DAFTAR PASIEN

Rabu, 18 September 2023

No. Prof. Dr. dr. Kiking Ritarwan,MKT,Sp.S(K) PPDS : NAD
(kiking) Rencana Penunjang / Terapi (08.00 WIB)
Nama Pasien Usia Seks TGL Masuk MR Diagnosa Ruangan Ket
Vitamin B komplex 3x1, VIP albumin 3 x 1
Paru: NAC 3x200mg
inj. Meropenem 1gr/8jam (start 12/9/23) ACC PPRA
Klindamisin (start 12/9/23) 4x300 --> sesuai PPRA
Neb. Meprovent 2,5mg/8jam (+) Inj. Gentamisin 240mg/24jam
(15/09)
Interna : inj Asam Traneksamat 500 mg/ 8 jam
Post ensefalopati + Post VP Shunt (L) kocher d/t Hidrosefalus obstruktif ec PCNSL inj Esomeprazole 40 mg/24 jam
dd GBM + Sepsis ec pseudomonas aurigenosa ec CAP ec Klebsiella Pneumonia + PJT Lt 7 kamar UDCA 3 x 250 mg
1 H M Yunan 77 LK 02/09/2023 901207 Raber
Acinetobacter baumani + PPOK Stabil group E + PSMBA ec gastritis erosiva dd 7.09 Bedah Saraf: IVFD Rsol 20gtt
variceal + Multiple Kolelithiasis + Kolesistitis + Ulkus Dekubitus + Hipoalbuminemia Inj Meropenem 2gr/8jam
Inju Gentamisin 80mg/24jam
Inj Manitol 125ml/8jam
Inj Furosemid 20mg/24 jam
Inj Dexamethason 10mg/8jam
Inj Omeprazole 40mg/12 jam
Inj Asam tranexamat 500mg/8jam
Inj Fenitoin 100mg/8jam
Dr. dr. Alfansuri Kadri, Sp.S(K) (alfansuri)
PPDS : MLY
No. Rencana Penunjang / Terapi (08.00 WIB)
Nama Pasien Usia Seks TGL Masuk MR Diagnosa Ruangan Ket
Neuro (DPJP)
-Bed rest
-Head up 30 derajat
-O2 via NK 5 lpm
-Diet sonde rendah garam
-IVFD Rsol 20gtt/i
-Inf Manitol125cc/6jam tapp off (H3)
-Inj. Deksametasone 5mg/6jam (H3)
Hemiparese Dekstra ec SOL Intrakranial ec Abcess Serebri + HT Stg I + Susp TB Paru
1 Gong Matua Harahap 57 LK 06/09/23 901599 RB1 3.3.5 DPJP -inj. Ceftriaxone 1 gr/12 jam
Kasus Baru Terkonfirmasi Bakteriologis dalam Pengobatan OAT Fase Intensif
-Inj. Ranitidine 1amp/12jam
-Kandesartan 1x16mg
-Vit B komp 3x1
- paracetamol 3x1
- menunggu jawaban konsul bedah saraf
Bedah saraf
- rencana assesment ulang

IVFD RSol 20 gtt/mnt

Inj. Deksametason 1 amp/12jam
Inj. Ranitidin 1amp/12jam
Hemiparesis sinistra + PN VII, IX, X Tipe UMN Sinistra + Post craniotomy a/i
2 Azirul Arifin 79 LK 15/09/2023 779116 RA5 3.2 DPJP Inj. Ceftriakson 1 gr/12jam
brain tumor + PPOK + Pneumonia + HHD Stage II vitamin B Komplek 3x1
Pasang NGT, Kateter
rencana mri brain kontras menunggu jadwal

Generalized Onset Motor Tonic Clonic Seizure ec Susp NPSLE dd Acute - Inj Diazepam 1 Amp bolus pelan k/p
3 Sofia Manurung 18 PR 16/09/23 902502 Symptomatic Seizure RA3 3.1 Raber - Pantau kejang
- rencana EEH hari ini

Neuro (DPJP)
- O2 NRM 13 lpm
- IVFD Rsol 20 gtt/i
- Inj Ranitidin 1 amp/12 jam
- Inj. Metilprednisolon 125 mg/8 jam --> AFF
Tetraparese Tipe LMN ec PPH dd Electrolyte imbalance + Effusi minimal kiri +
4 Fazri Zakaria 35 LK 16/09/23 902510 RA2.3.3 DPJP - Inj Ceftriaxone 1 gr/12 jam
Pneumonia Komunitas
- Vit B Komp 3 x 1 tab
- KSR Tab 3 x 600 mg
Paru
- NAC 3X200 mg
-R/ kultur sputum
Acc Rawat Bersama
Head CT Scan Non Kontras (menunggu ekspertise)
Aspilet 1 x 80 mg
Inj Ranitidin 1 amp/12 jam
Hemiparese Dekstra + Parese N XII Tipe UMN Dekstra ec Susp Stroke Iskemik Vit B Komp 3 x 1 tab
Rekuren + NSTEMI TR 2/7 GRACE 133 CRUSADE 58 + HFrEF fc lll (EF 30%) + Susp. Kardio (DPJP)
5 Irfan Hasyri 57 LK 16/09/23 902497 CVCU bed 10 Raber
DVT dd Selultis o/t R leg + PAD o/t both legs + DM Tipe 2 + AKI dd CKD (CrCl 18 Total kebutuhan cairan 0,8 x 2500 = 2000 cc/24 jam
ml/min) + Susp. pneumonia + Hipoalbumin (2.5) - Kebutuhan protein 0,8 x 70 = 56 gr
- IVF NaCl 0,9% 10 tpm
- Drips UFH 850 IU/jam
- Inj. Furosemide 40mg/8jam
- Aspilet 1x80mg
Neuro
- Clopidogrel 1x75mg
-- IVFD Rsol 20 1x40mg
Atorvastatin gtt/i
-- Inj Deksamethasone
Carvedilol 2x3,125mg5mg/6 jam (H-2)
-- PCT
Inj Ranitidin
3 X 10001mg amp/12 jam
-- Vip
Amlodipin
Albumin 1 xsach
10 mg
2x1
Apatis ec Susp TE dd/ ensefalitis + Pneumonia Komunitas + HHD dengan Hipertensi - Kandesartan 1 x 16 mg
6 Kasro Tarigan 53 LK 16/09/23 902518 RA2 2.2.2 DPJP
Stage 2 + PSMBA ec gastritis erosiva dd stress ulcer - Vit B Komp 3 x 1 tab
- R/MRI brain kontras
- R/Lumbal Punksi
- menunggu hasil HIV 3 metode
PARU
- Inj. Levofloxacine 750 mg/24 jam (17/09)
Dr. dr. Puji Pinta Sinurat, Sp.S(K) (puji) - Nebule Meprovent 1 resp /8 jam
901599 - Nebule pulmicort 2.5 mg/12 jam
- NAC 3X200 mg
No. Rencana Penunjang / Terapi (08.00 WIB)
Nama Pasien Usia Seks TGL Masuk MR Diagnosa Ruangan Ket I : R/ Kultur Sputum : susul bahan

Atasi penyakit dasar Aspirin 1 x 80 mgSimvastatin 1x 20 mg (malam)

Somnolen ec ensefalopati sekunder ec sepsis ec Ulkus decubitus grade I-II o/t Vit B comp 3x1KSR 3x1Capsul Garam 1x1Fisioterapi dilanjutkan
gluteus + Hemiparese Sinistra + PN VII Tipe UMN Sinistra ec Post Stroke Iskemik + INTERNA (DPJP): Oksigen via NK 5 lpm, IVFD NaCl 0.9 %, Inj.
1 Roga Br. Sebayang 83 PR 03/09/2023 863328 RA 6 1.8.1 Raber
Pneumonia Geriatri + Malnutrisi + CAD anterolateral + High risk Thrombosis + Metoklopramide 10g/12jam, Inj. Levofloxasin 750mg/24 jam, NAC
Elektrolit Imbalance 3x200mg

IVFD R.Sol 20 gtt/i

Inj. Ranitidin 20mg/12jam
Ensefalopati Sekunder ec ARDS ec Sepsis ec Pneumonia + Hipokalemia + Disfagia + Aspilet 1x80mg
2 Siti Rabuana Manik 60 PR 12/09/2023 898427 Afasia Motorik + Hemiparese Dupleks ec Post Stroke Iskemik + Hipokalemia + RITN DPJP Fenitoin 2x100mg
Epilepsi Simptomatik + DM Tipe 2 + Hipertensi Stage II Vitamin B comp 3x1
KSR 3x600mg

dr. Kiki M. Iqbal, Sp.S(K) (kiki10)

PPDS : MEL
No. Rencana Penunjang / Terapi (08.00 WIB)
Usia Seks TGL Masuk MR Diagnosa Ruangan Ket
 Aspilet 1x80mg --> tunda
Terapi Kardio IVFD Nacl 0,9% 10 gtt/i, Inj. ampisilin sulbactam 1,5 gr/6
jam (H-5), Inj. gentamisine 80 mg/12 (H-5), Inj. ranitidin 1amp/12 jam,
PJT lantai 4 Inj. furosemide 20 mg/24 jam, bisoprolol 1x2,5 mg, ramipril 1x2,5 mg,
1 Muzakir 65 LK 15/09/2023 902432 Demensia Vaskular ec Stroke Iskemik + Infective Endocarditis + CHF Raber
kamar 401 spironolaktone 1 x 25 mg, Xarelto 2 x 15 mg selama 3 minggu terlebih
dahulu (H-2). Head CT Scan: Infark akut di sentrum semiovale kanan.
Infark lama di kapsula eksterna sampai corona radiata kanan. Atrofi
serebri senilis. Sinusitis maksilaris kanan.

Inj. diazepam 1 amp bolus pelan jika kejang (k/p) , R/ EEG di ruangan,
R/ Ct Scan --> Batal. Pasien telah paliative care
Somnolen + Generalized Onset Motor Tonic Clonic Seizure + Hemiparese Dupleks
Terapi Interna : IVFD Aminofluid 1fl/24 jam, VIP albumin 3x1 sachet,
2 Husin Sitorus 83 LK 15/09/2023 901891 ec Susp. Brain Metastasis + Well Differentiated AdenoCa Anal + Post Sigmoidoskopi RA4 3.1 Raber
Inj. Ampisul 1.5 mg/ 6 jam mulai 13/9/2023), Inj. Furosemid 20 mg/ 12
a/i Unresectable Anal Cancer + Hipoalbuminemia + Hiponatremia
jam (jika TDS>100mmHg), Inj. Omeprazole 40 mg/12 jam, Inj.
Ondansetron 1 amp/12 jam, MST 2x10mg, NAC 3x200mg

Inj. Deksametason LD 10 mg selanjutnya 5mg/6 jam H3, Inj. Ranitidin

1 amp/12jam, Vitamin B Komplek 3x1, Anjuran pasang NGT, Kateter,
R/MRI IV Kontras (penjadwalan). INTERNA (DPJP): Tirah baring,
Somnolen + Hemiparesis Dekstra + PN VII Tipe UMN Dekstra + Secondary
Oksigen via NK 4 LPM, Pasang NGT, Diet sonde, IVFD NaCl 0,9%
3 M Syafii 45 LK 16/09/2023 897699 Headace ec TE + HIV std IV dengan wasting syndrome + SSTI a/r scrotal dd RA4 3.4 Raber
25gtt/i, IVFD SmofKabiven 1fls/24jam, Drip PCT 1fls bila T >38C, Inj.
scarum +Anemia ec penyakit kronis (8,2) Ampisilin Sulbactam 1,5gr/6jam, Inj. Ranitidin 50mg/12jam, ARV TLD
1x1 (pada pasien), Cotrimoxazole tab 480mg => 3-3-3 (start
26/07/2023), PCT 3x500mg

dr. Chairil A. Batubara, MKed(Neu), Sp.S(K) PPDS : OLV

(chairil)
No. Rencana Penunjang / Terapi (08.00 WIB)
Nama Pasien Usia Seks TGL Masuk MR Diagnosa Ruangan Ket

- Head Up, Inj. Ranitidin 1amp/12 jam, Vitamin B Komp 3x1,

Clopidogrel 1x75mg
INTERNA: - O2 via ETT, Diet M1 1800 kkal , 60 gram protein + Ekstra
putih telur, IVFD RL 20gtt/i, Inj. Esomeprazole 40mg/24jam, Drip
parasetamol 1000 mg/8 jam
- Koreksi albumin 20% 100 cc 1 flash (selesai 18/9/23)
Sopor ec Sepsis ec Pneumonia CAP dd HAP + Post Stroke Iskemik + Susp Ca Paru + (2,5-2,22) x 90 x 0,8 = 20 gram
HHD Dengan Ht terkontrol + Hiponatremia Hiposmolar Normovolume (131) + Old Anestesi: Inj Norepineprin 8 mg + nacl 0,9% 50cc --> 6,5 cc/jam
1 Anas M SE 82 LK 08/09/2023 502591 ICU IGD RABER
Fraktur tertutup collum humerus (R) Inj. fentanyl 300 mcg + miloz 15 mg dalam 50 cc nacl 0,9%
HOM: Inj. Heparin 2 x 5000 iu sc Bila tidak ada perdarahan, bila
dijumpai perdarahan heparin kita tunda
PAI: Nebulizer Ventolin 1 amp / 8 Jam, Nebulizer Fulmicort 1 amp / 12
Jam
PTI: Inj.Amikasin 1g/24 jam (start 18/9/23), Inj Meropenem 1
amp/8jam dlm 100 cc NaCl 0.9% hbs 3 jam (start 9/9/23 s/d 18/9/23),
Drip Fluconazole 200mg/24 jam, Klindamisin 4x300mg
IVFD R.Sol 20gtt/i, Inj. Ranitidin 1 amp/12jam, Inj. Ketorolac
1amp/8jam (H2)
IR Mayu Suwondo Diazepam 3x 1 mg, Amitriptilin 3x6.25 mg, Paracetamol 3x 1000mg,
2 56 LK 18/09/23 902585 Low Back Pain ec Susp HNP L5-S1 RA2 2.2. 1 DPJP
Vit. B Komplek 3x1
R/ Fisioterapi, MRI Lumbosacral Non Contrast

- Inj. Metilprednisolon 125 mg/6 jam/IV (H1) (Tapering off)

- Vitamin B Comp 3 x 1 tab
R/ Foto Thorakal AP/L
Paraparese Tipe UMN + Hipestesi Sttg Th10-11 + Retensio Urin et Alvi ec Susp.
Interna (DPJP): Diet M2 1500 kkal
3 Bambang Hermanto 43 LK 18/09/23 902567 Fraktur Patologis ec Bone Metastasis + Susp. Multiple Myeloma dd Limfoma + AKI RA 5 2.6. 1 Raber
IVFD NaCl 0.9% 20 gtt/I, IV Smofkabiven 1 fls/24 jam, Inj. Ampisilin-
stage III dd CKD Grade III dd CKD Grade IV + Hipoalbumin
Sulbactam 1,5 gram/12 jam, Inj. Ranitidin 50 mg/12 jam, MST 2x10
mg, Parasetamol 3x500 mg K/P

- Inj. Deksametason 10 mg/IV (Loading dose) -> 5 mg/6 jam/IV (H2)

(Tapering off)
- Loading Pirimetamin 75 mg, R/ Pemberian Pirimetamin 200 mg
Focal Onset Motor Tonic Without Impaired Awaraness Seizure + Hemiparese dilanjutkan 3 x 25 mg dan Klindamisin 4 x 600 mg
Sinistra ec SOL Intrakranial dd Tuberkuloma dd TE dd PCNSL + Pneumonia Komuniti - Levetiracetam 1 x 500 mg
4 Jayadi 46 LK 18/09/23 650945 RB 1 3.4. 5 Raber
dd TB Paru Kasus Relaps + CHF fc II + Efusi Pericard + HIV Stadium II - Vitamin B Comp 3 x 1 tab
- Rencana EEG, MRI Brain IV Contrast (konfrimasi DPJP)
KARDIO: Inj. Furosemide 40 mg/12 jam, Kandesartan 1x8 mg,
Spironolakton 1x25 mg

- ACC Rawat Bersama, Pro Assessment

- Pantau TTV, Defisit Neurologis
INTERNA: Inj Omeprazole 40 mg/12jam, Inj Traneksamat 500
Ptosis OS ec Sindroma Horner + Susp. Tumor Mediastinum + Efusi Pleura Minimal
5 Erwin Daniel 26 LK 18/09/23 902545 RA 5 2.5.2 Raber mg/8jam, Sukralfat Syr 4xC2, NAC 3 x 400mg
Sinistra + Efusi Perikard + Acute Liver Injury + Anemia ec Perdarahan
PARU: IVFD NaCl 0,9% 20 TPM, Inj. Ampisilin Sulbactam 1,5gr/6jam,
Inj. Ranitidin 50mg/12jam, Inj. Ketorolac 30mg/8jam, NAC 3x200mg.

- ACC Rawat Bersama

Mangatur Manalu
6 52
- Bed Rest Head Up 30
Apatis + Ptosis OS + Parese N.VII Tipe UMN Sinistra ec Susp Infiltrasi Tumor
- Inj. Dexametason 10 mg LD Selanjutnya 5 mg/6 jam Tapp Off
Intrakranial ec Nasofaring Carcinoma T4N3M0 + Hipoglikemia (76) + Hiponatremia
LK 18/09/23 898502 RA4 3.1. 2 Raber - Inj. Ranitidin 50 mg/12 jam
(130) + Hipokalemia (3.2) + Anemia ec penyakit kronis dd perdarahan (8.2)
- Parasetamol 3 x 1000 mg
- R/ MRI Brain IV Kontras (Penjadwalan diruangan)

Bed Rest Head Up 30

IVFD Rsol 20 gtt/i Makro
Aspirin 1 x 80 mg
7 Surya Pepi Suhendri 58 LK 18/9/2023 827633 Secondary Headache + Hemiparese Dextra + PN.VI OS ec Stroke Iskemik RA2 3.3.3 DPJP Inj. Ketorolac 30 mg/ 8jam
Inj. Ranitidin 50 mg/12 jam
PCT 3 x 1000 mg
B comp 3x1

Atasi penyakit dasar

Interna: IVFD NaCl 0,9% 1 fls --> IVFD NaCl 0,9% 20 tpm
Inj. Ranitidin 50mg/12 jam
ivfd D40% 2flc
Sopor ec Ensefalopati Sekunder ec Prolonged hipoglikemia dd/ Sepsis + DM Tipe II
ivfd Nacl 3% 10tpm ( 140-132) x 60x0,6 = 1 fls Nacl 3%
Adenokarninoma Paru Kiri T4N3M1b (Nodul infiltratif kontralateral dan pita suara)
8 Zulkifli Bin Ubit 62 lk 18/09/23 899883 RA6 1.3 RABER inj. Metilprednisolon 62,5mg/12jam
Stage IVA ECOG III
inj. Meropenem 1gr/8jam (konsul PPRA di ruangan)
inj. Levofloxacine 750mg/24jam (konsul PPRA di ruangan)
NAC 3x200mg
MST 2x1--> konsul management pain di ruangan
Neb. Ventolin 2,5mg/8jam
 Paracetamol 3 x 1000mg
Amitriptilin 1 x 12,5mg AFF ganti 3 x 6,25 (1/4 Tab)
Vitamin B Comp 3 x 1
LBP ec Susp Spondilosis Lumbalis + bs Jaundice ec CBD Stone dd Tumor Caput
9 Renta Purba 60 PR 18/09/23 902361 RA3 2.6.4 RABER Inj. Ketorolac 30 mg/ 8jam
Pancreas dd Tumor Ampula Vateri + Hipoalbumin (2,91) + Acute Liver Injury
Diazepam tab 2-2-5 mg --> 2mg pagi, 2 mg siang , 5 mg malam
susul hasil Ro Lumbosacral
R/ Konsul fisioterapi

Apatis ec Susp Brain Metastasis + Paraparese Tipe LMN ec Bone Metastasis +

acc rawat bersama
10 Fu Han 66 LK 18/09/23 876372 Adenocarcinoma Paru Kanan Post kemoterapi lini I siklus 6 + Kolelitiasis + CAP dd RA6.1.14 RABER
Head CT Scan dengan IV Kontras (setelah perbaikan KU)
HAP+ Hemoptisis

IVFD Rsol 20 gtt/i (makro)

Koreksi Kalium (3,5-1,8) x 60 x 1/3 = 34 Meq --> 1,5 Flc dalam 200 cc
Nacl 0,9% Kecepatan 8 gtt/i Makro
11 Angga Kristovel Sianturi 18 LK 18/09/23 902720 Tetraparese Tipe LMN ec Paralysis Periodic Hypokalemia RA5 3.1.1 DPJP KSR tab 3 x 600 mg
Vit B komp 3x1

R/ Cek Kalium Post Koreksi & Fungsi Tiroid

Bed Rest Head Up 30

IVFD Rsol 20
Inj.Dexametason 5 mg/8 jam (H2)
Inj. Ranitidin 50 mg/12 jam
Visual Loss ODS + Hemiparese Sinistra + Secondary Headache ec SOL Intrakranial ec Inj. Ketorolac 30 mg/8 jam IV
12 Yuswati 48 PR 18/09/23 902726 RA2 3.1.4 DPJP
Tumor Primer Intrakranial dd/ Brain Metastase + Ulkus Dekubutis Parasetamol 3 x 1000 mg
Vit B Komp 3 x 1

R/ MRI Brain IV Kontras di Ruangan

R/ Konsul bedah Plastik diruangan

Head CT scan Non Kontrast

ACC Rawat Bersama
INTERNA: Rehidrasi cairan 2 fls Nacl 0,9% -- IVFD Nacl 0,9% 20 gtt/i
IVFD Smofkabiven 1 fls/24 jam, Inj Omeprazole 40mg/12 jam, NAC
Somnolen + Anisokor Pupil ec Susp TE dd/ Tuberkoloma + HIV Std IV + PCP + 3x200 mg
Wasting syndrome + AKI std I dd + CKDG3a (GFR 47 ml/min/1.73 m²) + - TLD (Tenofovir 1x300 mg Lamivudine 1x300 mg Dolutagavir 1x50 mg
13 Hardisupratman Hutabarat 44 LK 18/09/23 896048 RA 4 3.1.5 Raber
Hipoalbuminemia (1.98) + Trombositopenia ec viral infection (30.000) + Anemia ec ) (Pada pasien dilanjutkan)
peny kronis dd perdarahan (9.9) - Kotrimoxazole 1x960mg > Ganti dosis : Kotrimoksazol 480 mg : 3-3-3
tab (start 18/09)
- Post Koreksi 1 fls Albumin 25% 100 cc
(+) Drip Flukonazole 200 mg/24 jam (start 19/09)
(+) Transfusi FFP 1500 cc > 500 cc per hari
Dr. dr Aida Fitri, Sp.S (K) (aida10) ASP
No.
Nama Pasien Usia Seks TGL Masuk MR Diagnosa Ruangan Ket

Secondary Headache ec Susp Meningitis TB+ TB Paru relaps + Susp. ILD +

1 Nanda cholid rizky 27 LK 13/09/2023 900596 RB 1 3.5.3 Raber Parasetamol 3 x 1000 mg
Hipokalemia + Malnutrisi + High + Gangguan mental organik

Somnolen ec ARDS ec Pneumonia CAP dd HAP + Hemiparese Dekstra + Parese NVII

2 Tumour Marpaung 72 PR 13/09/2023 902220 ICU Dewasa DPJP
tipe UMN Dekstra ec Post Stroke Iskemik

Afasia Motorik + Hemiparese Dekstra ec Susp. Toxoplasma encephalitis + HIV std IV

3 Perengki Sitinjak 39 LK 13/09/2023 902216 RA6 1.10.1 Raber R/ MRI Brain IV Kontras di Ruangan
dengan wasting syndrome + Oral Candidiasis + Pneumonia CAP dd PCP

Post penurunan kesadaran ec KAD dd HHS dd Sepsis ec Pneumonia CAP dd HAP + ACC PBJ sesuai TS DPJP
PJT Lt. 4
4 Epiati Br. Tarigan 44 PR 13/09/2023 902225 Acute Lung Edema + UAP dd NSTEMI + Trombositosis reaktif dd essensial (543.000) Raber Atasi penyakit mendasar
kamar 404
+ Anemia ec penyakit kronis dd perdarahan (10.5) Vit B komp 3x1

Fisioterapi
Hemiparese Dekstra ec Post Stroke (2019) + DM tipe 2 + Ulkus Diabetikum o/t Digiti
Visite hanya jika perlu.
IV Pedis Dekstra + Post BKA o/t (L) cruris (2020) + Post hipoglikemia (49>>129) + AKI
5 Nurwanca 54 PR 13/09/23 679906 RA3 2.6 Raber
std III dd CKDG5 + Anemia ec perdarahan dd peny kronis (9.6) + Hipoalbuminemia
(2,6) + Dislipidemia + Hiponatremia (133)

Apatis ec Ensefalopati Uremikum + Hemiparese Sinistra + Parese N. VII Tipe UMN CPG 1x75 mg (lanjutkan dari RS sebelumnya)
Sinistra + Parese N. IX, X Tipe UMN ec Post Stroke Iskemik + Hipertensi stage II + Amlodipin 1x10 mg
6 Desi Afriandi 47 LK 13/09/2023 902191 DM Tipe 2 + CKDG5D + PSMBA ec non varicela bleeding dd variceal bleeding + Pavi lnt 7 Raber Kandesartan 1x8 mg
Anemia ec perdarahan dd penyakit kronis (6.6) Vitamin B Komp 3x1
Advis atasi penyakit mendasari lainnya

Cek lab, Foto Thoraks, Head CT-Scan non-kontras.

Secondary Headache + Hemiparese Sinistra ec Neuro Psikiatrik Systemic Lupus
7 Riau Pintauli 27 PR 13/09/2023 878114 RA 2. 3.1.3 DPJP
Eritematosus (NPSLE)
Inf. Parasetamol 1 Fl ekstra

dr. Fasihah Irfani Fitri, M.Ked (Neu), Sp.S (K) PPDS : SHU
(fasihah)
No. Rencana Penunjang / Terapi (08.00 WIB)
Nama Pasien Usia Seks TGL Masuk MR Diagnosa Ruangan Ket
 Dr. dr. Iskandar Nasution, Sp.S(K) (iskandar)
PPDS : DNY
No. Rencana Penunjang / Terapi (08.00 WIB)
Nama Pasien Usia Seks TGL Masuk MR Diagnosa Ruangan Ket

IVFD Rsol 20 gtt/i, Aspilet 1 x 80 mg, Vitamin B komplex, KSR tab2x1.

Hemiparese dextra + P N VII, XII tipe UMN dextra ec Post Stroke Iskemik +
Drip parasetamol /8 jam.PARU: kodein 3x 20 mg, Neb Meprovent 2,5
1 Marwani 70 Lk 07/09/2023 901624 Pneumonia HAP + Post Trakeostomi + Hipokalemia + TB kasus baru berdasarkan Rb1 1.2.1 DPJP
mg/ 8 jam, vip albumin 3x1, TTD 2x1, vit b 6 1x1
bakteriologis
RHZE:: 600/300/1500/1000
inj. Ketorolak 1amp /12 jam,inj. Ranitidin 1 amp/12 jam,Vitamin B
komplek 3x1, amitriptilin 2x 12,5 mg, Fisioterapi
R/MRi whole spine-> Burst fracture corpus vertebrae L1 yang
mengakibatkan penekanan spinal cord setinggi Th12-L1 dan
spondilolisthesis L1 ke posterior Th12 grade I. Fraktur avulsi di supero-
anterior korpus vertebra L4. perubahan intensitas marrow corpus
2 Rusli 47 LK 07/09/2023 901683 Paraparese Tipe LMN + Retensio Urin et Alvi ec Trauma Medula Spinalis RA2 3.2.1 Raber
vertebrae Th12 - L2 menggambarkan bone edema/bone contusio.
perubahan intensitas medulla spinalis setinggi Th11-12 - L1, paling
berat setinggi level Th12-L1, menggambarkan edema dan perdarahan.
Stenosis kanalis spinalis setinggi Th11-12 sampai L1. Spinal Cord Injury
grade Basic 4.

IVFD Rsol 20gtt/i,Paracetamol drip 1 Fl (di IGD),Nimodipin 4x60 mg,inj

ranitdine 50 mg/12 jam,Inj. Ampisilim Sulbaktam 1 amp/6jam,Inf.
Manitol 125cc/6jam,Inj. As. Traneksamat 1 amp/8jam,PCT 2x1000mg,
3 Umi Kalsum 52 PR 13/09/2023 902249 Secondary Headache ec SAH + DM tipe 2+ Susp. Pneumonia SC3 Bed1 DPJP Amlodipin 1x10mg,Vit B komp 3x1, Pain manajemen : Inj. Fentanyl
300 mcg dalam 50 cc NaCl 0,9 %-----> 3cc/jam
Drip Paracetamol 1000 mg / Extra
Paracetamol 1000 mg / 8 jam

- O2 3 lpm NK
- IVFD Rsol 20 gtt/i
Hemiparese Dekstra + Parese N VII, XII Tipe UMN Dekstra ec Stroke Iskemik - Inj Ranitidin 1 amp/12 jam
4 Semi Fatmawati 59 PR 16/09/2023 902500 SC1 DPJP
(O3H3) - Aspilet 1 x 80 mg
- Vit B Komp 3 x 1 tab, Atorvastatin 1 x20 mg INTERNA: Diet DM 1500 kkal,
Inj. Sansulin Rapid 3x8 IU/SC, Inj. Sansulin G 1x10 IU/SC (malam)

Inj deksametason 5 mg/ 6 jam (Hari 3)tapp off/3 hari

Inj Ranitidin 1amp/12jam
PCT 2x 1000 mg
Vit B komp 3 x 1
Paru:
IVFD NaCl 0,9% 20 tpm
Somnolen + hemiparese dekstra ec TE + TB Milier dalam pengobatan OAT Oksigen 5 LPM NK
Inf. Levofloxacin 750mg/24jam (start 18/9/23)
5 Besly Hutasoit 61 LK 17/09/2023 902541 Fase Intensif + DM tipe II + Hipertensi Terkontrol + Ikterik ec Acute Liver RA6 1.1 Raber
Inj. Ranitidin /12jam
Injury + Hipoalbuminemia Nebul Salbutamol 2,5mg/8jam
Nebul Pulmicort 0,5mg/12jam
NAC 2x600 mg (3hari)
VIP Albumin 3x1
OAT stop sementara
R/ CT SCAN Thorax IV Kontras
R/ Bronkoskopi E-Bus
Vit B comp 3x1, drip paracetamol /8jam
Atasi penyebab dasar
BEDAH: IVFD Nacl 0,9% 20gtt/I
- substitusi albumin
(2,5 - 2) 75 x 0,8 = 18.7
Somnolen ec Ensefalopati sekunder ec Sepsis ec Susp Pneumonia + Acute 2 fls albumin 20% dalam 50cc
Bedah Vaskular:
Limb ischemic rutherford class VI o/t (L) leg + NSTEMI TIMI RISK 1/7 GRACE
6 Dyonisius Romano Tarihoran 52 LK 17/09/2023 902559 Pavi Lt. 7 7.13 Raber R/ (L) below knee amputation Urgency
107 CRUSADE 40 + HHD dengan Hipertensi stage 1 + Hipoalbuminemia Kardiologi:
(2.06) + Hipokalemia (3.1) + Anemia Bisoprolol 1 x 5mg
Atorvastatin 1 x 40 mg
NKR 2 X 2.5 mg
Ramipril 1 x 5 mg
Inj. Furosemide 40 mg/24 Jam
Cek ulang Troponin
Inj Diazepam KP kejang (bolus pelan), Fenitoin 2x100mg, Aspilet 1x80mg,
Deksamethasone Inj 5mg/6jam (H-1), Vit B Komp 3 x 1, Rencana EEG pagi ini,
Rencana Brain MRI IV Contrast. Head CT Scan Non Kontras:
Infark kronis pada lobus fronto-temporo-parietalis kanan. Infark lakunar pada
basal ganglia dan capsula interna kanan. Atrofi serebri senilis. Sinusitis frontal
Apatis + Focal onset motor Tonic Clonic Seizure ec Susp Ensefalitis Viral dd kiri, etmoidalis bilateral, sphenoid kanan dan maksilaris kanan
PARU: O2 2-6 lpm
Autoimun + Tumor Paru Kiri (Jenis ?) T4N0M0 Stage III A ECOG 3 +
7 Safriani Lubis 58 PR 17/09/2023 902565 RA5 3.4 Raber IVFD NaCl 0,9 % 20 TPM
Hemiparese sinistra + Parese N VII, XII tipe UMN sinistra ec post stroke Inj. Ampisillin Sulbactam 1,5 gr/ 6 jam
iskemik + Susp TB Paru kasus baru + DM Tipe 2 Inj. Ranitidin 50 mg/ 12 jam
NAC 3 x 200 mg
Parasetamol 3 x 500 mg
Vit. B Comp 3 x 1
Neb. Pulmicort 0,5 mg/ 12 jam
Neb. Salbutamol 2,5 mg/ 8 jam.
Dr. dr. Khairul P. Surbakti, Sp.S(K) (khairul10) PPDS : ALD
No. Rencana Penunjang / Terapi (08.00 WIB)
Nama Pasien Usia Seks TGL Masuk MR Diagnosa Ruangan Ket

IVFD R.Sol 20gtt/i, Inj. Deksametason 5mg/8jam (H2), Inj. Ranitidin

Apatis + Hemiparese Dekstra ec Susp Brain Metastase + Hipertensi Stage II + (R)Ca 50mg/12jam, inj ceftriakson 1 gr/ 12 jam(H4), Vitamin B Comp 3x1
1 Eva Sitorus 48 PR 14/04/2023 902281 RA2 3.1.2 DPJP
Mammae + Post Kemoterapi + Pneumonia R/ MRI Brain IV Contrast senin (18 sept 2023)
R/ Tumor Marker (susul hasil)

IVFD . R.sol 20gtt/i, Inj. Ketorolac 1 amp/8jam, Inj. Ranitidin 1 amp

Amlodipin 1x10mg, Parasetamol 3x1000mg, Vitamin B Comp 3x1
2 Amir Butar-butar 69 LK 14/04/2023 640222 Low back pain ec HNP ec Multiple Kompresi Lumbal L2,3,4+ Hipertensi Stage II RA6 1.10.2 DPJP R/ Konsul Ortopedi(susul jawaban). Ro Lumbal AP/Lat :
Spondylolisthesis L4-5 grade I. Fraktur kompresi vertebra Th 12, L 1, L2
dan L5. Spondiloarthrosis lumbalis.
IVFD R.Sol 20gtt/i, Inj. Ranitidin 50mg/12jam, Aspilet 1 x 80 mg,
Kristina Sinaga Somnolen +Focal onset focal to bilateral tonic clonic + hemiparese dekstra ec Vitamin B Comp 3x1, Simarc 1x2mg , R/cek INR /3hari
3 60 PR 14/04/2023 902359 RA2 2.3.1 DPJP
Stroke Iskemik + Atrial fibrilation KARDIO: digoxin 1x 1/2 tab, inj futosemid/12jam

Acc rawat bersama, atasi penyakit dasar, Vit B komp 3 x 1

4 Zenab Br Surbakti 50 PR 14/04/2023 805903 Somnolen ec Ensefalopati sekunder ec Sepsis ec TB Paru Relaps + Hipertensi Stage I RA5 3 3 1 Raber

IVFD R sol 20 gtt/i

Parese N.XII Tipe UMN + Hemiparesis sinistra ec stroke iskemik rekuren (O6H4) + Inj ranitidin 50 mg/12 jam
5 Ewi Elvina Br Sembiring 49 PR 14/04/2023 862326 RA2 3.1.2 DPJP
CKDG5D ( selasa-jumat) ec DN dd HN + DM tipe 2 + HT stg 1 Aspilet 1 x 80 mg
Vit b komp 3 x 1
dr. Neni Nurchalida, M.Ked(Neu), Sp.S (neni) PPDS : IKR
No. Rencana Penunjang / Terapi (08.00 WIB)
Nama Pasien Usia Seks TGL Masuk MR Diagnosa Ruangan Ket

Bed rest, IVFD Rsol 20gtt/i, Fenitoin 2x100mg, Amlodipin 1x10mg,

Somnolen + Focal onset myoclonic seizure ec Hipoksik Iskemik Ensefalopati + ICU Dewasa
1 Elmando 68 LK 09/09/23 901849 DPJP NAC 3x400mg, Paracetamol 3x500mg, R/ EEG diruangan (Jika
Hemiparese Dekstra ec Post Stroke Iskemik + Pneumonia Bed 4
Transportable)

Hemiparesis sinistra + Deviasi konjugat sinistra + Parese N.XII tipe UMN sinistra ec -Parasetamol tab 3x1000mg
2 Suriyama 52 PR 11/09/23 893419 SAH + Post MVR a/i MR Severe dengan prolaps AML d/t degenerative Myxomatous HCU PJT Bed 3 Raber - Heparin/simarc AFF (7 Hari), Kapsul Garam 3x1, As.Valproat
(POD 3)+ LAA Reduction + TPM (POD-5) d/t MR Severe 2x250mg
 - Bed Rest Head Up
- IVFD Rsol 10 gtt/i makro
- 02 2 Lpm Via NK
- Inj, Dexametason 5 mg/ 24jam (H1)
Secondary Headache + Hemiparese Dupleks ec Susp Sol Intrakranial ec dd/ Multiple
3 Nurul Farhana 28 PR 11/09/23 902013 RA2 3.1.1 DPJP - Inj. Ranitidin 50 mg/12 jam
Abses Serebri -Tumor Primer Intrakranial - Tuberkoloma + CHF ec VHD dd/ PJR
- Parasetamol 2 x 1000 mg
- Vit B komp 3 x 1
- Susul hasil MRI Brain IV Contrast

Hemiparese Dextra ec Susp. Brain Metastasis + PPOK Eksaserbasi Sedang dalam

ACC rawat bersama di bagian neurologi
4 Effendi Pulungan 71 LK 19/09/23 878538 PPOK Stabil Grup E + Hemoptisis Ringan ec Tumor Paru Kanan (jenis?) T4N2M1b RA5 2.5 Raber
Rencana head CT Scan
(dinding dada) Stage IVA ECOG 2 + Cancer Pain (VAS :7)

Koma ec Uremik Ensefalopati dd Sepsis ec SSTI o/t (L) leg dd Pneumonia CAP dd
HAP + Acute on CKD + SSTI ec Ulkus Diabetikum Wagner 2 o/t (L) leg + DM tipe 2 + ICU Dewasa
5 Sativa Kumar 45 LK 19/09/23 902677 Raber ACC rawat bersama di bagian neurologi, Vitamin B Comp 3x1
High Risk Trombosis dengan High Risk Bleeding + Anemia normokrom normositer Bed 6
ec Penyakit Kronis dd Perdarahan (9.5)

Neuro
Amitriptilin 1x12,5 mg
lanjutkan pemberian aptor 1x100 mg (dari kardiologi)
Rencana Fisioterapi
Kardio (DPJP)
Hemiparese Sinistra + Hemihipestesi Sinistra + Parese N. VII tipe UMN Sinistra ec
Ivfd Nacl 0,9% 10 gtt
6 Tan Hok King 69 LK 19/09/23 902803 Post Stroke Iskemik + HFrEF ec CAD (Ef 28%) + HHD dengan HT terkontrol PJT Lt.4 402 Raber
Inj. Furosemid 20mg/12 jam
+ AKI dd CKD
Aptor 1x100 mg
Spironolakton 1x25 mg
Ramipril 1x2,5 mg
Bisoprolol inisiasi 1x1,25 mg

7 Febriani Limbong
IVFD Rsol 20gtt/i, Inj. Diazepam 1 amp k/p kejang bolus lambat, Inj.
Apatis + General Onset Motor Tonic Clonic Seizure + Secondary Headache +
Deksametason 10mg Loading Dose, Selanjutnya 5mg/6jam, Inj.
32 PR 19/09/23 902848 Hemiparese Dupleks ec SOL Intrakranial ec Brain Metastase + Ca Mammae (R) + RA2 2.1 DPJP
Ranitidin 50mg/12jam, Fenitoin kaps 2x100mg, Parasetamol
Post Kemoterapi 5 siklus + Bisitopenia
2x1000mg K/P, Vit B komp 3x1 tab

IVFD Nacl 0,9% 20 gtt/i

Inj. Ranitidin 50mg/12jam
Inj. Deksametason 10 mg Loading dose, selanjutnya 5mg/12jam
Suhirman Somnolen ec Ensefalopati Sekunder + Secondary Headache + Hemiparese Dekstra Clindamisin 4x600mg ya
8 46 LK 19/09/23 902857 RB 1 3.4 Raber
ec Susp. TE + HIV + Bisitopenia Parasetamol 3x1000mg
Kapsul Garam 3x1
Vitamin B Comp 3x1
R/ cek IgG dan IgM anti Toxoplasma

dr. M. Gandhi, M.Ked(Neu), Sp.N PPDS :

No. (muhammad5)
Nama Pasien Usia Seks TGL Masuk MR Diagnosa Ruangan Ket

dr. Suska Lara Br Ginting, M.Ked (Neu), Sp N

PPDS :
No. (suska)
Nama Pasien Usia Seks TGL Masuk MR Diagnosa Ruangan Ket