KORAN BEDAH SARAF Sabtu, 24 Agustus 2013

Lontara 3 Bedah Saraf (Kamar HCU) (Amirah 085255404636)

No 1. IDENTITAS Ambo Upe L/57thn/5-4-1950 RM: 617722 Jamkesda MRS 6/7/2013 Bed 1 DPJP AT DIAGNOSIS POH 49 Craniectomi e.c EDH Biparietooccipitalis RENCANA & TERAPI IVFD RL 1000 cc/hr Head up 30 Panzo 40 mg/24 j/iv Sistenol 4x2 tab/ Nebulizer bila perlu Zamel syr 3x2 cth Terapi lain sesuai TS Gizi Kinik Ampicillin/Sulbactam 1 gr/8jam/IV Head up 300 O2 8 lpm via tracheotomy IVFD RL 20 tpm Lanjut sesuai TS Gizi Klinik Panzo 24j/iv Injeksi amikacin 500 mg/12 jam/IV dalam NaCl 100 cc Inj Hexilon 125 mg/24 jam/IV IVFD RL 700 cc/24 jam Peptisol 6x250 kkal Panzo 40 mg/24 jam/IV Ceftriaxone 1 gr/8 jam/IV Sistenol 3x2 tab (bila perlu) Nebulizer (NaCl + Fentolin) Suction on demand Kultur darah IVFD RL 500 cc/24 jam Piracetam 3 gr/8jam/IV Ranitidin 50 mg/8 jam/IV Ketorolac 3 gr/8 jam/IV (bila perlu) Nebulizer tiap 6 jam (Fentolin+NaCl) Suction on demand Kultur darah Head up 30 IVFD RL 20 tpm Ceftazidime1g/12j/iv Rawat luka dekubitus Nebulizer (bila perlu) Lanjut Terapi TS neuro, gizi, mata Aricept 2x1 Head up 30 IVFD RL : Tutofusin = 2:1 Ceftazidin 1gr/12j/iv Piracetam 3gr/8j/iv Panzo/24j/iv Aricept 2x1 HASIL PEMERIKSAAN -

2.

SyamsAuddin L/60thn/2-1-1953 RM: 616715 Jamkesmas MRS 10/8/2013 Bed 2

AAI

POH 39 Craniectomy ec. ICH Frontalis dextra External drainage ec. Hydrocephalus Communicans POH 37 Trakeostomi

3.

Masdar L/17thn/23-2-1996 RM: 615983 Umum MRS 25/6/2013 Bed 3

NS

POH 61 craniectomi ec. EDH temporal (D)

4.

Hanaking 38thn/5-11-1974 RM: 437654 MRS: 21/7/2013 Umum HCU 2

AAI

POH 34 Craniectomy ec SDH region frontotemporoparietaldextra + fr. depressed osfrontalis D (TCB GCS 11 E4M6V1) ; Operasi tgl 21-7-2013 GCS 11 E4M6V1

5.

Suyanto L/26thn/1-1-1985 RM: 621925 Jamkesmas MRS 28/5/2013 Bed 5 Rifai L/53thn/1-7-1959 RM: 612096 Jamkesmas MRS 1/6/2013 Bed 6 Syahril Fahri L/13thn/8-11-1999 RM: 605480 Jamkesmas MRS 21/4/2013 Bed 7 S. Abdul Rahman L/29-3-1997/16 tahun RM: 622554 Jamkesmas MRS 13/8/2013 Bed 8

AT

Pneumonia + skull defect temporoparietal D/S Post craniectomy hari ke 93 e.c SDH frontotemporalD +ICH parietal S + Decubitus

6.

AT

POH 87 Craniectomy ec. EDH temporoparietal (D) post tracheostomy

7.

AT

POH 106 Craniectomi e.c SDH + EDH Temporal (D) + ICH Frontobasal + parietooccipital (D) Defect Bitemporal Pneumonia ortostatik

8.

NS

POH 9 craniectomy TCS GCS 10 (E2M5V3) Fraktur diastoni sutura coronaria Fraktur depressed os. Temporal (S) ICH occipital (S)

Head up 300 Elkana syr 3x1cth Aricept 5 mg 2x1 Ambroxol 3x1 cth Phenitoin 25 mg 3x1 Terapi lanjut sesuai TS Gizi klinik dan pulmonologi anak Head up 300 O2 NRM IVFD RL 20 tpm Ceftriaxon 1 gr/12 jam/iv Ketorolac amp/8j/iv Ranitidine 1 amp/8 j/iv Semax 4x10 tetes Miring kiri-kanan Fujimin 3x2 tab Elkana syr 1x5 ml Paracetamol syr 3x5 ml (bila perlu)

Lontara 3 Bedah Saraf (Kamar 1)

9. Ilham L/1 tahun RM:619397 Jamkesmas MRS 24/7/2013 Bed 2 AAI POH 16 Cranioplasty meningioencephalochel -

KORAN BEDAH SARAF Sabtu, 24 Agustus 2013

Lontara 3 Bedah Saraf (kamar 2)
10. Hasriadi L/17thn/30-6-1996 MRS 14/08/13 RM: 611926 MRS: Bed 1 NS D/ POH 4 Cranioplasty IVFD RL 28 TPM Ceftriaxone 1 gr/12 jam/iv Keterolac 1 amp/8jam/iv Ranitidine 1 amp/8jam/iv Rawat Luka Aff Drain (24/08/2013) Konsul KulKel (24/08/2013) D/Varicella Ceftriaxone 1gr/12jam/iv Ketorolac 30mg/8jam/iv Ranitidine 50mg/8jam/iv Fenitoin 100mg/8jam/drips (100cc NaCl0,9%) Glaucon 50mg/8jam/oral Diet biasa Rawat luka/6h IVFD RL 28 tpm Ceftriaxon 1 gr/12jam/iv Ranitidin 50 mg /8jam/iv Keterolac 30 mg/8jam/iv Kultur dan sensitivitas darah Konsul RM IVFD KaEN 3B 500cc/24jam Ceftriaxone 2x 150 mg/24jam Novalgin 3x amp/8jam/iv Lab (13/08) WBC 6,5 RBC 4,91 HGB 11,5 HCT 35,2 PLT 465 GDS 96 UR 15 CR 0,8 GOT 117 GPT 11 Na 148 K 4,0 Cl 109 CT 700 BT 300 PT 9,7 (10,8) INR 0,8 aPTT 31,7 (26,6) HBsAg (-)

11.

Iskandar Djau L/44thn/12-6-1969 MRS 13/08/13 RM: 622550 Jamkesmas MRS: Bed 2

NS

POH 10 craniectomy e.c., ICH temporal D + EDH temporal D + kontusio frontobasal S Terapi lanjut TS psikiatri

Lab (14/08) WBC15,2 RBC 2,72 HGB 8,6 HCT 26,7 PLT 153 Lab (13/08) CT 800 BT 200 PT 11,3 (10,8) INR 0,904 aPTT 21,7(26,6) GDS 96 UR 28 CR 0,7 GOT 57 GPT 51 Na 143 K 3,9 Cl 116 HBsAg (-) AntiHCV (-)

Lontara 3 Bedah Saraf (Kamar 3)

12. Raru L/45thn/9-7-1967 RM: 614927 Jamkesmas MRS 19/8/2013 Bed 1 Abd. Rahman L/4thn/24-3-2013 RM: 613926 Jamkesmas MRS 24/6/2013 Bed 3 Ny. Rawasiah 23.5.1946/67 tahun 624000/Jamkesda MRS 22/8/2013 Bed 2 AT POH 30 Removal tumor ec. Tumor fossa posterior -

13.

NS

POH 4 Craniectomi e.c. Subdural Hygroma

14.

WA

TCR GCS 15 ec ICH temporooksipital (D) EDH temporal (D)

IVFD RL 28 tpm Ceftriaxon 1 g/12 j/iv Ketorolac 1 amp/8 j/iv Ranitidin amp/8 j/iv

Lab 22/8/2013 : RBC 2,51 HGB 8,2 HCT 25 PLT 221 Lym 0,82 Kol. Tot 187 As. Urat 2 Na/K/Cl 142/43/110 GOT/GPT 23/13 LED i/II 40/85 CT/BT 6/3 PT/APTT 10,2/26,9 GDS 126 Ur/Cr 31/0,5

Lontara 3 Bedah Saraf (Kamar 4)

15. Ny. Patmawati/ P 1-10-1997 623301/JKM/ MRS 19-8-2013 Bed 1 16. Mirza Al Fajri L/5bln/7-3-2013 RM: 619937 MRS: 20/8/2013 Bed 2 Farel L/9thn/25-4-2004 MRS 15/08/13 RM: 622948 Jamkesmas Bed 3 Muh Basri L/9thn/20-1-2004 RM: 575629 MRS 19/8/13 Jamkesmas Bed 4 Keyla L/11bln/4-9-2012 RM: 603417 Jamkesmas Bed 6 AAI Craniosinositosis + Hydrocephalus AT POH 5 Craniotomy e.c open fraktur depressed os frontal Head up 30 Aff infus Ganti oral As. Mefenamat 3x1 Cefadroxyl 2x1 Ranitidin 2x1 Gv/ 6hari Diet biasa Tunggu Jadwal operasi Lab 19-8-2013 WBC 9,13 RBC 4,63 Hb 12,4 HCT 37,0 PLT 321 CT 800 BT 200 PT 11,5 INR 1,00 aPTT 26,0 Na 145 K 4,5 Cl 109 GDS 87 Ur 27 Cr 0,5 GOT 12 GPT 8

Lab 15/08 WBC 16,09 RBC 4,48 HGB 12, HCT 34,3 PLT 367 CT 800 BT 200 PT 9,2(11,5) INR 0,8 aPTT 27 GDS 81 GOT 20 GPT 20 Na 137 K 4,9 Cl 110 Ur 12 Cr 0,4

17.

DW

POH 6 VP-Shunt ec. Hydrocephalus + tumor intracranial

Cefadroxil syr 2x1 cth PCT syr 3x1 cth Rencana CT Scan Kontras

Lab(15/08) WBC20,3 RBC4,44 HGB13,3 HCT41,6 PLT265 CT600 BT200 PT8,9(10,2) INR0,71 aPTT21,2(24,8) GDS155 UR25 CR0,7 GOT17 GPT41` Na146 K3,6 Cl112 HBsAg(-) AntiHCV(-)

18.

AAI

Skull Defect Reg. Frontal Pro-Cranioplasty

Rencana Operasi Senin (26/08/2013) Cek Persiapan

Lab 14/08 WBC 5,7 RBC 3,94 HGB 12,2 HCT 34,8 PLT 325 CT 800 BT 300 PT 9,2(11,5) INR 0,8 aPTT 27 GDS 101 GOT 30 GPT 25 Na 137 K 3,7 Cl 103 Ur 10 Cr 0,4

19.

AAI

POH 5 VP Shunt e.c. Hydrocephalus

Cefadroxil syr 2x1/2 cth PCT syr 3x1/2 cth Elkana syr 3x1/2 cth

Lab 30/07 WBC 7,1 RBC 4,38 HGB 11,4 HCT 36 PLT 242 CT 700 BT 300 PT 9,2(11,5) INR 0,8 aPTT 27 GDS 98 GOT 36 GPT 16 Na 139 K 4,5 Cl 107 HBsAg(-) CT scan kepala (10/04Dandy walker syndrome

Lontara 3 Bedah Saraf (Kamar 5)

20. Zainuddin L/29thn/3-12-1983 RM: 623242 MRS: 18/813 Umum AT GCS 15 POH 4 Craniotomy e.c. Closed Fracture Depressed Aff infus Ganti oral Cefadroxil 2x500 mg Asam mefenamat 3x500 mg Ranitidine 2x150 mg Rawat luka Laboratorium 18/8/2013 WBC: 8.5; RBC: 3.20; HGB: 9.6; HCT: 30.0; PLT: 234; CT/BT: 7/2; PT/APTT: 12.6/27.6; GDS: 108; Ur/Cr: 26/0.7 SGOT/SGPT: 7/9; Na/K/Cl: 141/4.0/111

KORAN BEDAH SARAF Sabtu, 24 Agustus 2013

21. Bed 3 Fandi/L/14thn/7-101998/623754 MRS 20-8-2013 Bed 2 Jamkesda Sutrisno/L/17thn/11-1996/623711 MRS 20-8-2013 Umum Bed 6 NS TCR GCS 15 + fr. Zygomaticum fr linear os temporal D + kontusio regional frontal IVFD RL 28tpm Cefadroxyl 2x500 mg As.Mefenamat 3x250 mg Ranitidin 2x150 mg IVFD RL 28tpm Broadcet 1gr/12j/iv Ketorolac 1amp/8j/iv Ranitidine 1amp/8j/iv Asam traneksamat amp/8jam/iv Betadin kumur 4x1 Headp up 30 IVFD RL 18 tpm Inj ceftrikason 1gr/12jam/iv Inj ketorolac 30mg/8jam/iv Inj ranitidine 50 mg/8jam/iv Piracetam 3 gr/8jam.iv Rawat luka Konsul ulang mata O2 4 8 lpm Ceftriaxone 1 gr/12jam/IV Ketorolac 30mg/8jam/IV Ranitidin 50mg/8jam/IV Ambroxol Syr 3x2cth Terapi sesuai TS bagian Anestesi Diet biasa GV Lab 20-8-2013 RBC 4,02 Hb 11,3 HCT 35,5 PLT 499 WBC 19,2 GOT 82 GPT 29 Na 143 K 3,63 Cl 113 CT 7 BT 230 PT 10,9 INR 0,9 GDS 161 Ur 21 Cr 0,6 Lab 20-8-2013 WBC 36,08 RBC 5,19 hb 14,4 PLT 299 GDS 203 Ur 22 Cr 0,8 GOT 33 GPT 30 PT 11,2 INR 0,9 aPTT 21,3 Na 143 K 3,23 Kl 112

22.

NS

TCR GCS 15 fr depressed os frontal POH 3 craniectomi + multiple fraktur wajah POH 2 ORIF

23.

Lewa L/30thn/1-1-1983 RM: 623189 Umum MRS 17/8/13 Bed 5

AT

POH-5 Craniectomi ec. Openfrakture Os Frontal

Lab 18/08/13 WBC 10,34 RBC 2,51 HGB 7,1 HCT 21,7 PLT 130 HB 7,1

24.

25.

Muh. Arfa L/12-3-1973 RM : 623572 Askes Wajib MRS 19/08/2013 Bed 3 Jusri L/35thn/1-1-1978 RM: 623241 Umum MRS 18/8/13 Bed 8

AAI

POH 5 Debridement e.c. Vulnus Laceratum Reg Frontotemporal

Lab 21/08/2013 WBC 9.5, RBC 3.38, HB 9.6, HCT 30, PLT 229, CT 730, BT 300, HbsAg Non Reactive

AT

POH-6 Craniectomy ec. Closed fracture depressed region temporal dekstra (GCS 9 E2M5V2) Operasi tgl 18/8/2013 GCS 11 E4M6V1

Lab 1(19/8/13) Wbc 13,64 Rbc 3,82 Hb 11,8 Hctt 34,6 PLT 203

Lontara 3 Bedah Saraf (Kamar 6)

26. An.Fendi L/10bln/3-10-2012 JKM RM: 603184 MRS: 19/8/2013 Bed 1 Erwin Tri U/ L 26/10/1969 RM : 624170 MRS 23/08/2013 Bed 2 Leonardo L/21thn/19-8-1991 RM: 611669 MRS 4/8/13 Bed 3 Abd. Halim 564467 25/9/1989 MRS 21/08/2013 Bed 4 AAI Meningoencephalocele Rencana Operasi Senin (26/08/2013) Tunggu Hasil Lab Lab (24/08/2013) WBC 19.65; RBC 4.67; PLT 529; HB 11.2; HCT 34.0; GDS 95; Ur 6; Cr 0.2; GOT 39; GPT 20; Na 140; K 3.4; Cl 111; NbsAg Non R#eactive; Anti HCV Non Reactive; PT 10.7; INR 0.90; APTT 28.4; CT 700; BT 200 Lab (23/08/2013) WBC 13.07; RBC 4.98; PLT 241; HB 15.4; HCT 42.8; GDS 94; Ur 24; Cr 0.80; GOT 19; GPT 17; Na 141; K 4.41; Cl 112; HbsAg Non R#eactive; Anti HCV Non Reactive; PT 10.6; INR 0.90; APTT 27.6; CT 700; BT 200 Lab 04/08/13 WBC 7,7 RBC 4,7 HGB 13,7 HCT 42 PLT 264 GDS 101 UR 26 CR 0,7 GOT 16 GPT 41 Na133 K 3,9 Cl 104 HBsAg (-) AntiHCV (-) CT 700 BT 300 PT 9,7(10,8) INR 0,8 aPTT 18,7 (23,7) Lab 04/08/13 WBC 7,3 RBC 5,41 HGB 15 HCT 46,2 PLT 300 GDS 103 UR 22 CR 0,8 GOT 25 GPT 65 Na133 K 3,9 Cl 104 HBsAg (-) CT 800 BT 300 PT 11,2 INR 0,93 aPTT 29,6

27.

WA

TCR GCS 15 (E4M6V5) + V. Laserasi reg supraorbita (S) + Reg. Occipital + Bloody Ottorrhea

28.

NS

POH 21 VP Shunt e.c. Hydrocephalus + Tumour Intracranial

29.

D/ Skull Defect Reg. Temporal D Operasi 17/8/2012

O2 4 LPM Head up 300 IVFD RL 28 TPM Ceftriaxone 1 gr/12 jam/IV Ranitidin 1 Amp/8 jam/IV Ketorolac 1 Amp/8 jam/IV Cefadroxil 2x500mg Ranitidine 2x150mg As. Mef 3x1 Nerodex 2x1 Mobilisasi aktif CT scan kontras Tunggu jadwal operasi

Palem Atas Palem Bawah

30 Mabreskha Agus kaloli 624040 27/02/2012 MRS 22/08/2013 Askes B1/1 IDENTITAS DPJP WA D/ TCR 15 R/ cefadroxil Novalgin Nebulisasi NaCl 0,9% 22/08/2013 GDS 94, Ur 21, Cr 0,2, SGOT 56, SGPT 24, Kol Tot 169, As. Urat 2,7, CT 800, BT 300, PT 10,6 control 11,3, APTT 27,9 control 25,8, HbsAg ( -), HCV (-), WBC 17,38, RBC 3,51, HGB 9,6, PLT 304, HCT 28,0

Titipan
No DIAGNOSIS RENCANA & TERAPI HASIL PEMERIKSAAN

L1BD (interna)NUR HALMA ISHAK(085240971936) L1BB(interna) NUR HALMA ISHAK(085240971936) L1AD(interna) NUR HALMA ISHAK(085240971936) L1AB(interna) NUR HALMA ISHAK(085240971936) L2BD (uro) NUR HALMA ISHAK(085240971936) L2BB (ortho) NUR HALMA ISHAK(085240971936) 3

KORAN BEDAH SARAF Sabtu, 24 Agustus 2013

L2AD (digestif) NUR HALMA ISHAK(085240971936) L2AB (onko) NUR HALMA ISHAK(085240971936) L3BB(neuro) NUR HALMA ISHAK(085240971936)
No 31. IDENTITAS Tn Domeng, 1/1/1934 (79thn) RM: 621329 MRS: 1/8/2013 ASKES K1B4 Tn Saiful 5/11/1986(26thn) RM: 601772 MRS: 6/8/2013 JPS K3B3 Tn Mustomo 1/12/1968(44thn) RM: MRS: 15/8/2013 JKM K3B2 Ima Muslimah 5/5/1983(30thn) RM: 621622 3/8/2013 JPS intermediate DPJP WA DIAGNOSIS D/ POH 22 external drainage e.c SDH RENCANA & TERAPI Ganti verban Diet biasa Cefadroxil 2x500mg Ranitidin 2x150mg Asam mefenamat 3x500mg IVFD RL 28 tpm Ganti verban Diet biasa Ceftriaxone 1gr/ 12j/iv Ketorolac 30mg/8j/iv Ranitidine 50mg/8j/iv Lapor dr Nasrullah, Sp.BS Evaluasi lanjut untuk persiapan operasi Rawat sama Terapi sesuai TS Saraf Diet Biasa IVFD RL 28tpm Metoclopramide amp/8j/iv Novalgin 1amp/8j/iv Ranitidine 1amp/8j/iv Observasi GCS Terapi obgyn lanjut HASIL PEMERIKSAAN

32.

NS

D/ POH 9 revisi shunting ec hydrocephalus susp. craniopharygioma

Lab 13-08-2013 GDS 117 Ur/Cr 36/0,9 GOT/GPT 13/16 HbsAG non-reactive Anti HCV non-reactive PT 8,6 control 10,8 INR 0,71 APTT 21,5 contro

33.

NS

D/LBP ec HNP

34.

DW

D/ POH 9 external drainage ec spontaneous ICH + IVH

Lab (18/08) WBC 13,12 RBC 4,05 HGB 11,2 HCT 33,8 PLT 218 GDS 109 UR CR 1,1 GOT 31 GPT 18 Na145 K 3,96 Cl 112

CT Scan kepala (control) 18/8 Perdarahan intracerebri D ( dibanding foto lama tanggal 16/8 tidak perubahan signifikan

L3AB (KUL-KEL) NURHALIMA ISHAK (085240971936)

N o 35 . IDENTITAS Arfa 13/7/1996 RM:623966 MRS: 22/8/2013 JKM DPJP DIAGNOSIS RENCANA & TERAPI HASIL PEMERIKSAAN Foto Thorax ( 22/8) Spondilitis TB CT Scan vetebrolumbal Spondylicitis TB VTH 6-9

WA

D/Spondylitis TB

R/ terapi lanjut, Stabilisasi bila keluarga seuju.

L4BD (obgyn) NUR HALMA ISHAK(085240971936) L4BB (nifas) NUR HALMA ISHAK(085240971936) L4AD(anak) NUR HALMA ISHAK(085240971936) L4AB(anak) NUR HALMA ISHAK(085240971936)
No 36. IDENTITAS Rina Arianti 13/8/1999(5thn) RM: 617111 Konsul tanggal : 15/7/2013 Jamkesmas K8B2 DPJP NS DIAGNOSIS D/ POH 22 laminektomi + paraplegia e.c Fibrotic duramater vertebra TH 6-9 RENCANA & TERAPI Cefadroxil 2x500mg Paracetamol 3x500mg Ganti verban Diet Biasa Lain sesuai TS Anak Urinalisis 17/8 Warna: kuning keruh Ph:5 BJ:1.020 Leukosit :penuh Eritrosit:5-7 HASIL PEMERIKSAAN

ICU( M. Awwalul Akram/085210612216)

37. Enre L/1-7-1956 RM: 620648 MRS 26/07/2013 JKD Bed 1 Feri L/1-1-1997 RM: 623803 MRS 21/08/2013 ASKES Bed 2 Kuku wiranto L/15thn/3-3-1998 RM: 622355 MRS 12/08/2013 JKD Bed 3 Ardiansyah L/19thn/31-12-1993 Fraktur kompresi Thorakal IX GCS 15 (E4M6V5) Terapi sesuai ts Anastesi Diet via NGT Rencana MRI Lab 18/08/2013 WBC 13,73RBC 3,94 Hb 11,1 Hct 35,4 PLT 265 GDS 153 Ur 37 Cr 0,6 GOT 148 GPT 153 ALB 2,9 Na 140 K 3,8 Cl 106

38.

WA

POH-1 Craniectomi ec. ICH right Frontobasal Region GCS 2x (E1M1Vx)

Terapi sesuai ts Anastesi Diet via NGT GV dan Aff Drain

Lab 22/08/2013 WBC 12,8 RBC 3,63 Hb 10,9 Hct 35,4 PLT 125 GDS 136 Ur 28 Cr 0,8 GOT 49 GPT 14 ALB 3,5 Na 136 K 4,1 Cl 105 CT 600 BT 800 PT 13,5 INR 1,22 aPTT 29,6

39.

AAI

POH 11 Craniectomy e.c. ICH Bifrontal. GCS 4 (E1M2V1) + open depressed os frontal + susp. Fraktur antebrachium D/S Operasi tgl 13-8-2013 GCS 5x (E2M3Vx)

Terapi injeksi lanjut Diet via NGT GV dan Aff Drain Konsul Ortopedi

Lab 21/08/2013 RBC 4,21 Hb 11,9 Hct 36,3 PLT 636 WBC 18,99 GDS 96 Ur 37 Cr 0,7 GOT 70 GPT 118 Na 133 K 4,5 Cl 101

40.

DW

POH 19 Craniectomy e.c. SDH Frontotemporobasal S + SAH (GCS5x E1M4Vx)

Terapi injeksi lanjut Diet via NGT

Lab 18/08/2013 WBC 14,9 RBC 3,22 HGB 9,2 HCT 29,1 PLT 994 GDS 100 GOT

KORAN BEDAH SARAF Sabtu, 24 Agustus 2013

RM: 583910 MRS: 06/08/2013 JKD Bed 5 41. Rohani P/25thn/20-10-1998 RM: 623184 MRS: 17/08/2013 JKM Bed 9 AN. AFDAL/L 20/6/2006 623272 Mrs 18/06/13 Jamkesmas H Abd Hamid 01/01/49 64 tahun 622986 16/08/13 UMUM VIP 3 Hj. Ponde 01/07/1940 621658 JAMKESDA 04/08/2013 VIP 4 DW Operasi tgl 6-8-2013 GCS 6X (E2M4Vx) Boleh pindah ruangan HCU 100 GPT 140 Alb 3,6 Ur 44 Cr 0,7

POH-7 Craniectomi ec. EDH Frontotemporal D + Basis Temporal (GCS 10) Operasi kraniektomi tgl 17/8/2013 GCS 13 E3M6V4

IVFD RL:D5% 28 tpm Ceftriaxon 1gr/12jam/iv Ketorolac amp/8jam/iv Ranitidin amp/12jam/iv Kalnx amp/12jam/iv

Lab 17/08/13 WBC 24 RBC 3,75 HGB 11,3 HCT 35,2 PLT 331 GDS 127 UR 18 CR 0,4 GOT 31 GPT 43 ALB 3,1

42.

POH-6 Trepanasi ec. Opn depressed fraktur R. temporoparietal S GCS 4x E1M3Vx

Terapi sesui dr anestesi Diet via NGT Gv dan Aff Drain

Lab WBC 7,1 RBC 4,05 HGB 11,3 HCT 34,4 PLT 145 G DS 109 UR15 CR 0,3 GOT 75 GPT 66 GDS 59 UR 29 CR 0,3 ALB 2,9 Na 141 K 3,4 Cl 105 PT 10,9 INR 0,92 aPTT 22,8

43.

POH 9 craniectomy ec open depressed fracture frontal S + SAH+ fraktur basis kranii; Operasi Craniectomi 16/8/13 GCS 10 E3M5V2

Terapi injeksi lanjut Diet via NGT GV dan Aff Drain

Lab (19/08) WBC 9,75 HGB 10,1 HCT 30,3 PLT 156 GDS 59 UR29 CR 0,3 GOT 38 GPT 31 GDS 59 UR 29 CR 0,3 CL 114 ALB 2,4

44.

WA

POH 20 craniectomy e.c. ICH frontal basal D (GCS9x E4M5Vx) Operasi tgl 4-8-2013

Head up 30o Terapi lanjut Diet via NGT Aff Hecting semua GV

Lab 22/08/13 WBC 8,3 RBC 3,02 HGB 7,7 HCT 23,6 PLT 168 GDS 273 UR 129 CR 1,2 GOT 27 GPT 17 ALB 1,9 CT 800 BT 300 PT 13,8 APTT 26,2 INR 1,3 Na 158 K 2,8 Cl 111 Alb 2,3

GCS 9x E4M5Vx

PICU ( M. Awwalul Akram/085210612216) NICU ( M. Awwalul Akram/085210612216)

45. BY NY. NURKHOMTIMA 6/8/2013 623178 JAMKESMAS 17/8/13 DW MENINGOENCEPHALOCELE O2 0,5 LPM IVFD D10% 8 TPM CEFTAZIDIME 14 MG/36 JAM/IV SUSU FORMULA 8X30M/OGT Lab 13/08/13 WBC 10,74 RBC 4,56 HGB 15,8 HCT 44,1 PLT 638 GDS 88 UR 23 CR 0,3 GOT 24 GPT 16 CT 730 BT 3.00 APTT 27,6 PT 9,7 Na 131 K 5,3 Cl 103 HBSag non Reactive AntiHCV Non Reaktive

PCC (GANESHA 085656 017660)

46. Dr.Leonardo L/48thn/14-10-1964 RM: 503495 MRS: 09/06/2013 Lt.4 ROOM 401 SUPER VIP A ASKES 47. Ny.Nurzamzam P/51thn/27-12-1961 RM: 620153 MRS: 24/7/13 Lt.4 ROOM 418 VIP A ASKES DW Glioblastoma Post Removal Tomour + Chemotherapy AAI Meningiocephalitis Post Op. VP-Shunt D73 DM Type II Laboratorium 15/8/13 Na/K/Cl: 145/4.4/106 Pro.Tot:8.5; Alb: 3.1; Chol.Tot 244; HDL: 31; LDL: 159; TG: 243 Laboratorium 14/8/13 WBC: 9.5; RBC: 3.76; HGB: 9.6; HCT: 30.6; PLT:404; Ur/Cr: 68/0.61; GDS: 121; Foto Thorax AP 15/8/2013 Dilatatio Aortae Laboratorium 16/8/13 PT: 10.2; APTT: 20.0; Echocardiogram 15/8/2013 Deep Vein Thrombosis Laboratorium 13/8/13 WBC: 10.1; RBC: 3.67; HGB: 11.4; HCT: 35.7; PLT:245; SGOT/SGPT: 21/23; Laboratorium 10/8/13 Na/K/Cl: 144/3.8/102; GDS: 127; Pro.Tot:8.5; Alb: 3.4; As.Urat: 7.1; Chol.Tot 222; HDL: 58; LDL: 111; TG: 155

RSUH (GANESHA 085656 017660)

48. Tn.La Alfian L/20thn/02-03-1993 RM: 012627 MRS: 11/7/2013 Lt.4 Room 406 Ny.Hidjrah P/63thn/31-12-150 RM: 013359 MRS: 15/8/2013 LT.4 ROOM 406 ASKES AAI Post Explore Nervus Radialis D28 Post Transfer Tendon D21 Laboratorium 26/7/13 WBC: 7.60; RBC: 4.54; HGB: 12.5; HCT: 37.1; PLT: 202; BT: 3; CT: 9; PT: 15.9; APTT: 33.8; Ur/Cr: 8.8/0.7; GDS: 69; As.Urat: 4; SGOT/SGPT: 14.1/4.9; Na/K/Cl: 134/3.7/103 Laboratorium 15/8/13 WBC: 7.20; RBC: 4.07; HGB: 12.0; HCT: 35.9; PLT: 232; Laboratorium 16/8/13 BT: 3; CT: 8; PT: 13.8; APTT: 31.1; Ur/Cr:23/0.4; GDS: 164; SGOT/SGPT: 13/8; Na/K/Cl: 137/3.6/108 Foto Thorax PA 16/8/2013 Dilatatio, elongation et atherosclerosis aortae Laboratorium 17/8/2013 WBC: 10.08; RBC: 4.03; HGB: 12.3; HCT: 35.9; PLT: 285; Laboratorium 13/8/13 BT: 3; CT: 730; PT: 9.9; APTT: 24.6; Ur/Cr:193/0.8; GDS: 103; SGOT/SGPT: 64/41; Na/K/Cl: 149/3.7/113

49.

AAI

Post Laminectomy e.c. HNP POD 5

IVFD RL 28tpm Ceftriaxone 1gr/12j/iv Ketorolac 1amp/8j/iv Ranitidine 1amp/8j/iv

50.

Tn.M.Mulqran L/19thn/29-12-1994 RM: 013262 MRS: 13/8/2013 ASKES

AAI

POD 12 Craniectomy e.c. EDH + ICH Frontal (S) POD 5 External Drainage

IVFD RL 28tpm Ceftriaxone 1gr/12j/iv Ketorolac 1amp/8j.iv Ranitidine 1amp/8j/iv Mannitol2x50mg/12j Diit lunak via NGT Mobilisasi mika-miki

KORAN BEDAH SARAF Sabtu, 24 Agustus 2013

51. Ny.Hasmiani Ismail P/35thn/30-12-1978 RM: 013389 MRS: 12/8/2013 Lt.4 Tn.Elyas Sandy L/19thn/24-7-1994 RM: 008765 MRS: 16/8/2013 Lt.3 Room 314 ASKES DW Chronic Cephalgia e.c Meniangoma Regio Frontalis

52.

POD 8 VP-Shunt ,e,c, Encephalomalasia

IVFD RL 28tpm Ceftriaxone 1gr/12j/iv Ketorolac 1amp/8j.iv Ranitidine 1amp/8j/iv

Laboratorium 17/8/2013 WBC: 15.01; RBC: 4.93; HGB: 14.96; HCT: 43.6; PLT: 264; Laboratorium 16/8/2013 Cr: 0.8; PT:15.5; APTT: 30.9;