LAPORAN IRD TANGGAL 24 - 30 JULI 2020
BEDAH SARAF
OPERASI
NO
TRAUMA
CKS 345 + EDH FRONTAL D VOL 70 CC + EDH FRONTAL S VOL 15 CC +
1 EDEMA CEREBRI + DIASTASIS SUTURA CORONALIS + VULNUS ABRATIO
REGIO FASCIALIS ά POST TDE EDH (DWI/L/18TH/11488803/24072020)
CKR 456 TANPA LESI INTRAKRANIAL + SUBGALEAL HEMATOMA REGIO
PARIEOTOOCCIPITAL S + OPEN WOUND REGIO OCCIPITAL S ά
2 2
DEBRIDEMENT PRIMARY SUTURE (LA)
(SANTI/P/56TH/11488862/26072020)
MILD ARDS + CONTUSION PULMONUM BILATERAL + COB 114 + BURST
LOBE FRONTOPARIETAL S + FRAKTUR DEPRESSED OS FRONTAL S +
3 FRAKTUR OS TEMPOROPARIETAL S + FRAKTUR OS FRONTAL D +
FRAKTUR MAXILLA S NON LEFORT + FRAKTUR RIMA ORBITA
SUPEROINFERIOR S + PNEUMONIA CAP IMMUNOCOMPROMISED ά TDE
BURST LOBE (SAMADI/L/42TH/11488874/26072020)
CKS 345 + EDH TEMPORO BASAL S VOL 3 CC + EDH FRONTAL S VOL 4.5
CC + FR. LINIER FRONTAL D + FR. LINIER TEMPORAL D + FR RIMA ORBITA
SUPERIOR D + FR. RIMA ORBITA INFERIOR D + FR MAXILLA D/S NON
4 LEFORT + OPEN WOUND REGIO SUPRAORBITA S + CF METAPHYSEAL L
DISTAL RADIUS + CF L STYLOID ULNA ά NON OPERATIVE MANAGEMENT
+ CT SCAN KONTROL JIKA GCS TURUN 2 POINT (AHMAD
HASYIM/L/15TH/11488851/26072020)
CKR 356 + CONTUSIONAL HAEMORRHAGE REGIO PONS + MULTIPLE
CONTUSIONAL HEMORRHAGE FRONTAL + SAH + FR OS FRONTAL + FR
5 MAXILLA LEFORT II + OPEN WOUND REGIO FRONTAL + OPEN WOUND
LABIALIS SUPERIOR ἁ DEBRIDEMENT PRIMARY HECTING LA (MOCH ALIF
FERDIANSYAH/L/20TH/11489138/29072020)
JUMLAH 5 3
NO NON-TRAUMA
JUMLAH 0 0
NON-OPERASI
NO
REG OPERATOR RABER TRAUMA RABER
CKR 456 TANPA LESI INTRACRANIAL + VULNUS ABERASI REGIO FACIALIS + OPEN WOUND
BP 1 LABIALIS SUPERIOR ά NON OPERATIVE MANAGEMENT BP
(FAIDA/P/38TH/11488818/25072020)
COB 1X2 ON VENTILATOR + MULTIPLE CH FRONTAL D SUSP DAI + SUBDURAL HYGROME
BIFRONTAL + IVH + STICHED WOUND REGIO SUPRA ORBITA S + MULTIPLE VULNUS
ABRASIO REGIO FRONTAL + SUSP. TRAUMA OCCULI S + OF MIDDLE SHAFT L ULNA GR IIIA +
OF 1ST, 2ND, 3ST L METATARSAL + OF DISTAL PHALANX L GREAT TOE + OF PROXIMAL BP, BR
PHALAX L 5TH TOE + CF PROXIMAL PHALANX L 4TH TOE ά OBSERVASI 6 JAM HINGGA
PUKUL 11.00, (26/07/20) -> DILAPORKAN ULANG BILA MEMBAIK PRO EVD KOCHER D
(SATTUR/L/61TH/11488848/25072020)
BT, BP, 3 DOC + SDH ACUTE FTPO S (12,5MM, 10 SLICES )+ SAH + HT ST II ά TDE SDH 4
PARU, IPD (NYOMAN/L/51TH/11366185/25072020)
TENSION PNEUMOTHORAX D + CKR 456 + SUBDURAL HYGROMA FRONTAL BILATERAL + OF
DISLOCATION L WRIST + CF INFERIOR L RAMI PUBIS + CF L ACETABULUM + CF
BP,BR 4 INTERTROCHANTER L FEMUR ά NON OPERATIVE MANAGEMENT BT, BR
(KOSIM/L/53TH/11488873/26072020)
HEMATOTHORAX S ON CHESTUBE + CONTUSIO PULMONUM S + FR COSTAE 2,3,4
POSTERIOR S + FR COSTAE 4,5,6 LATERAL S+ CKR 456 TANPA LESI INTRACRANIAL +
HEMATURIA + CF LATERAL THIRD L CLAVICLE + CF L SCAPULAR BODY + CF R INFERIOR
BP 5 RAMI PUBIS + CF R NECK FEMUR + OF MIDDLE THIRD L FEMUR GR II + VULNUS BT, BR, BU
LACERATUM LATERAL SIDE L LOWER LEG + VULNUS ABRATION ANTERIOR SIDE R KNEE +
VULNUS ABRATION R PEDIS ά NON OPERATIF MANAJEMEN (M
MAHRUF/L/32TH/11488996/27072020)
FRACTURE DISLOCATION AT LEVEL VERTEBRAE CERVICAL III-IV ASIA B+ CKR 456 + STICHED
6 WOUND REGIO FRONTAL ά NON OPERATIVE MANAGEMENT BR
(MATOHIR/L/72TH/11489072/28072020)
CKR 356 TANPA LESI INTRAKRANIAL + MULTIPLE ABRASIO REGIO WAJAH + OBS NECK
7 INJURY ά NON OPERATIVE MANAGEMENT (YITNO/L/42TH/11489073/28072020) BP, BR
CKR 456 + ICH PARIETAL S + DISLOCATION R ELBOW + CF R INFERIOR RAMIPUBIS + CF R
8 DISTAL TIBIA + CF R FIBULA SEGMENTAL + OF DISTAL THIRD L TIBIA FIBULA GR III + HT ST 2 BR
-> NON OPERATIF MANAGEMENT (ALIMAH/P/78TH/29072020)
OBSERVASI FEBRIS + HIDROSEFALUS ON UNPATENT VP SHUNT + GLOBAL
9 DEVELOPMENTAL DELAY -> URGENSI INSERSI VP SUNT KOCHER S + AFF VP SHUNT KEEN S
(KARAISSA/P/3,5TH/11332912/29072020)
CKR 456 + EDH REGIO FRONTAL S 3CC +SAH + FR LINEAR OS FRONTAL + FR MAXILLA
LEFORT I DAN II + FR ZMC D + FR RIMA ORBITA SUPERIOR D/S + CF R GALEAZZI + CF BASE
10 R 2ND METACARPAL + VULNUS ABRATION MEDIAL SIDE R KNEE ἁ KONSERVATIF BP, BR
(SUMINTO/L/45TH/11489132/29072020)
CKR 356 + SAH + CEPHAL HEMATOMA OCCIPITAL S + HYPERTENSION STAGE II +
11 CARDIOMEGALY ἁ KONSERVATIF + OBSERVASI KETAT + CT KONTROL JIKA GCS TURUN 2 CARDIO
POINT (.LASMINI/P/68TH/11489153/29072020)
JUMLAH 11 9
REG OPERATOR RABER NO NON- TRAUMA RABER
CHRONIC HEADACHE DT SEVERE HYDROCEPHALUS + CVA INFARK + HT ST II ά PRO VP
1 SHUNT KOCHER D (BRAHAN DARMAJIE/L/65TH/10494447/24072020) NEURO
DOC DT CVA ICH + IVH + HIPERTENSI EMERGENSI DT HT ST II TIDAK TERKONTROL ά NON
2 OPERATIVE MANAGEMENT, EVALUASI TANDA MBO (ASNIPAH/P/59 NEURO
TH/11488778/24072020)
SOP CEREBRI DT SUSP METASTASIS + INTRATUMORAL BLEEDING + REUMATOID HEART
3 DISEASE ά URGENT MRI KEPALA DENGAN KONTRAS (BUDI NEURO
SETIYONO/L/55TH/11488811/24072020)
DOC + CVA INFARK + HT ST II + HYDROCEPHALUS ά EVALUASI 8 JAM + URGENT VP SHUNT
4 JIKA GCS NAIK > 2POIN, EVD JIKA GCS MENETAP/TURUN
(KASIADI/L/63THN/11488815/25072020)
DOC EC SUSP. ME BAKTERI DD TB + HT STAGE II + DM TYPE 2 + HIV ST IV NEWLY
5 DIAGNOSED + HYDROCEPHALUS COMMUNICANS ά URGENT VP SHUNT KOCHER D (DIANA
NURAINI/P/41TH/11488429/26072020)
SOP CEREBRI DT SUSP MENINGIOMA KONVEKSITAS REGIO TEMPORAL D + HT ST II ἁ
6
PERBAIKAN KU + URGENT EKSISI TUMOR (UMI LATHIFATUL/P/44TH/11472486/29072020)
SOP CEREBRI DT SUSP HIGH GRADE TUMOR DD TERATOMA + HYDROCEPHALUS ON VP
7 SHUNT + PNEUMONIA  URGENT TREPANASI EKSISI KP CP SHUNT (MUH. IKA
RIFKY/L/1TH/9.7KG/11484771/29072020)
JUMLAH 7 4
 LAPORAN KONDISI RUANGAN TANGGAL 24 - 30 JULI 2020
SEKSI: BEDAH SARAF

LAMA
RUANG NO DIAGNOSIS TGL MRS PRE OP SIAP OP POST OP KONSERVATIF RABER
RAWAT

14
SOP CEREBRI DT SUSP HIGH GRADE TUMOR DD TERATOMA + HYDROCEPHALUS ON VP
15 1
SHUNT + PNEUMONIA  URGENT TREPANASI EKSISI KP CP SHUNT (MUH. RIFKY/L/1TH)
7/29/2020 1 BA

16
CKR 356 + OPEN WOUND FRONTOPARIETAL D + FR DEPRESSED FRONTAL D + SUBDURAL
1 HYGROMA FRONTAL BILATERAL + FR LINIER OCCIPITAL D -> KONSERVATIF (VIKI 22/7/2020 1
DWI/L/16TH)
17
HYDROCEPHALUS EC MALFUNGSI VP SHUNT + SOP CEREBRI DT SUSP RATCHKE CLEFT CYST
2 DD CRANIOPHARYNGIOMA + PNEUMONIA HAP -> POST REVISI VP SHUNT (NIA 21/7/2020 1 PARU
MARDIANA/P/34TH)
1 COB 1X2-2X5 + DAI + EDEMA CEREBRI  KONSERVATIF (ANDINI/P/23 TH) 7/17/2020 1

18 CKR 456 + ICH PARIETAL S + DISLOCATION R ELBOW + CF R INFERIOR RAMIPUBIS + CF R

2 DISTAL TIBIA + CF R FIBULA SEGMENTAL + OF DISTAL THIRD L TIBIA FIBULA GR III + HT ST 2  7/29/2020 1 BR
KONSERVATIF (ALIMAH/P/78TH)

CKR 356 - 456 A + ALCOHOL INGESTION + ICH FRONTAL S + EDH FRONTAL S + EDH FRONTAL
1 D + FR COMMINUTIF DEPRESSED OS FRONTAL + FR LINIER OS PARIETAL S + FR RIMA ORBITA 20/7/2020 1 BP,BR
SUPERIOR COMMINUTIF D + FR RIMA ORBITA SUPERIOR D + FR FRONTONASAL + FR
19 MAXILLA D/S NON LE FORT + FR ZMC D POST REKONSTRUKSI OS FRONTAL (WILI/L/31TH)

2 OPLL VTH CERVICAL 2-6 POST DECOMPRESI + INSTRUMENTASI (PONCO WIDODO/L/53TH) 7/27/2020 1

20
21
JUMLAH 0 1 3 3 3
 LAPORAN AKUT BEDAH SARAF TANGGAL 24 - 30 JULI 2020
BEDAH SARAF
NO UMUR/JK TGL MRS
COB 1X2 - 2X2 + MULTIPLE CF FRONTAL D SUSP DAI + SUBDURAL HIGROMA +
IVH + VULNUS ABERASI REGIO FACIALIS + FR NECK CONDYLE S +OF MIDDLE
1 SHAFT L ULNA GR 3A + OF 1,2,3 L METATARSAL + OF DISTAL PHALANX L GREAT L/61TH 26/7/2020
TOE + OF PROXIMAL PHALANX L 4TH,5TH TOE --> POST SDD KOCHER S
(SATTUR)

HYDROCEPHALUS COMMUNICANS + SUSP ME BAKTERI DD TB + EDEMA

2 CEREBRI + DM TIPE II + HT ST II + HIV --> PRO URGENT VP SHUNT (DIANA P/41TH 26/7/2020
NURAINI)

CKS 345-325 + EDH FRONTOBASILER S 35CC + FR LINIER FRONTAL S + FR LINIER

TEMPORAL S + HEMATOME PERIORBITA D/S + OPEN WOUND SUPRAORBITA S +
3 CF METAPHYSEAL L DISTAL RADIUS SH II + CF L STYLOID ULNA + FR RIMA L/15TH 26/7/2020
ORBITA SUPERIOR D + FR RIMA ORBITA INFERIOR D + FR MAXILLA D/S NON
LEFORT --> POST TDE EDH (AHMAD HASYIM MUZADI)

CKR 456 + ICH PARIETAL S + DISLOCATION R ELBOW + CF R INFERIOR

4 RAMIPUBIS + CF R DISTAL TIBIA + CF R FIBULA SEGMENTAL + OF DISTAL THIRD L P/78TH 29/7/2020
TIBIA FIBULA GR III + HT ST 2 -> NON OPERATIF MANAGEMENT (ALIMAH)

OBSERVASI FEBRIS + HIDROSEFALUS ON UNPATENT VP SHUNT + GLOBAL

5 DEVELOPMENTAL DELAY -> URGENSI INSERSI VP SUNT KOCHER S + AFF VP P/3.5TH 29/7/2020
SHUNT KEEN S (KARAISSA)

SOP CEREBRI DT SUSP MENINGIOMA KONVEKSITAS REGIO TEMPORAL D + HT

6 P/44TH 29/7/2020
ST II  PERBAIKAN KU + URGENT EKSISI TUMOR (UMI LATHIFATUL)

CKR 456 + EDH REGIO FRONTAL S 3CC +SAH + FR LINEAR OS FRONTAL + FR

7 MAXILLA LEFORT I DAN II + FR ZMC D + FR RIMA ORBITA SUPERIOR D/S + CF R L/45TH 29/7/2020
GALEAZZI + CF BASE R 2ND METACARPAL + VULNUS ABRATION MEDIAL SIDE R
KNEE  KONSERVATIF (SUMINTO)

CKR 356 + CONTUSIONAL HAEMORRHAGE REGIO PONS + MULTIPLE

CONTUSIONAL HEMORRHAGE FRONTAL + SAH + FR OS FRONTAL + FR
8 L/20TH 29/7/2020
MAXILLA LEFORT II + OPEN WOUND REGIO FRONTAL + OPEN WOUND LABIALIS
SUPERIOR  DEBRIDEMENT PRIMARY HECTING LA (MOCH ALIF FERDIANSYAH)

JML 5

LAPORAN ICU BEDAH SARAF

NO DIAGNOSA / NAMA UMUR/JK TGL MRS
1 RESPIRATORY FAILURE + PNEUMONIA HAP + ICH + IVH + HYDROCEPHALUS + L/50TH 24/06/2020
SEPSIS -> POST VP SHUNT (SULTAN)

2 CVA ICH TPO D 55CC + EDEMA CEREBRI + HT ST II -> POST TDE ICH + ICP P/57TH 18/6/2020
KONTRALATERAL (ERLINDAWATI)

MILD ARDS + CONTUSIO PULMONUM BILATERAL + COB 114 + BURST LOBE FTP
S + FR DEPRESSED OS FRONTAL S + FRAKTUR OS TEMPOROPARIETAL S +
3 FRAKTUR OS FRONTAL S + FR MAXILLA S NON LEFORT + FR RIMA ORBITA L/42TH 26/7/2020
SUPEROINFERIOR S + PNEUMONIA + IMMUNOCOMPROMISED -> POST TDE
BURST LOBE (SAMADI)

4 OPLL VERTEBRAE CERVICAL 2 - 6 -> POST DEKOMPRESI + INSTRUMENTASI L/53TH 27/7/2020

(PONCO)
STATUS EPILEPTICUS DT SUSP MENINGITIS TB DD BAKTERI + PNEUMONIA + TB
PARU + MODERATE COMMUNICATING HYDROCEPHALUS + SUBDURAL
5 L/5 BL 12/7/2020
HYGROMA FRONTOPARIETAL D/S + EFUSI PLEURA D/S + GIZI BURUK -> POST
EVD KOCHER D (ABIL)

DOC DT SOP CEREBRI DD SUSP RUPTUR ANEURISMA + SAH + HYDROCEPHALUS

6 P/56TH 22/7/2020
ON EVD + HT ST II --> POST VP SHUNT KOCHER S (NGATINAH)

JML 7
 KONSULAN TANGGAL 24 - 30 JULI 2020

SEKSI TGL NAMA DIAGNOSA JAWABAN JUMLAH

 LAPORAN OK BEDAH SARAF TANGGAL 24 - 30 JULI 2020
LAPORAN OK PAVILIUN
BEDAH SARAF

No TGL NAMA BILLING RUANG DIAGNOSIS TINDAKAN ANESTESI OPERATOR BIMBINGAN

JUMLAH 0 0

LAPORAN OK EKSTIRPASI

No TGL NAMA BILLING RUANG DIAGNOSIS TINDAKAN ANESTESI OPERATOR BIMBINGAN

BEDAH SARAF

JUMLAH

LAPORAN OK SENTRAL
BEDAH SARAF
No TGL NAMA BILLING RUANG DIAGNOSIS TINDAKAN ANESTESI OPERATOR BIMBINGAN

HYDROCEPHALUS ON MALFUNGSI VP SHUNT KOCHER S POST REVISI VP

1 27/07/20 NIA MARDIANO 11481458 13HCU SHUNT (G91.9) + SOP CEREBRI DT SUSP RATHKE'S CLEFT CYST DD VP SHUNT KOCHER D (02.34) GA TAL M
CRANIOPHARYNGIOMA (D44.4) POST EVD KOCHER D H-8

2 28/07/20 PONCO WIDODO 11488582 19 OPLL VTH CERVICAL 2 - 6 (M48.8) DECOMPRESI (03.09) + INSTRUMENTAASI GA TAL M
DOC DT SUSP ME BAKTERI DD TB (R55) _ HYDROCEPHALUS
3 29/07/20 DIANA NURAINI 11488429 13HCU COMMUNICANS (G91.9) + HT STAGE II (I10) + DM TYPE II (E11) + HIV ST VP SHUNT (02.34) GA TAL M
IV NEWLY DIAGNOSED (B20)

4 29/07/20 NGATINAH 11488655 13HCU DOC DT SUSP RUPTUR ANEURISMA (I67.1) + SAH + HYDROCCEPHALUS VP SHUNT KOCHER S (02.34) GA TAL M
(G91.9) POST EVD KOCHER S H2 + HT ST II + PNEUMONIA

FR COMMINUTIF DEPRESSED OS FRONTAL + FR LIIER OS PARIETAL S + CF

R PROXIMAL HUMERUS NEER TYPE II (S42.23) + CF DISTAL SHAFT L REKONSTRUKSI OS FRONTAL + SCREW INSERTION + HUMERUS +
5 30/07/20 WILI 11488351 19 FEMUR COMMINUTIVE (S72.8) + FR RIMA ORBITA SUPERIOR INTERLOCKING NAIL FEMUR (79.36) + REKONSTRUKSI TULANG GA DON BIMBINGAN + C-
ARM
COMMINUTIF D + FR RIMA ORBITA INFERIOR D + FR FRONTONASAL + FR WAJAH
MAXILLA D S NON LEFORT + FR ZMC D

JUMLAH 5 6
 BIMBINGAN TANGGAL 24 - 30 JULI 2020
NO BIMBINGAN PPDS DPJP
1
2