LAPORAN PASIEN RAWAT INAP

RUANG INAP NEUROLOGI RS H. ADAM MALIK

TANGGAL 28 MARET – 4 April 2023

NO DIAGNOSA PRIA WANITA JUMLAH

1. Stroke Iskemik 3 2 5
2. SOL Intrakranial 1 1 2
3. Meningitis 1 1 2
4. Low Back Pain - 1 1
5. Ensefalopati Sekunder - 1 1
6. Stroke Hemoragik - 2 2
7. Subdural Hematoma - 1 1
8. Spondilitis TB - 1 1
9. GBS - 1 1
10. Migrain - 1 1
Jumlah 4 12 16

PASIEN BARU

Usia /
No Nama Tgl Masuk Diagnosa DR Ket DPJP
Kelamin
1. Alfredo Jakob 34 / LK 28/03/2023 Apatis + Hemiparese DNY SC ALF
Sinistra ec Susp Brain
Metastasis dengan
Intratumoral Hemorrhage +
Adenokarsinoma Paru Kiri
T3N1M1b (brain) stage IVB
ECOG 2 + HHD dengan HT
Stage II + AKI DD CKD +
PSMBA ec Stress ulcer dd
gastritif erosiva +
trombositopenia (43.000) +
Status hipokoahulasi (INR
1.62)
2. Nelly Damanik 63 / PR 28/03/2023 Tetraparese tipe LMN ec DNY RA 6 ALF
CIDP + Pneumonia
Komuniti
3. Erna 24 / PR 28/03/2023 Migrain Without Aura + DNY RA 2 ALF
Episode Depresi Sedang dd
Bipolar Episode Depresi
4. Rizky Pranata 22 / LK 29/03/2023 Somnolen + General Onset DNY RB 1 ISN
Tonic Clonic Seizure ec
Susp. Meningitis TB + TB
Paru Kasus Kambuh +
Elektrolit Imbalance
5. Perasat 58 / LK 30/03/2023 Focal Onset Motor Tonic ALD RA 2 CAB
Seizure ec Epilepsy
Symptomatic + Hemiparese
Dextra + Parese Nervus VII,
XII Tipe UMN Dekstra ec
Post Stroke Iskemik +
Hipertensi Stage 2 + DM
Tipe 2
6. Halifah Ginting 42 / LK 30/03/2023 Hemiparese Dekstra + ALD SC CAB
Parese N. VII Tipe UMN
Dekstra ec Stroke Iskemik +
HHD ec Hipertensi Stage II
+ Pneumonia Komunitas
7. Julianto Jalukhu 61 / LK 31-03-2023 Apatis + Hemiparese SHU SC NN
Sinistra + Focal Onset
Motor Clonic Seizure +
Parese N. VII, IX, X, XII
Tipe UMN Sinistra ec
Stroke Iskemik
8. Rumiah Lembeng 60 / PR 01-04-2023 Somnolen ec Ensefalopati JUN RA 2 SUS
Sekunder ec Uremic
Ensefalopati + AKI std III
dd CKD G4 (eGFR
22ml/min/1.73 m2) ec DN
dd HN + DM Tipe 2 +
 Hipertensi Stage 1 + AKI dd
CKD + Anemia ec Penyakit
Kronis
9. Krisnoh Hutauruk 35 / LK 02-03-2023 Paraparese Tipe LMN (Syok SHU RA 2 GAN
Spinal) + Hipestesi
Setentang Th 11-12 +
Retensi Urine et Alvi ec
Trauma Medulla Spinalis
 PASIEN PULANG

UMUR/ TGL TGL

No NAMA JK DIAGNOSIS DR KET DPJP
MASUK KELUAR
1. Jamurdin 60 25-03-2023 31-03-2023 Koma ec Sepsis ec IKR EXITUS PPS
Ensefalopati Sekunder +
Tetraparese Tipe LMN
Ekstremitas Superior + Tipe
UMN Ekstremitas Inferior ec
Spondilitis TB + Pneumonia
Komuniti + CKD on HD
2. M. Soleh 69 25-03-2023 02-03-2023 Focal Onset Motor Tonic IKR PBJ KRT
Seizure Without Impaired
Awareness ec Epilepsi
Simptomatik + Hemiparese
Dekstra + Parese N. VII Tipe
UMN ec Chronic Subdural
Hematoma + Hipertensi Stage
II
3. Lukman Hakim 30 22-03-2023 29-03-2023 Acute Symptomatic Seizure ec JUN PBJ SUS
Uremic Ensefalopati + CKD
Grade V + Pneumonia
Komuniti + Post PSMBA +
Post Stroke Iskemik +
Hipertensi Stage II + Anemia
ec Penyakit Kronis dd
Perdarahan
4. Simalai 56 20-03-2023 02-04-2023 Hemiparese Dextra ec Stroke DNY PBJ ISN
Sarumah hemoragic (SAH) + Post
Hipoglikemia + CKDG5D +
Anemia ec peny kronis (8.2) +
DM tipe 2 + Pneumonia
Komuniti
 LAPORAN PASIEN RAWAT INAP VIP
RUANG INAP NEUROLOGI RS H. ADAM MALIK
TANGGAL 28 MARET – 4 April 2023

JUMLAH PASIEN
NO DIAGNOSA PRIA WANITA JUMLAH
1. Stroke Hemoragik
2. Stroke Iskemik
3. Ensefalopati Sekunder
4. Meningitis Tuberculosa
5. Guillaine Barre Syndrome
6. Myastenia Gravis
7. Neuropsychiatric Systemic Lupus
Erythematosus
8. Spondilitis Tuberculosa
9. Toxoplasma Ensefalitis
Jumlah

PASIEN BARU
UMUR/ TGL
No NAMA DIAGNOSIS DR KET DPJP
KELAMIN MASUK

1. Lelyana Ginting 44 / PR 28-03-2023 Koma ec Stroke Hemoragik DNY DPJP ALF

(ICH + IVH) + Hipertensi
Stage I + CKD on HD (Rabu-
Sabtu)
2. Nurdiana Sitorus 71 / PR 01-4-2023 Somnolen ec Meningitis JUN DPJP SUS
Bakterial dd TB + Sepsis +
Hipertensi Stage I + DM Tipe
2 + Hiperkolesterolemia +
Pneumonia Komuniti + AKI
dd CKD + Elektrolite
Imbalance + Alkalosis
 Respiratorik
3. Barmen 63 / LK 01-04-2023 Generalized Onset Tonic JUN DPJP SUS
Simanjorang Clonic Seizure ec Epilepsi
Simptomatik + Hemiparese
Sinistra ec Post Stroke
Iskemik + Hipertensi Stage 2
4. Asnidar Zega 36 / PR 02-03-2023 Paraparese Tipe UMN + SHU DPJP GAN
Hipestesi setentang Th 10-11
ec Susp. Spondilitis TB dd
Pyogenik

PASIEN PULANG

UMUR/ TGL TGL

No NAMA DIAGNOSIS DR KET DPJP
JK MASUK KELUAR
1. Lelyana 44 / PR 28-03-2023 31-03-2023 Koma ec Stroke DNY EXITUS ALF
Hemoragik (ICH +
IVH) + Hipertensi
Stage I + CKD on
HD (Rabu-Sabtu)
2. Ganep 59 / LK 26-03-2023 29-03-2023 General Onset NAD PBJ KHS
Noven Motor Tonic Conic
Siregar Seizure ec Epilepsy
Symptomatic +
Afasia Global +
Hemiparese Dekstra
+ Parese N. VII
Tipe UMN Desktra
ec Post Stroke
Iskemik +
Hipertensi Stage I +
Dm Tipe 2
 LAPORAN PASIEN RAWAT BERSAMA
RUANG INAP NEUROLOGI RS H. ADAM MALIK
TANGGAL 28 MARET – 4 April 2023

No Nama Umur JK Diagnosis DPJP DR KET

1. Saiful 30 LK Paraestesia Pedis Bilateral ALF DNY RB 1
ec Drug Induced
Polineurpati + MDR dalam
pengobatan jangka panjang
bulan ke-3
2. Maryam 51 PR Somnolen + Post EVD ( R) ALF DNY ICU IGD
Kocher (H5) a/i
Spontaneous IVH (onset
H9) + HHD ec Hipertensi
Stage II + Post Debridement
a/i Snake Bite o/t (R) Hand
+ Pneumonia Komuniti
3. Roslina Siregar 55 PR Sopor ec Encepalopati ISN DNY ICU
Sekunder ec Uremic Dewasa
Ensefalopati + CKDG5 e.c
HN + Hipertensi terkontrol
+ Asidosis metabolik +
Anemia e.c peny.kronik dd
Perdarahan + Hiponatremia
( 118) + Hiperkalemia ( 5,8)
4. Ida Rusianna 58 PR Afasia Global + Hemiparese CAB ALD RB 2
Dupleks + P. N VII Tipe
UMN Dekstra ec Post
Stroke Ischemic + Atrial
Fibrilasi + Acute Limb
Ischemic
5. Dedi Darmawan 45 LK Secondary Headache ec CAB ALD RA 5
Susp Brain Metastasis +
 Adenokarsinoma Paru
Kanan + CAP + Anemia ec
Peny Kronis
6. Ong Beng Lie 71 LK Paraparese tipe UMN ec NN SHU RB 1
Susp Spondilitis TB + MDR
TB dalam Pengobatan
Jangka Panjang Bulan ke 1
+ DM tipe II + Disuria +
Dermatitis
7. Sri Ngatin 60 PR Apatis + General Onset NN SHU PAVI Lt7
Tonic Clonic Seizure ec
Acute Symptomatic Seizure
ec Susp. Brain Metastase +
Massa Intraabdomen +
Anemia ec peny. Kronis
(8,9) + AKI dd CKD stage
IV + Hipoalbumin (2,18)
8. Bajisokhi Dachi 50 LK Sopor ec Ensefalopati NN SHU ICU
Uremikum + CKDG5 (post Dewasa
HD 1x) + BPH (Post TURP
tahun 2022) + Anemia ec
Penyakit Kronis dd
Perdarahan (6.8) +
Hipoglikemia (69) +
Hipertensi Stage II +
Alkalosis Respiratorik
10. Salomon 42 LK Episodic Vestibular SUS JUN RB 3
Sembiring Syndrome ec BPPV +
Neuropati DM + (R
Diabetic Foot Ulcer Wagner
Classification Grade 2 +
DM Tipe 2
11. Dermawati Purba 67 PR Apatis ec Ensefalopati SUS JUN RA 6
 Sekunder ec Uremic
Ensefalopati + Hemiparese
Sinistra ec Stroke Iskemik
(O14H1) + AKI stg III dd
CKD G5 ec HN dd DN +
PSMBA ec gastritis erosifa
dd stress ulcer + anemia
(6.0) ec perdarahan dd
penyakit kronik + HT stage
II + DM Tipe 2
12. Ruslan Manik 73 LK Hydrophobia ec Susp SUS JUN RITN
Rabies Excitation Phase
13. Irwan Johanes 42 LK Apatis ec Ensefalopati SUS JUN RA 4
Ginting Sekunder ec Uremic
Ensefalopati dd Sepsis +
Hemiparese Dekstra ec Post
Stroke Iskemik +
Pneumonia HAP dd CAP +
HHD dengan HT st II +
AKI dd CKD st IV (eGFR
18ml/min) + Hipokalemia
(3.3)
14. Budiman 65 LK Koma ec Ensefalopati GAN SHU ICU
Marpaung sekunder ec Syok Sepsis ec Dewasa
Pneumonia Komuniti
dd/HAP + Post Stroke
Iskemik + AKI std II dd
CKD + Ulkus Diabetikum
o/t Gluteus + DM tipe 2 +
Asidosis Tipe Campuran +
Anemia ec penyakit kronis
(6,4)+ Hipoalbumin (1,8)+
Hiponatremia hipoosmolar
normovolume (129)