LAPORAN PASIEN RAWAT INAP

RUANG INAP NEUROLOGI RS H. ADAM MALIK

TANGGAL 31 Oktober – 6 November 2023

NO DIAGNOSA PRIA WANITA JUMLAH

1. Stroke Iskemik
2. Stroke Hemoragik
3. Brain Metastase
4. Ensefalopati Sekunder
5. Tumor Primer Otak
6. Toxoplasma Ensefalitis
7. Meningitis TB
8. HNP Lumbalis
9. Abses Serebri
10 Post Traumatik Epilepsy
11 Spondilitis TB
12 Spondilolisthesis
13 Malaria Serebral
14 NPSLE
15 Tetanus Generalisata
JUMLAH

PASIEN BARU

Usia /
No Nama Tgl Diagnosa DR KetDPJP
Kelamin Masuk
1. Rosmeri Samosir 44/PR 31/10/23 Low back pain + NAD RA 2 PPS
Paraparese tipe LMN ec
susp spondilitis TB dd
tumor primer medula
spinalis dd metastasis
spinal + kardiomegali +
susp TB paru
2. Sukma Br. 65/PR 31/10/23 Sopor + Hemiparese NAD RA 2 PPS
Tarigan Dekstra ec Stroke Iskemik
+ Hipertensi Stage II

3. Pandapotan 40/LK 31/10/23 Sopor + Generalized NAD RA 2 PPS

Simanjuntak Onset Motor Tonic Clonic
Seizure + Hemiparese
Dekstra ec Stroke Iskemik
+ Hiperglikemia + Susp.
Pneumonia
4. Juni anuarni 37/PR 2/11/23 Apatis + secondary MLY RA 2 KMI
purba headache ec High grade
Tumor Glioblastoma
5. Siti aminah 54/PR 2/11/23 Paraparese Tipe UMN + MLY RA 2 KMI
Hipestesi Setentang T4-T5
+ Retensi Urin Et Alvi ec
Susp SOL Medulla
Spinalis ec metastases +
Susp tumor paru +
hiponatremi
6. Randani 26/LK 2/11/23 Apatis + Secondary MLY RA 2 KMI
Headache + Hemiparese
 Sinistra Ec SOL
Intrakranial Ec Susp TE
Dd Tuberkuloma+ Susp
HIV
7. Midian Sitorus 61/LK 2/11/23 Apatis + Episodic MLY RA 4 KMI
Vestibular Syndrome ec
Insufisiensi
Vertebrobasiler ec CHF
NYHA III ec HFrEF +
Dislipidemia + Hipertensi
stage II
8. Parlindungan 52/LK 2/11/23 Vertigo sentral + Diplopia MLY SC KMI
Manalu Binokular + PN III Parsial
OD+ PN VI OD + PN VII
tipe UMN dekstra +
Disartria ec stroke iskemik
9. Ayu Fatma 18/PR 2/11/23 Secondary Headache + MLY RA 3 KMI
Azzahra Tetraparese Tipe UMN ec
Susp. Multiple Sklerosis
10.

11.

12.

13.

14.

15.

16.

17.

PASIEN PULANG

UMUR/ TGL TGL

No NAMA JK DIAGNOSIS DR KET DPJP
MASUK KELUAR
1 Sukma 65/PR 31/10/23 2/11/23 Koma ec Gagal Nafas NAD EXITUS PPS
+ Sepsis ec Susp.
Pneumonia +
Hemiparese Dekstra
ec Stroke Iskemik +
Hipertensi Stg II +
CHF fc III ec MS
Moderate + AF NVR
2
3
 4

LAPORAN PASIEN RAWAT INAP VIP

RUANG INAP NEUROLOGI RS H. ADAM MALIK
TANGGAL 31 Oktober – 6 November 2023
JUMLAH PASIEN
NO DIAGNOSA PRIA WANITA JUMLAH
1. Stroke Iskemik
2. Stroke Hemoragik
3. Ensefalopati Sekunder
4. Fahr Disease
5. Spinal Metastase
6. Meningitis TB
Total
PASIEN BARU
UMUR/ TGL
No NAMA DIAGNOSIS DR KET DPJP
JK MASUK
1 Eka 28/PR 31/10/23 Dyspnue + Somnollen NAD RITN PPS
Ramadayanti ec Krisis Myastenia
Gravis + susp
Pneumonia
2 Latifah Hanum 56/PR 31/10/23 Sopor ec Susp. SOL NAD PAV PPS
Intrakranial + Hipertensi
Stage I

PASIEN PULANG
UMUR/ TGL TGL
No NAMA DIAGNOSIS DR KET DPJP
JK MASUK KELUAR
1 Drs Witono 55/LK 20/10/23 1/11/2023 Koma ec Gagal NOV/ME EXITUS ISN
nafas +L
Hemiparesis
Dekstra + Parase N
VII Tipe UMN
Dekstra ec Brain
Metastase +
Adenocarsinoma
Paru Kiri
T4N3M1c post
Kemoterapi 6
siklus + Hipertensi
+ Acute liver
injury
2

LAPORAN PASIEN RAWAT BERSAMA

RUANG INAP NEUROLOGI RS H. ADAM MALIK
TANGGAL 31 Oktober – 6 November 2023
No Nama Umur JK Diagnosis DPJP DR KET
1 Batara 64 LK Somnolen ec susp PPS NAD RA 4
hepatik ensefalopati dd
uremik ensefalopati
2 H. Pujianto 56 LK Postural tremor ec PPS NAD RB 6
metabolik (azotemia) +
CKDG5 ec Diabetic
Nefropati post HD +
DM Tipe 2 + Anemia
ec penyakit kronik dd
perdarahan (8.6) +
PSMBA + SJS dd
Pemfigus dd Psoriasis
Musliyadi 42 LK Hemiparesa Sinistra + PPS NAD RA 3
Parese N. VII, XII tipe
UMN Sinistra ec Susp.
Toksoplasma Ensefalitis
+ HIV Stad III + Oral
candidiasis,
Pardamean 72 LK Somnolen ec PPS NAD RA 4
Lumban Tobing Ensefalopati Uremikum
dd Sepsis + Ulkus
Diabetikum + DM Tipe
2
Gilbert 22 LK Meningitis TB dalam PPS NAD RA 5
pengobatan fase lanjut
bulan ke 8 + Post
craniotomy tumuor
removal (Maret 2023)
ec tuberkuloma +
Hiperbilirubinemia ec ?
+ Hipokalemia (2.9) +
Anemia penyakit kronik
(hb 8.1)
Rasmita 78 PR Postural Tremor Manus PPS NAD RA 6
Bilateral ec Metabolik
(Azotemia) + CKD
G5D + HHD dengan
HT tidak terkontrol +
Efusi Pleura bilateral +
Pneumonia Geriatri +
Anemia e.c. Chronic
Disease dd. Perdarahan
Kronis + Alkalosis
Respiratorik
Sautus Pautus 44 LK Tetraparese Tipe LMN KHS IKR RB 6
Simbolon ec Hipokalemia +
pionefrosis (L) + Batu
ureter proksimal (L)
Post Nefrostomi
Perkutan (L) (H+1) +
Batu calyx superior (R)
+ Contracted Ginjal (R)
Kasmurni 75 PR Apatis ec Ensefalopati KHS IKR CVCU
Tanjung sekunder + Pneumonia
CAP + Efusi pleura
bilateral minimal+ CHF
fc III ec HHD+ Efusi
Pericard Mild-
Moderate+
Hipoalbumin (3.0)+
Konjungtivitis OD +
Susp Tinea korporis +
suspek sindrom geriatric
dr. Fajrinur 59 PR Hemiparese Desktra + ISN NOV/MEL PJT
Syarani, Sp.P Parese N VII Tipe UMN
Dekstra ec Post Stroke
Iskemik + Atypical
Chest Pain + CHF ec
HHD + ASD Sekundum
+ DM Tipe 2
Lysa Afriani 42 PR Somnolen ec ARDS ec KMI MLY ICU
Adenocarcinoma Paru IGD
kanan T4N2M1c (paru,
pleura, bone, brain)
stage IVB ECOG 3 +
Post Kemoterapi 6
siklus + Post
Radioterapi Tulang 10x
+ Post Radioterapi
Kepala 10 kali + Fokal
Onset Tonic Seizure +
Hemiparesis Dekstra ec
Brain Metastasis +
Anemia ec Penyakit
Kronis +
Trombositopenia +
 PSMBA
Sulina Mayanti 54 PR Somnolen ec KMI MLY RA 3
Ensefalopati Sekunder
ec HIE + Hipokalemia +
Pneumonia CAP dd
HAP + AKI Std III
ddCKD G5 (eGFR 12
ml/min/1.73 m2
Mangara Tua 58 LK Apatis ec Ensefalopati KMI MLY RA 4
Sidebang Sekunder e.c. Uremik
Ensefalopaty dd Hepatic
Ensefalopaty + PSMBA
ec variceal bleeding dd
non variceal bleeding +
Trombositopenia ec
Chronic liver disease +
Hipoalbumin + Anemia
ec perdarahan dd
penyakit kronik (10.6) +
Hipoalbumin (2.98) +
Hiperkalmia (5.9)
Terip Sembiring 61 LK Disartria ec susp.stroke KMI MLY PJT
iskemik dd hemoragik +
Hipertensi + Susp. CTS
sinistra + On TPM a/i
Bradikardia simptomatis
ec TAVB