour

Aminosteril 16% Kec 3,5 cc/ hour
Ceftazidime 160 mg/8 hours IV
Omeprazole 3 mg/8 hours IV
Asam tranexamat 30 mg/ 12 hours
3. By Ny Evi Kusnaini/Female/15 days (15-4-2019)/ Days 5/ Bed 7 ( improvement)

S : (-)

O : A : Nasal Prong

B : SIMV PEEP 5 FiO2 30% RR: 38 x/m SpO2 : 97%

C : HR: 126 x/ m

D : Hipoactive isochoric popil, Light reflex +/+

E : Sinus Rhytm
Lab 30-4-19
F: Fluid balance Hb : 14.3
I : 920 cc L : 13.320
Tr : 266.000
O : 540 cc Ht : 41
IWL : 210 cc Albumin : 3.3
Total : 170 cc/24 hours
Abdominal Region
I : flat Dry Gauze (+)
P: Soft
P: Thympani
A: Bowel sound (+)
A : Hernia diafragma sinistra (bochdalek type) Post defect repair POD 6 (24-4-19)+
Hipoalbumin

P : IVFD D10 1/5 NS + Ca Glukonas 19 cc + Kcl 4 cc speed 7,8 cc/ hour

aminosteril 6% kec 2,5 cc/ hour
ampicilin 40 mg/8 hours IV
Ceftazidime 80 mg/8 hours IV
Paracetamol 15 mg / 8 hours IV
4. By M Rizki / male/29 days (1-4-2019)/ Day 6/ Bed 12

S : (-)

O : A : ETT

B : SIMV PEEP 5 FiO2 30% RR: 42 x/m SpO2 : 100%

C : HR: 143 x/ m

D : Hipoactive Isochoric Pupil, Light reflex +/+

E : Sinus Rhytm
Lab 19-4-19
F: Fluid balance
Hb : 14.8
I : 755 cc L : 10.770
Tr : 519.000
O : 640 cc
Ht : 46
IWL : 120 cc GDS : 65
Total : -5 cc/24 Jam

Abdominal Region
I : dry gauze (+) flat
P : soft
P: tympani
A : Bowel sound (+)

A : Hernia diaphragm Post repair Hernia diaphragm POD 5 (25-4-19)

P : IVFD D10 1/5 NS + Ca Glukonas 19 cc + Kcl 4 cc speed 7,8 cc/ hour

ampicilin 40 mg/8 hours IV
Ceftazidime 80 mg/8 hours IV
Vitamin K 1 mg / 8 hours IV
Tranexamat acid 30 mg/ 12 hours IV
Omeprazole 30 mg/ 12 hours IV