KORAN BEDAH SARAF

MINGGU, 22 / 12 / 2019
NO. IDENTITAS DIAGNOSIS LAB RADIOLOGI TERAPI PLANNING DPJP
PALEM ATAS

PALEM BAWAH

B2/K7 Nurfaidah. Traumatic Brain Injury GCS 15 (7-12-19) HB: -Head up 30 derajat -ceftriaxone 1 gram/12 DW
16-11-1976. 12,5 WBC: 19,9 PLT: 315 HCT:36 jam/iv -omeprazole 40mg/24 jam/Iv -ketorolac
903864. GDS : 139 ur/cr : 42/0,56 30mg/8jam/iv -nasal kanul
MRS : 07/12/2019 SGOT/SGPT : 22/20 Na/k/Cl : 146/4,
2/112

LONTARA 2
LONTARA 2 BAWAH DEPAN

LONTARA 2 BAWAH BELAKANp

LONTARA 3 NON BEDAH SARAF

LONTARA 3 BAWAH BELAKANG
Kamar 2 SYAIFUL ASHAR POH 7 laminectomy removal 11-12-2019 IVFD NaCl 0,9% 20TPM AIH
Bed 3 10/11/1981 tumor spinalis intramedullar Hb: 13,1 Cefixime 200mg/12jam/oral
901768 WBC: 19.8 Asam mefenamat 500mg/8jam/oral
MRS: 06/11/2019 HCT: 38 Omeprazole 20mg/12jam/oral
PLT:. 378.000 Mobilisasi
GDS: 101
Ur/Cr:48/0.80
Na/K/Cl: 137/4.7/103
Kamar 3 HERMIN POH 4 laminectomy removal 18-12-2019 IVFD NaCl 0,9% 20TPM AAI
Bed 2 17/05/1988 tumor Hb: 12.8 Ceftriaxone 1gr/12jam/iv
903891 WBC: 23.1 Ketorolac 30mg/8jam/iv
MRS: 09/12/2018 HCT: 39 Omeprazole 40mg/12jam/iv
PLT: 160
GDS: 90
Ur/Cr: 26/0.61
SGOT/SGPT: 18/44
Na/K/Cl: 136/3.9/107
Kamar 4 SITI HAPSAH Abses cerebri 15-12-2019 MSCR Kepala dengan kontras sesuai TS Neurologi -Rencana craniectomi drainase abses NAS
Bed 2 31-12-1949 Hb: 11.0 (31-11-2019) - Multiple lesi pada -Optimalisasi KU
901861 WBC: 6.3 lobus temporoparietal dextra -Rencana MRI kontras
MRS : 18-11-2019 PLT: 45.000 suspek metastasis DD/
Ur/CR: 133/1.46 globlastoma
GDS:103 - focal brain injury
Albumin:2.3
Na/K/Cl: 141/2.2/115
Kamar 4 MARIAMA Cephalgia + Hemiparese Duplex 08-12-2019 MSCT KEPALA DENGAN sesuai TS neurologi - rencana craniectomy removal tumor AIH
Bed 4 01/08/1976 + SOL intracranial susp. Hb: 12.8 KONTRAS (14/12/2019)
903905 meningioma WBC: 7.8 Kesan : meningioma regio parietal
MRS: 09/12/2019 HCT: 36 dan temporal dextra disertai
PLT: 277 midline shift ke kiri sejauh +/- 1.39
GDS: 122 cm
Ur/Cr:47/0.52
SGOT/SGPT:5/19
Na/K/Cl: 138/3.8/107
HCU NAHATIKA POH 52 craniotomi dekompress 11/12/2019 Infus NaCl 0,9% 20 0tpm NAS
Bed 1 01-12-1959 EDH + POH 30 trakeostomi WBC: 12.9 Ceftriaxone 1 g/12 jam/iv
898529 HGB: 10.2 Manitol 100cc/6 jam/iv
MRS : 16/10/2019 PLT: 607 Omeprazole 40 mg/24 jam/iv
GDS:104 Semak 0,1% 20 tetes/nasal
Ur/Cr:10/0.41 Vip albumin 3x1 tab/oral
Albumin:2.7 latihan tutup kanul trakeostomi
Na/K/Cl: 139/3.8/107
CRP kuantitatif: 133,6;
Prokalsionin:0,16
HCU bed Asmia Usman 14- (12-12-19) HB: Head up 20 O2 10 liter/menit AIH
3 08-1956 10,0 WBC: 9,54 PLT: 148 HCT: NaCl 0,9% 20 tpm
903683 28,8 GDS : 149 Na/k/Cl : 141/3,0/102 Ceftriaxone 1gr/12jam/iv
MRS : 05-12-2019 PT/APTT: 9.8/21.9 INR:0.94 Bilirubin Metamizole 1gr/8jam/iv Omeprazole
Tot:0.78 Bilirubin direk:0.58 Albumin: 40mg/24jam/iv
3.1
HCU AB CENNING - Traumatic intracerebri 15-12-2019 - Natrium Clorida 0.9% 28TPM Konservatif DW
Bed 5 03/05/1940 hemorrhagic Hb: 11.0 - Metronidazole 1gr/8ja,/iv
905106 - Subarachnoid hemorrhagic WBC: 6.3 - ceftriaxone 1gr/24jam/iv
MRS : 19/12/2019 - Pneumocephal PLT: 45.000 - omeprazole 40mg/24jam/iv
- fracture basis cranii Ur/CR: 133/1.46 - terapi lain sesuai TS neuro
- loss of consciousness GDS:103
Albumin:2.3
Na/K/Cl: 141/2.2/115
HCU MAEMUNAH POH 2 laminectomy 15-12-2019 IVFD NaCl 0,9% 20TPM DW
Bed 6 31-12-1954 foraminectomy disectomy Hb: 11.0 Ceftriaxone 1gr/12jam/iv
453691 WBC: 6.3 Ketorolac 30mg/8jam/iv
MRS : 17/12/2019 PLT: 45.000 Omeprazole 40mg/12jam/iv
Ur/CR: 133/1.46 Metilprednisolon 125mg/8jam/iv
GDS:103 takar drain/24jam
Albumin:2.3
Na/K/Cl: 141/2.2/115

LONTARA 3 ATAS BELAKANG

LONTARA 3 ATAS DEPAN

Kamar 2 Muftihatul Khaera 08- Ependymom Lab 09-12-2019 Hb: 13,1 WBC: MSCT Scan Kepala (dengan Infus NaCl 0,9 % DW
bed 2 03-1993 7,8 PLt: 313 kontras) 31-07-2019 Multiple Omeprazole 20mg / 12 jam / IV
652944. meningioma (residif) Pirasetam 1gr/12 jam / IV
MRS: 09/12/2019 Enchepalomalacia skull defect Metamizole 1gr/8jam/iv
regio temporal sinistra

LONTARA 4

LONTARA 3 BEDAH SARAF

KAMAR 1 A
 KAMAR 1 B
MUH ILHAM / TBI GCS 15, vulnus laceratum
Labolatorium
manus dextra
17/12/2019 - Head up 30'
904837 - WBC 28,83 - Ketorolac 30mg/8jam/iv
12-12-200R - RBC 5,11 - Cefriaxone 1gr/24jam/iv
- HGB 14,2 - Omeprazole 40mg/24jam/iv
- PLT 230
- PT/INR/APTT 12,2/1,19/26,5
- GDS 106
-Ur/Kr 23/0,57
Kamar 1B Bed 1 - SGOT/SGPT 85/40 WA

KAMAR 2
LABORATORIUM (22/11/2019)
WBC : 7.6
RBC: 5.14
MSCT KEPALA dengan kontras
HGB : 15.9
RADIAH / 902367 (25/11/2019) - Asam mefenamat 500 mg/8 jam/oral
Kamar 2 Cefalgia kronik ec SOL suspek PLT : 260.000 - Rencana Craniotomi Removal Tumor
30-04-1975 (44 thn) - Massa lobus frontal suspek - Omeprazole 20 mg/12 jam/oral DW
Bed 1 meningioma PT/APTT 10.5/20.7 (Tunggu Jadwal)
MRS: 22-11-2019 meningioma disertai herniasi - Dexametason 0.5 mg/8 jam/oral
GDS : 78
subfalcine ke sinistra
Ur/Cr : 16/0.74
SGOT/SGPT : 16/22
Na/K/Cl : 142/3.8/107
LABORATORIUM (19-12-2019) MSCT KEPALA dengan kontras - Infus NaCl 0.9% 20 tpm - Ceftriaxone 1 gr/12
MUFTIHATUL KHAERA WBC: 8.8 RBC: 3.89 HGB: 10.5 PLT: (31/7/2019) - Multiple jam/IV - Omeprazole 40 mg/12 jam/IV -
Kamar 2 POH-2 Craniotomy Removal
S / 652944 08-03-1993 282 PT/APTT/INR: 11.5/23.8/1.12 Meningioma (residif) - Ketorolac 30 mg/8 jam/IV - Asam Tranexamat DW
Bed 2 Tumor ec Ependymoma Residif
MRS: 9-12-2019 GDS: 99 Ur/Cr: 16/0.61 Na/K/Cl: Enchepalomalacia - Skull defect 500 mg/8 jam/IV - Takar Drain / 24 jam - Diet
142/3.8/108 regio temporoparietal sinistra Bebas
LABORATORIUM (13/12/2019)
WBC: 8.2 MRI BRAIN dengan kontras
RBC: 4.43 (11/12/2019)
HGB: 13.3 - Gambaran absces cerebri sinistra
PLT: 286 disertai midline shift ke kanan
GDS: 104 sejauh +/- 0.6 cm
Protein Total: 7.2
Albumin: 3.9 MSCT KEPALA dengan kontras
Globulin: 3.3 (25/11/2019)
RAHMAWATI / 902124 - Asam Mefenamat 500 mg/8 jam/oral
Kamar 2 Cephalgia kronis ec susp. Na/K/Cl: 142/4.0/1120 - Rencana Craniotomi Evakuasi Tumor
15/01/1976 (43 thn) - Sugestif Tuberculoma lobus - Omeprazole 20 mg/12 jam/oral DW
Bed 3 Astrocytoma (Kamis, 19 Desember 2019)
MRS: 19/11/2019 temporal dan ganglia basalis - Dexametasone 0.5 mg/8 jam/oral
URINALISA (7/12/2019) sinistra yang mengakibatkan
Ureum urine (UUN) : 4 herniasi subfalcine
FUNGSI GINJAL (3/12/2019) FOTO THORAKS (20/11/2019)
Ur/Cr: 25/0.7 - TB Paru lama aktif lesi luas
- Efusi Pleura dextra
KIMIA LAIN (22/11/2019) - Cardiomegaly
Calsium: 8.1
Magnesium: 3.12
LABORATORIUM (14/11/2019)
WBC: 22.1
FOTO THORAKS (11/9/2019)
RBC: 4.42
- Tidak tampak kelainan radiologik
HGB: 11
AULIA SAPUTRI / - Paracetamol 125 mg/8 jam/oral
HCT: 37
Kamar 2 873514 Wound Dehiscence post VP CT KEPALA tanpa kontras - Cefixime 40 mg/12 jam/oral
PLT: 1075 NAL
Bed 4 02-09-2018 (1 thn) Shunt (15/2/2019 - Curcuma syr 1 cth/12 jam/oral
PT/APTT/INR: 11.7/28.2/1.13
MRS: 13/11/2019 - Meningoencephalocele regio - Rawat Luka per hari
GDS:102
occipital
Ur/Cr: 15/0.32
- Absen septum pellucidum
SGOT/SGPT: 21/15
Na/K/Cl: 137/3.7/104
FUNGSI HATI (13/12/2019)
Protein Total: 6.8
Albumin: 3.9
FOTO THORAKS (11/10/2019)
- Cardiomegaly disertai dilatatio
LABORATORIUM (8/12/2019)
aortae
WBC: 10.6
- Asam Mefenamat 500 mg/8 jam/oral
NURHAYATI / 858200 RBC: 4.04
Kamar 2 Meningioma Supracellar MRI BRAIN dengan kontras (09- - Omeprazole 20 mg/12 jam/oral - Rencana Removal Tumor (Tunggu
31-12-1966 (52 thn) HGB: 12.2 DW
Bed 5 Frontotemporal Sinistra 10-2019) - Dexametason 0.5 gram/8 jam/oral Jadwal)
MRS: 02/12/2019 PLT: 290
- Meningioma regio parasellar yang - Terapi sesuai TS Gizi Klinik
PT/APTT/INR: 11.7/18.2/1.14
mendesak dan menyempitkan
GDS: 176
cornu anterior ventrikel lateralis kiri
Ur/Cr: 40/0.59
- Sinusitis maxillaris kiri
SGOT/SGPT: 31/91
HBs Ag: Non Reactive
Na/K/Cl: 142/3.3/110
GLUKOSA (12/12/2019)
GDS: 133

FUNGSI THYROID (2/12/2019)

FT4: 0.81
TDHs: 4.57

GLUKOSA (25/11/2019)
MSCT KEPALA dengan kontras
HbA 1c: 7.1
NAJAMMAH / 902425 (25/11/2019) - Asam Mefenamat 500 mg/8 jam/oral - Rencana Craniotomi Removal Tumor
Kamar 2
31-12-1960 (58 thn) Osteoma Frontal Dextra - Osteoma frontalis sisi dextra - Omeprazole 20 mg/12 jam/oral (Selasa, 17 Desember 2019) -> Batal - NAL
Bed 6 LABORATORIUM (22/11/2019)
MRS: 22-11-2019 - Infark lobus frontotemporoparietal - Dexametason 0.5 gram/8 jam/oral Tunggu penjadwalan kembali
WBC: 13.3
dextra
RBC: 4.40
HGB: 12.3
PLT: 438
PT/APTT/INR: 10.8/22.5/1.04
GDS :300
Ur/Cr : 32/0.42
SGOT/SGPT: 16/21
Na/K/Cl: 140/3.4/105
KAMAR 3
-ini non clondo SBY -cemozon 2gr/12jam/iv -
Paraplegi intra Th 10-11 vorji four
Kamar 3 Hammurabi / 902247 omeprazol 40mg/24jam/iv -metamizol
post slebibon posterior poh 6 (+) NAL
Bed 1 20-11-2019 1gr/8jam/iv -paracetamol 1gr/8jam/iv (jika
lamineemy
demam)
Kamar 3
Bed 2
 -Ceftriaxone 1gr/12jam/iv
-Ketorolac 30mg/8jam/iv
Kamar 3 JUMRIN / 903595 Labortaorium (16-12-2019)
spinal cord injury + paraplegia -Omeprazole 40mg/24jam/iv AAI
Bed 3 16-11-1982 GDS : 71
-Asam Trenexamat 500mg/8jam/iv
-Metylprednisolon 25mg/8jam/iv

Laboratorium (16-12-2019)
pT/aPTT : 10.6 / 29.6
ASRAWI PRATAMA /
Kamar 3 GDS : 106
885014 mrs : 16-12- Siul defek parietal Menunggu jadwal DW
Bed 4 Ur/Cr : 24 / 0.92
2019
SGOT/SGPT : 37/74
Na/K/Cl : 143 / 3.7 / 106
-Ceftriaxone 100mg/12jam/oral
MUH. RIZKY / 902971 -Asam mefenamat 250mg/8jam/oral
Kamar 3
05-03-2009 POH 4 vp shunt -Omeprazole 20mg/12jam/oral NAL
Bed 5
MRS: 10-12-2019 -Cemaxon 1gr/12jam/imm
-Paracetamol 500mg/8jam/imm
LABORATORIUM (12/12/2019)
ELVANO ATHA PT/APTT: 11.8/31.7
Kamar 3 PATABANG / 899484 GDS: 97
Meningoencephalocele Menunggu jadwal Rencana eksisi menunggu jadwal NAL
Bed 6 27-08-2019 Ur/Cr: 11/0.31
MRS: 12/12/2019 SGOT/SGPT: 48/32
Na/K/Cl: 133/4.9/105
KAMAR 4
USG LUMBAL - Tampak benjolan
pada regio lumbal ukuran 10cm x
10cm x3cm - Konsistensi kenyal,
Labolatorium 2/12/19 - WBC 12,7 - nyeri tekan (-), batas tegas, tidak
DEAH ANJANI /
RBC 5,25 - HGB 11,0 - PLT 440 - ada MSCT Whole Abdomen
Kamar 4 903323
Menigiocele PT/INR/APTT 10,1/0,97/34,9 - GDS dengan kontrasn3/12/2019 - Defek Menunggu jadwal AIH
Bed 1 04-03-2017 (2 thn)
83 - Ur/Kr 22/0,45 - SGOT/SGPT dinding posterior CV S1 disertai
MRS : 15-12-2019
25/14 herniasi canalis sacralis sugestif
suatu lipomeningocele - Distensi
buli buli disertai hydronephroureter
bilateral

Labolatorium 6/12/19 - WBC 9,8 -

MUHAMMAD REZKI / CT Kepala ( Tanpa Kontras )
Kamar 4 RBC 5,15 - HGB 12,8 - PLT 269 - - NaCl 0,9% 43 tpm - ceftriaxone
903679 03-04-2019 POH 2 Vp Shunt 06/12/19 - Severe hydrocephalus AAI
Bed 3 PT/INR/APTT 10/0,96/26,1 - GDS 97 250mg/12jam/iv - paracetamol 120mg/8jam/iv
MRS 16-12-2019 non communicans
- Ur/Kr 8/0,41 - SGOT/SGPT 34/37
ISO

HCU BEDAH SARAF

Bed 1 YUSTIAN ICH tarkel dextra ec TBI post Lab 06/12/2019
26-6-2004 tracheostomy WBC: 6.57 WA
899717 RBC: 4.24 MSCT KEPALA tanpa kontras
MRS: 26-10-2019 HGB: 11.9 -Infus natrium chloride 0.9% 28 tpm
(05/11/2019) - perdarahan
HCT: 35.7 -Nebule n-Ace/8 jam
intracerebri lobus termporal dextra
PLT: 313 -Oksigenasi 3 lpm
( dibandingkan dengan foto tanggal
GDS: 82 -omeprazole 40mg/24 jam/ intravena
27/10/19) perbaikan -brain
Ur/Cr: 19/0.46 -Metamizole 1 gr/8jam/intravena
swelling
Na/K/Cl : 135/3.6/103
SGOT/SGPT: 45/60
Albumin: 3.4
Bed 2 MUH AZRIEL ILHAM -Subdural hemorrhage post Lab 18/12/2019 -Infus natrium chloride 0.9% 20 tpm NAL
21-02-2006 craniotomy + hydrocephalus WBC: 18.1 -O2 10 liter/NRM
903367 communicans + seizure + RBC: 3.32 - -Phenitoin
MRS: 02/12/2019 decubitus ulcer HGB: 10.2 drips 110mg/12jam/intravena
HCT: 31.1 -diazepam oral 20 mg/8jam/ngt
PLT: 316 -extra metamizole 500 mg/8jam/iv ( extra bila
GDS: 43 demam)
Ur/Cr: 15/0.32 -cemoxan/2 gr/24 jam/iv -
Na/K/Cl : 134/3.7/102 pindah perawatan isolasi
Bed 3 MUH. SYAWAL POH 6 VP Shunt SGOT/SGPT/albumin:
Labolatorium 18/12/201936/13/2.9
- WBC CT SCAN (21/11/2019) - Infus NaCl 0,9 % AAI
RASYID / 902002 Kimia
9,52 darah(19/12/19) - Massa suprasellar sugestif - Ceftriaxone 1gr/12jam/iv
20-03-1962 (57th) calsium/magnesium:
- RBC 3,51 - HGB 11,17.4/2.13
- PLT 2 - GDS pituitary macroadenoma -Paracetamol 500 mg/8jam/intravena
MRS : 09-12-2019 98 - Ur/Kr 31/2,30 - Hydrocephalus non communican -Omeprazole 40mg/24jam/iv
FOTO THORAKS (26/11/19) -kjs gizi klinik
- Suspek massa mediastinum dd -oksigenasi 10 lpm nrm
lymphadenopathy
BY.NY.NURLINA hidrocephalus komunikans AAI
25-10-2019. infected VP Shunt + Lab 19/12/2019 -O2 nasal kanul 1 liter
900685. Bronkopneumoni +MRSA WBC: 18.09 -Phenitoin drips 100mg/12jam/intravena
MRS: 10-12-201 RBC: 3.52 -paracetamol; 500 mg/8 jam/iv
HGB: 9.9 -ahli rawat ke TS pediatric divisi pulmo
HCT: 29.8
PLT: 114
Bed 4 GDS: 147
Ur/Cr: 8/0.18
Na/K/Cl :124/5.1/100
SGOT/SGPT/albumin: 19/19/2.0
Sputum BTA 3X pewarnaan
(17/12/19):
negatif
MUHAMMAD ILHAM Traumatic brain injury GCS 14 Lab 14/12/2019 -Infus Natrium klorida 20 tpm NAS
11-11-1989. 904539. E3V5M6 + EDH fraktur dextra WBC: 26.1 -omeprazole 40 mg/24 jam/iv
MRS: 14-12-2019 RBC: 4.71 -metamizole 1gr/24 jam/iv
HGB: 12.8 -Cemoxan 1 gr/12jam/intravena
HCT: 39.5 -glaucan tab 500 mg/8jam/oral
PLT: 85 -head up 30
GDS: 171 -Phenitoin 40 mg/24jam/intravena
Ur/Cr: 33/0.78 -besok ganti oral dan pindah perawatan biasa
Bed 5 Na/K/Cl : 139/3.3/104 jika tidak ada rhinore
SGOT/SGPT: 93/47 -aff kateter
Bed 6 MUH ALDY Traumatic brain injury GCS10 LAB (11/12/2019) CT Scan kepala tanpa kontras - Head up 30 WA
SYAPUTRA + kontusio cerebri WBC: 11,6 (01/12/2019) - IVFD natrium chloride 0.9% 20 tpm
01-05-2007 HGB: 10,4 -Gambaran contusio cerebri - omeprazole 10 mg/12 jam/oral
903215 HCT: 31,1 -Subgaleal hematomregio - Cefixime 100mg/12jam/oral
MRS: 01/12/2019 PLT: 315 temporoparietal sinistra -oksigenasi 3 lpm
GDS: 126 - Mobilisasi
Na/K/Cl : 136/4.3/103 Foto Leher AP + Lateral (01-12- - paracetamol 250mg/8jam/oral (bila demam)
2019)
-Suspek anterolisthesis CV C2
terhadap C3

Foto Thorax PA/Ap (01-12-2019)

-Cor dan pulmo normal

Bed 7 FARREL GIESELLO Hemiparese sinistra + LAB (18/12/2019): - head up 30 DW

WIDODO Penurunan Kesadaran ec WBC: 4,7 - IVFD natrium chloride 0.9% 24 tpm
24-02-2014 infark cerebri luas HGB: 11,6 - phenitoin 50mg/12jam/intravena
904982 HCT: 34 - asam valproat 250mg/12jam/oral
MRS: 18/12/2019 PLT: 478
GDS: 110
UR/CR: 15/0,26
SGOT/SGPT: 117/29
NA/K/CL: 137/4,1/106
Bed 8 ADRIAN HINDOM ICH Frontal Post Craniotomy LAB (16/12/2019) FOTO THORAKS PA/AP - IVFD NaCl 0,9% 20 tpm AIH
06-1-1961 Evakuasi Hematoma H-5 WBC: 5,5 (17/12/19) - Cefixime 200gr/12 jam/ oral
904716 HGB: 14,3 - TB paru aktif lesi luas - Omeprazole 20mg/24 jam/oral
MRS: 16-12-2019 HCT: 41 - Asam Mefenamat 500 gr/8 jam/oral
PLT: 130 CT KEPALA TANPA KONTRAS
GDS: 102 (16/12/19)
PT/APTT: 12,0/249,0 - Perdarahan intracerebri lobus
Ur/Cr: 48/1,15 frontalis sinistra yang
SGOT/SGPT: 20/34 mengakibatkan herniasi subfalcine
Na/K/Cl : 141/3,1/109 ke dextra sejauh +/- 0,8cm dengan
estimas volume pendarahan +/- 16
cc
- Pendarahan intracerebri lobus
fronto temporal dextra dengan
estomasi volume pendarahan +/- 8
cc
- Brain swelling
Bed 9

Bed 10 RESKO SISWOYO TBI GCS 9 + EDH Parietal LAB (18/12/2019): - head up 30 WA
10/01/1969 Dextra WBC: 14,0 - Oksigenasi Nasal Kanul 3 L/menit
904861 HGB: 7,5 - IVFD NaCl 0.9% 20tpm
MRS: 17/12/2019 HCT: 23 - ceftriaxone 1 gram/12jam/intravena
PLT: 221 - omeprazole 40mg/24jam/intravena
PT/APTT: 10,9/0,91 - ketorolac 30mg/8jam/intravena
GDS: 111
UR/CR: 48/0,91
SGOT/SGPT: 62/51
NA/K/CL: 140/5,2/115
Bed 11 SARDIAH Traumatic Brain Injury GCS 15 LAB (19/12/2019): - head up 30 DW
10/07/1974 (E2M6V5) WBC: 12,4 - IVFD NaCl 0.9% 20 tpm
904990 + Kontusio Cerebri HGB: 8,4 - ceftriaxone 1 gram/12jam/intravena
MRS: 18-12-2019 HCT: 24,3 - omeprazole 40mg/24jam/intravena
PLT: 161 - metamizol 1gr/8jam/intravena
- ketorolac extra jika nyeri
- Cendolytrees eye drop
Bed 12 BUNGA Traumatic Brain Injury GCS 10 LAB (16/12/2019): - head up 30
01-07-1965 (E2M5V3) WBC: 21,2 - oksigenasi via nasal kanul 3 LPM
904697 HGB: 12,0 - IVFD NaCl 0.9% 24tpm
MRS: 16/12/2019 HCT: 37 - ceftriaxone 1 gram/12jam/intravena
PLT: 250 - omeprazole 40mg/24jam/intravena
PT/APTT: 11,3/24,4 - metamizol 1gr/8jam/intravena
GDS: 115
UR/CR: 26/0,69
SGOT/SGPT: 24/19 AIH
NA/K/CL: 142/3,6/105

ICU-PICU

Bed 3 Muhammad Iqbal 29- Hydrocephalus non (20-12-2019) WBC: IVFD Kaen 3B - Dexamethason 5mg/12 AAI
PICU 09-2005 823239 MRS: communicans post vp shunt 9.1 RBC: 4.69 HGB: 13.5 PLT: 424 jam/iv - Ceftriaxone 2 gr/24 jam/iv
20-12-2019 GDS: 104 Albumin: 2.0 Na/K/Cl :
136/4.2/101 SGOT/SGPT: 30/15
Ur/Cr: 10/0.49
Bed 4 Huzaifah Harun Stroke CCH (20-12-2019) WBC: NaCl 0,9% 20 tpm WA
04-07-1957 31.1 RBC: 2.51 HGB: 7.7 PLT: 224 Omeprazole 40mg/24ja/iv
901045 Albumin: 2.0 Na/K/Cl : 136/2.8/102 Ifalmin 2tab/8jam/hari
MRS : 25-11-2019

NICU

RSUH

PCC
213 Rusni Sufram/6-1- POH 4 VP SHUNT + Laboratorium (14-12-2019) CT scan kepala tanpa kontras (14- -Infus NaCl 0.9% 28 tpm AAI
1953/Laki-laki/852014 Normopressure hydrocephalus WBC : 9.0 12-2019) -Ceftriaxone 1 gr/12 jam/iv
+DM tipe 2 RBC: 3.95 -Gambaran chronic small vessel -Metamizole 1 gr/8 jam/iv
+Hipertensi HGB : 12.7 ischemia -Omeprazole 40 mg/24 jam/iv
HCT : 38 -Brain atrophy -Ondansetron 4 mg/12 jam/iv
PLT :371 Terapi lain sesuai TS interna
Ur/Cr: 48/0.83 Foto thorax AP boleh rawat jalan bila KU baik
16-12-2019 -Cardiomegaly dengan tanda-tanda
PT/APTT/INR 9.8/25.3/0.94 bendungan paru
GDS: 365
SGOT/SGPT: 13/18
Na/K/Cl: 135/3.4/99

309 M Rusly Rasyid 28- POH 8 cranioectomy evakuasi Laboratorium (21-12-2019) - Nacl 0,9% 28 tpm NAS
11-1948 902535 hematom ec ICH frontobasalis Albumin: 2.6 -ceftriaxone 1 gram/12 jam/intravena
MRS: 14-12-2019 sinistra -omeprazole 20 mg/24 jam/IV
-ketorolac 30 mg/8jam/iv
-GV/3 hari
-aff hecting 1/2
-Boleh rawat jalan setelah koreksi gizi klinik
Bila oral:
-Cefixime 200mg/12jam/oral
-Asam mefenamat 500mg/8jam/oral
-Omeprazole 20mg/12jam/oral
-Terapi TS Gizi klinik lanjutkan
BRAIN CENTRE

Bed 1 Burhan Mude POH 20 cranioectomy evakuasi (20-12-2019) -Citicoline 1 gr/12 jam/iv DW
9-7-1965 ICH HB: 10.5 -Omeprazole 40 mg/24 jam/iv
903247 WBC: 13,7 -Mecobalamin 500mg/12jam/iv
PLT: 625 -Jaga patensi trakeostomi
HCT: 31.8 -Suction bila lendir trakeostomi banyak

IGD
 List pasien DPJP

Minggu, 22 Desember 2019

AAI

no perawatan identitas diagnosis

Muh syawal rasyid 902002

2 HCU BED 3 hidrosefalus non komunikan
20/03/1962 (57th) MRS : 09/12/2019

3 L3BD HCU BED 4 By. Ny. Nurlina

hidrocephalus komunikans post VP Shunt + infected VP Shunt
Made Gendra 26/6/1945 (74Tahun) 901069
4 L3BD 3 bed 2 tumor intrakanial susp glioblastoma post craniotomy removal tumor
MRS: 08/11/2019
5 L3 BD K4 B2 Putu Widya Cahyani Hidrocephalus non communicans
Rusni Sufran 6/1/1953 (56 th) POH 4 VP shunt
6 PCC 213
852014 MRS: 16/12/2019
Kamar 3 HERMIN MARIANA
Bed 6 17/5/1988
7
903829
MRS: 09/12/2019
LONTARA 3 BD K4B3 MUHAMMAD REZKI / 903679 03-04-2019
8 Hydrocephalus
MRS 16-12-2019

NAS

no perawatan identitas diagnosis

Muh Azriel Ilham 21-02-2006 (13 tahun)

3 L3BD HCU bed 2 Subdural hemorrhage post craniotomy + hydrocephalus communicans
903367

MUHAMMAD ILHAM 11-11-1989. 904539.

4 L3BD HCU Bed 5 Traumatic brain injury GCS 14 E3V5M6
MRS: 14-12-2019

5
POH 8 craniectomy evakuasi hematom
6 PCC 309 M Rusly Rasyid/28-11-1948/902535

FRISA ANDHIKA / 901278

7 VIP 4 Post Op hari 2 craniotomy removal tumor + suspek meningioma
13-03-1985
Siti Hapsah 31-12-1949 901861 MRS : 18-11-
8 L3 BB Kamar 4 Bed 1 Space occupying Lesion Intracranial DD/ Brain Metastase Tumor
2019
9 L3 BB HCU bed 1 Nahatika 01-12-1959 898529 POH 48 craniotomy dekompresi EDH + POH 26 Trakeostomi
udhin 903236
10 L3 BB Kamar 2 Bed 1 POH 15 cranieotomy evakuasi ICH + temporoparietal dextra
02-12-1953
SITI HAPSAH
11 L3 bb HCU bed 5 31-12-1949 Abses cerebri
901861
AULIA SAPUTRI / 873514
12 L3BD Kamar 2 Bed 4 02-09-2018 (1 thn) Wound Dehiscence post VP Shunt
MRS: 13/11/2019
NAJAMMAH / 902425
13 L3BD Kamar 2 Bed 6 31-12-1960 (58 thn) Osteoma Frontal Dextra
MRS: 22-11-2019
muhammad rizky 902971
14 L3BD kamar 3 bed 5 hidrocephalus ec massa intraventrikel
05-03-2009 MRS:10/12/2019
adi marwan, 656913, 20/07/1995(24tahun),
15 L3BD kamar 3 bed 4 Hemangioma regio occipital
MRS : 9/12/2019
elvano atha patabang, 899484, 27/08/2019,
16 L3BD kamar 3 bed 6 meningoencephalocele
MRS : 12/12/2019
17 L3BD K1A B 1 ANDIKA / 903527 29-04-1997 Tumor sphenoid
hammurabi / 31-12-1963 / 902247
18 L3BD B fraktur kompresi vertebra thoracalis
MRS : 20/11/2019
Paraplegia Ec spinal Cord Injury setinggi Thorakal 7-9. Traumatic Brain
19 L3BD Kamar 1b.2 MUH. NUR FITRAH / 904425 23-12-2000
Injury GCS 15
DW

no perawatan identitas diagnosis

1 BC bed 1 Burhan Mude/Lk/903247/10-07-965 POH 20 kraniektomi evakuasi ICH

Nurfaidah. 16-11-1976.
2 Palem bawah B2/7 Traumatic brain injury GCS 15
903864. MRS : 07/12/2019
3 L3 AD Kamar 2 bed 2 Muftihatul Khaera 08-03-1993 652944 Ependymoma Residif
RADIAH / 902367
4 L3BD Kamar 2 Bed 1 30-04-1975 (44 thn) Cefalgia kronik ec SOL suspek meningioma
MRS: 22-11-2019
RAHMAWATI / 902124
5 L3BD Kamar 2 Bed 3 15/01/1976 (43 thn) Cephalgia kronis ec susp. Astrocytoma
MRS: 19/11/2019
NURHAYATI / 858200
6 L3BD Kamar 2 Bed 5 31-12-1966 (52 thn) Meningioma Supracellar Frontotemporal Sinistra
MRS: 02/12/2019
FARREL GIESELLO WIDODO/ 24-02-2014 Penurunan Kesadaran ec Epilepsi ec SOL
7 L3BD HCU BED 7
/904982
SARDIAH 10/07/1974 904990
8 L3BD HCU BED 11
MRS: 18-12-2019 Traumatic Brain Injury GCS 15 (E2M6V5) + Kontusio Cerebri
9 RSUH-ICU Hisyam/11-12-2001/ laki laki/133396 POH-4 vp shunt ec pineoblastoma
Muh Nur. Ramadhan
25/12/1999
10 L3BD K 3 bed 1 POH-8 Cranioplasty
898861
MRS 28/11/2019
11
ICU Bed 8 Muftihatul Khaera 08- POH 1 craniotomy removal tumor
12 03-1993
652944. MRS: 09/12/2019
13 RSUH sintiawati 21/05/1979 904416 hemiparese dextra ec glioblastoma

AIH

no perawatan identitas diagnosis

1 Palem bawah B1/6 Johanis Mangetan /LK/860486/22-05-1953 stroke ICH

2 ICU Bed 5 Asmia Usman/Pr/903683/14-08-1956 POH 13 kraniektomi evaluasi hematoma ICH temporoparietal dextra

3 ICU VIP 3 Syaiful Ashar/Lk/10-11-1981/901768 POH 2 Laminectomy removal tumor

4 L3BD 3 bed 3 Jumrin, 903595, 16/11/1982 spinal cord injury + paraplegia

ICH Regio frontal sinistra + regio frontotemporoparietal sinistra
5
L3BD HCU Bed 8 Adrian Hindom/ 904716/ 06-01-1961
BUNGA/ 01-07-1965/ 904697
6 L3BD HCU Bed 12 Traumatic Brain Injury GCS 10 (E2M5V3)

7 L3BD HCU Bed 2 Engseng 16/01/1992 904737 MRS 17/12/2019 Penurunan kesadaran + hemiparese sinistra ec SOL

8 L3AD K4B1 DEAH ANJANI / 903323 04-03-2017 Meningiocele

ICH Regio frontal sinistra + regio frontotemporoparietal sinistra
L3BD HCU Bed 8 Adrian Hindom/ 904716/ 06-01-1961

WA

no perawatan identitas diagnosis

1 ICU Bed 4 Huzaifah Harun/Lk/901045/04-07-1957 ICH post kraniektomi evakuasi

2
Yustian surya sumirat 26/06/2004
3 L3BD HCU Bed 1 traumatic brain injury GCS 9t + ICH parietal dextra + POH 17 trakeostomy
(15thn) 899717 MRS 27/10/2019
 Muh Aldy Syaputra 01-05-2007 (12 tahun)
4 L3BD HCU bed 6 Traumatic brain injury GCS10 + kontusio cerebri
903215
RESKO SISWOYO /10/01/1969
5 L3BD HCU bed 10 Post Craniotomy Evaluasi EDH
/904861 /MRS: 17/12/2019
6 Kamar 1B Bed 1 MUH ILHAM / 904837 12-12-200R TBI GCS 15, vulnus laseratum regio manus dextra
CT SCAN KEPALA TANPA KONTRAS:

- Tampak defek pada os occipitalis disertai herniasi menings dan cerebellum yang melewati defek tersebut

- Ventrikel lateralis dan ventrikel III tampakdilatasi. Ventrikel IV dan ruang subarachnoid dalam batas normal

- Tampakabsen septum pellucidum

- Sulci dan gyri dalam batas normal

- CPA dan pons dalam batas normal

- Sinus paranasalis dan aircell mastoid yang terscan dalam batas normal

- Fontanella anterior belum menutup. Tulang-tulang lainnya intak