KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

NO

IDENTITAS

1.

Irfan dg. Gassing

Laki-laki
23/8/1994 (19 thn)
RM 554828
MRS 19/9/2013
Jamkesmas

DPJ
P
NS

DIAGNOSIS

RENCANA & TERAPI

Lontara 3 Bedah Saraf (Kamar HCU)(Riska)

Hydrocephalus post VP shunt
IVFD RL28 tpm
POH 13 repair VP shunt
Ceftriaxone 1 gr /12 jam/IV
Ranitidine amp/8 jam/iv
Piracetam 3 gr/8j/iv
Ketorolac /8 jam/iv
diet sesuai TS gizi klinik
boleh pindah

Bed 1

2.

Asbar DG Naik
Laki-laki
Tgl lahir : 31-12-1969
(43 thn)
RM: 637698
Jamkesmas
MRS 17-11-2013
BED 2

NS

SDH Temporoparietal (D)

Post op cranioctomy hr 36

RL 28 tpm
Cefotaxime 1gr/8 jam/IV
Novalgin 3x1 amp/iv
Diet sesuai TS GK
Pindah ruangan

HASIL PEMERIKSAAN

Lab 19/12/13
WB :11,37 RB :3,44 HGB: 9,9
HCT: 30,4 PLT :499
Lab 18/12/13
WB: 12,8 RB :3,08 HGB: 9,3 H
CT:26,2 PLT:577 GDS :90 Ur :
14 Cr : 0,4 GOT: 26 GPT: 39 Pr
ot. Tot: 6,4 albumin :3,4 globuli
n :3,0 Na: 143 K: 3,8 Cl: 108
Lab 7/12/2013
WBC:13,36 RBC:3,00 HGB:8,8
HCT:26,8 PLT:281
Lab 6/12/2013
WBC 16,9 ; RBC 4,14; HB 12,3
; HCT 361 ; PLT 380; GDS 155;
Ur/Cr 14/0,4 ; GOT/GPT 23/22
; Albumin 3,3 ; Na 137 K 3,8 Cl
106
AGD (6/12/2013) : Alkalosis me
tabolic respiratorik
CT Scan kepala (kontrol) 12/1
1/2013:
Ujung VP shunt pada ventrikel
lateralis (S), tidak tampak lagi
dilatasi sistem ventrikel
(dibandingkan foto pada tanggal
16/10/13)
Swelling dan hematom soft
tissue regio parietooccipital (D)
Encephalomalacia (D)
Lab 11/11/2013
WBC 8,6; RBC 3,38; HGB 10,8
; HCT 29,7; PLT 240; Ur/Kr 32/
0,5; SGOT/SGPT 37/64; prot.tot
al 6,6; alb 3,6; CT/BT 8/3;
Lab 10/11/2013
WBC 14,3; RBC 3,55; HGB 11,
0; HCT 32,5; PLT 261; Na/K/Cl
135/3,8/110;
CT kepala 16/10/2013
Hydrocephalus non
communicans bandingkan dgn
foto tanggal 19/9/2013
Vp shunt terpasang dgn ujung
kanul pada ventrikel lateral
kanan
Lab 22/10/2013
WBC 9,04; RBC 4,49; HB 13,2;
HCT 37,9; PLT 373;
ur/cr 32/0,7;SGOT/SGPT 25/44;
protein total 6,8; alb 4,1;Na/K/
Cl 142/4,3/105;
Lab 6/10/2013
GDS 119; WBC 7,08; RBC 4,91
; HB 14,7; PLT 233; CT/BT 8/2
; PT/APTT 10,6/29,4; Na/K/Cl
146/3,8/112
HBsAG non reaktif
Lab 19/9/2013
CT/BT 8/2; PT/APTT 10,6/29,
4; Na/K/Cl 146/3,8/112; HbsAg
/Anti HCV non reactive; GDS 1
09; ur/cr 14/0,9; SGOT/GPT 22/
26; Albumin 4,2; WBC 9,82; R
BC 5,17; HGB 14,9; HCT 43,8;
PLT 279
Lab 18/12/13
WB : 6,0 RBC:2,62 HGB:7,4 H
CT: 21,0 PLT :187 GOT :38 GP
T: 82 Prot. Tot : 5,3 alb:1,8 glob
ulin : 3,5
Lab 8/12/2013
RBC; 3.09 wbc; 10,5 HGB: 8,7
HCT: 27,7 PLT : 298. GOT/GP
T: 116/25. Alb : 2,5. Na/K/CL:
146/3,9/118. CT/BT: 800/300.

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

PT/APTT: 14,4 control 10,2/ 24
3 control24,7. GDS: 134. Ur/Cr:
55/0,9. INR: 1,18.
Foto thoraks 8/12/2013
-Cardiomegaly dengan dilatatio
et elongation aortae dengan tand
a-tanda edema paru
-suspek efusi pleura sinistra
-fraktur segmental costa II-III &
fraktur transversal IV-V costa k
iri belakang
3.

Karman
Laki-laki
17/7/1996
RM 641532
MRS 11/12/2013
Jamkesda

Spinal cord injury

Post WSD thoraks S

IVFD RL 28 tpm
Inj cefotaxime 1 gr /12 jam/IV
Ranitidin amp/8 jam/IV
Novalgin amp/8j/IV
Piracetam 3 gr/8j/iv
Rawat dekubitus
Diet sesuai GK

Bed 3

Lab 18/12/13
WB :8,1 RBC:3,70 HGB:11,6
HCT :31,7 PLT :341
Laboratorium 12/12/13
WBC : 7,86 RB : 4,61 HB : 14,0
HCT : 38,9 PLT : 243 CT : 730
BT : 230 PT : 12,2 APTT : 37,1
Na : 139 K: 4,3 Cl : 107 GDS :
136 Ur : 31 Cr : 0,6 GOT : 89
GPT : 56
Foto thorax 11/12/13
Efusi pleura kiri
Pleural
reaction
kanan
Lab 11/12/2013
RBC; 4,61 wbc; 7,88 HGB: 14,
0 HCT: 38,9 PLT : 243. GOT/G
PT: 39/56. Alb : 2,5. Na/K/CL:
139/4,3/107. CT/BT: 730/230.
PT/APTT: 12,2 control 11,1/ 37
,1 control 25,0. GDS: 136. Ur/C
r: 31/0,8. INR: 1,0
Foto thoraks 11/12/2013
Efusi pleura kiri
Pleural reaction kanan
Lab 15/12/13
WBC : 13,62 RBC: 4,67 HGB :
13,3 HCT: 38,8 PLT: 222 CT :
800 BT:200 PT :12,7 APTT:2
6,7 Na : 143 K: 3,8 Cl: 116 GD
S:116 Ur: 27 Cr:0,8 GOT:30 GP
T:22

4.

Hafid
Laki-laki
1/3/1988
RM: 642004
MRS : 15/12/13
Bed 4

NS

POH 6 craniectomi e.c EDH bifro

ntal

IVFD NaCL 0,9% 20 tpm

Cefotaxime 1 gr/12/iv
Ranitidine amp/8/iv
Novalgin amp/8/iv
Piracetam /8/iv
Diet biasa

5.

Rika Ananda
Perempuan
27/10/1998
RM: 642262
MRS: 16/12/13
Umum
Bed 5

NS

TCS GCS 11 + ICH frontotemporal

S/

IVFD NaCL 0,9% 21 tpm

Cefotaxime 1 gr/12 j/iv
Ketorolac / 8j/iv
Ranitidine 1 amp/8j/iv
Piracetam 1 gr/8 jam/iv
Aff neck collar

Lab 16/12/13
WB: 37,18 RB: 3,61 HGB:11,2
HCT: 31,6 PLT: 271 CT: 930
BT: 330 PT :16,1 APTT: 35,4
GDS :135 Ur :13 Cr: 0,7 GOT:8
7 GPT:33 Na : 140 K: 3,06 Cl:1
10

6.

Mahmud
Laki-laki
6/3/1997 (16 tahun)
RM 640220
MRS 3-12-2013
Jamkesmas
Bed 6

AAI

-IVH
-contusio parietal S
-fraktur depress occipital D

IVFD RL 28 tpm
Cefotaxime 1gr/12j/iv
Ranitidin amp/8 jam/IV
Novalgin amp/8j/IV
Piracetam 3 gr/8j
Diet sesuai TS Gizi klinik
Cek Hb post transfusi

Lab 18/12/13
WB:9,2 RB: 2,20 HGB:7,0 HC
T:19,4 PLT :664 Ur : 21 Cr 0,30
GOT: 81 GPT: 204 Prot Tot : 4,
3 alb : 2,7 globulin: 1,8
Lab 13/12/13
WB : 8,1 RBC : 3,28 Hb : 10,1
HCT: 28,9 PLT: 198 GDS : 223
Ur: 41 Cr: 0,70 GOT : 71 GPT:
49 protein total : 6,8
Lab 4/12/13
WBC:8,90 RBC:2,90 Hb:8,4 H
CT:24,3 PLT:126
AGD : alkalosis metabolik
Lab 3/12/13
CT/BT: 8/3; GDS: 191; Ur/Cr:6
3/1,0; GOT/GPT: 312/103; Na/
K/Cl: 136/3,86/115; RBC: 2,50;
HGB: 7,4; WBC: 13,8; HCT: 2
2,4; PLT: 144

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

7.

Andi Tasa
Perempuan
03/04/1945 (68 tahun)
RM 584330
MRS 28/11/2013
Askes

WA

Tumor intracranialec
Susp metastase Ca throid

IVFD NaCl 0,9% 28 tpm

Cefotaxime 1gr/12jam/IV
Dexamethason/6j/iv
Farmadol drips 3x/hari
Rawat dekubitus
Diet sesuai TS gizi klinik

WA

POH 14 craniectomy e.c ICH fron

tal S/

IVFD RL 28 tpm
Cefotaxime 1 gr/12jam/iv
Ranitidine/8jam/iv
Novalgin/8 jam/iv
Asam tranexamat /8 jam/iv
Terapi sesuai TS Gizi klinik

Bed 7

8.

Miraj
Laki-laki
640717
25/5/1995
6/12/13
Umum
Bed 8

Jamaluddin
Laki-laki
641749
1/7/1961
12/12/2013
JKD
Bed 1
Sukriadi
Laki-laki
26/12/1999
642266
16/12/2013
JKD
Bed 2

10

NS

NS

Lontara 3 Bedah Saraf (Kamar 1) (Rima)

TCR GCS 15
IVFD RL 28 tpm
SDH Temporoparietal Dekstra
Ceftazidime 1 gr/12 jam/IV
POH 8 external drainage
Ketorolac amp 30 mg /8 jam/IV
Ranitidine 50 mgamp/8 jam
Semax 4x15 tetes di hidung

TCR GCS 15
EDh minimal occipital dextra
Fraktur linier os occipital dextra

Lab 19/12/13
WB: 12,2 RB :3,49 HGB:11,2
HCT:30,3 PLT:294 Ur:40 Cr : 0
,55 GOT:12 GPT: 27 Prot Tot :5
,9 alb: 3,3 Na: 124 K: 4,3 Cl:10
0
Lab :9/12/13
WB : 8,1 HCT: 28,9 HGB : 10,1
PLT : 198 RBC : 3,28 GDS : 2
23 Ur :41 Cr : 0,70 GOT : 71 G
PT: 49 Albumin: 2,6 globulin :
4,2 Na : 136 K : 5,2 Cl : 103
Lab 3/12/2013
GDS 205 Ur/Cr 24/0,8 GOT/GP
T 24/13 Alb 3,2 Na/K/Cl 137/3,
89/107 WBC 5,88 RBC 3,29 H
GB 10,2 HCT 29,5 PLT 102
Lab 28/11/2013
CT /BT : 630/3, PT/APTT : 1
2,9/19, INR : 1,09, GDS : 109,
SGOT/GPT : 19/10, Na/k/Cl : 1
40/3,5/116, WBC : 8,69, RBC :
3,62, HGB : 11, HCT : 31,7, PL
T : 134
Lab 16/12/13
Sensitivitas Ab: sensitive merop
enem
Lab 12/12/13
WB: 4,9 RB: 3,26 HGB:9,5 HC
T:28,10 PLT:239 GDS :95 Ur: 3
0 Cr: 0,65 GOT: 90 GPT: 127 al
b: 3,3 Na: 138 K: 4,0 Cl: 98
Lab 10/12/13
HGB : 7,2 WBC : 4,1 RBC : 2,5
6 HCT : 22,1 PLT: 166 Na : 131
K: 4,1 Cl: 105 GDS : 142 Ur : 2
7 Cr : 0,80 GOT: 48 GPT: 85 Al
b: 3,1
Foto thorax
Atelektasis sebagian lobus super
ior kanan
Lab12/12/2013
WBC 14,52 RBC 3,74 HB 13 P
LT 168 HCT 35,5 GOT/GPT 44
/83 UR/CR 36/1,0 GDS 199 PT/
APTT 13,5/28,2 CT/BT 800/3
00 NA/K/CL 139/3,8/102

Aff infus ganti oral

Cefadrocxyl 2x500 mg
Ranitidine tab 3x1
Piracetam tab x1
Asam mefenamat 3x1

Lontara 3 Bedah Saraf (Kamar 2) (Nila)

11

Heril anwar
Laki-laki
03/02/2004
RM 631858
MRS 09/12/13
jamkesmas

DW

POH 9 VP shunt

Cefadroxyl 2 x cth
PCT syrup 3 x 1 cth

Diet sesuai gizi/NGT

Lab 09/12/13
CT/BT 700/300 PT/APTT 10,
9/ 25,0 GDS 121 ur/cr 9/0,3 GO
T/GPT 26/25 alb 4,0 na/k/cl 135
/4,21/102 WBC 13,10 RBC 4,60
HGB 12,4 HCT 35,5 PLT 455

Bed 1
12

Tuminah
Perempuan
1/2/1967 (46 tahun)
RM 630639
MRS 21/11/2013
Jamkesmas
Bed 1

WA

Lontara 3 Bedah Saraf (Kamar 3) (Rima)

POH 4 craniectomy removal tumor
IVFD RL 28 tpm
t u. Paru D
Ceftazidime 1 gr/12jam/iv
Ketorolac amp/8jam/iv
Ranitidine amp/8jam/iv
GV + aff drain

14/12/2013
WBC: 12,75, RBC: 4,53 , HB: 1
1,2 , PLT: 367 , GOT/GPT: 30/1
0 , Na/K/Cl; 137/3,83/104, Alb:
3,1, prot.total: 5,7, GDS: 83 , Ur
/Cr: 19/0,8
11/12/2013
TSHS: 1,20, FT4: 0,74
PA sitologi 6/12/2013
Kesimpulan: lesi inflamasi, tida
k ada sel epitel maligna
Lab 2/12/2013

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

13

Yulia
Perempuan
621977
29/3/1994
MRS 17/12/2013
JKM

Skull Defek Regio temporoparietal

D

Tunggu Jadwal OP

POH 5 Craniectomy + removal tu

mor

Aff infus ganti oral

Cefadrocxyl 2x500 mg
Ranitidine tab 3x1
Piracetam tab x1
Asam mefenamat 3x1
Ganti Drain Hisap
Diet bubur halus

Bed 3
14.

Balma
Perempuan
16/5/1969 (44 tahun)
RM 638256
MRS 5/12/2013
Jamkesmas

NS

Bed 4

15

Miki
16/6/2005
637618
MRS 15/11/2013
JKM
Bed 3

DW

16

Sana
11/12/1950
642016
MRS 15/12/13

NS

17

Salmawati
2/2/2013
639862
30/11/2013
umum
b1

Lontara 3 Bedah Saraf (Kamar 4) (Febri)

POH 34 Cranioectomy ec. ICH frontal Dekstra
Rl 14 TPM
POH 3 debridement
Ranitidin 1,2 gr/12 jam
Ceftriaxone amp/12jam
Dulcolaks suposuturia

POH Cranictomy ec ICH frontal

Post cramectimy ec, ICH Dextra

Cefadroxyl 3x1
Nonflamin 3x1
Ranitidine 3x1
Piracetam 3x1
Antasida syr 3x1 cth

Cefadroxyl 2x500mg
PCT 3X500mg
Ranitidin 2x 500

WBC 10,57 RBC 4,67 HGB 11,

2 HCT 33,8 CT/BT 8/3; PT/A
PTT: 13,3/27,8; INR:1,10; HbS
Ag/antiHCV: nonreaktif
MSCT Kepala dengan kontras
Soft tissue mass region temporo
parietalis dextra yang mendekstr
uksi os temporoparietal dextra s
ugestif malignant
Lab 28/11/2013
CT 300BT 800 PT 13.3 APT
T 28.9 GDS 86 Ur/Cr 17/0.66 G
OT/GPT 17/25
CT Scan Kepala TanpaKontra
s 28/11/2013
Defek os parietal D
Tidak tampak kelainan patologik
intracerebral
17/12/2013
WBC: 15,50 RBC: 3,72 HGB: 1
0,4 PLT; 143
14/12/2013
RBC 5.24 Hb 13.9 HCT 42.6 P
LT d287 WBC 8.2 GOT/GPT 1
6/17 Prot. Total 5 Na/K/Cl 144/
4.06/110 GDS 105 Ur/cr 17/0.1
7
Echocardiogram 22/11/2013
Fungsi sistolik LV baik EF 67%
Normal echocardiogram
Lab 20/11/2013
GDS 130 Ur/Cr 17/0,7 GOT/GP
T 18/20 CT/BT 8/3 PT/APTT
12,5/22,3 Na/K/Cl 143/3,9/109
WBC 7,3 RBC 4,83 HGB 14 H
CT 38,3
CT Scan kepala tanpa kontras
20/11/2012
Kesan:fibrous dysplasia os temp
oralis kanan, os frontale sphenoi
d wing dan temporalis kiri yang
mendesak bulbus oculi ke anteri
or
Lab 2/12/13
WBC 11.48 RBC 4.46 HGB 11.
8 HCT 35.2 PLT 746 BT/CT 3
00/800 PT/APTT 12.6/23.8 IN
R 1.05 Ur/cr 14/0.36 As. Urat 2.
0 GOT/GPT81/40 Alb 3.5 Na/K
/cl 139/5.4/110
Lab 17/12/13
WBC 52,71 RBC 2,73
HB 7,8 HCT 23,6 PLT 185
NA/K/CL 139/3,9/113 GDS 66
UR/CR 35/0,90 GOT/GPT 44/1
6 ALB 2,7

18/12/2013
WBC 3,2 RBC 4,34 HB 12,5 H
CT34,8 PLT 413 ALB 3,9

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

18

Putri widya
10/2/2009
642422
17/12/2013
Bed 5

DW

TCR GCS 16
EDH frontal sinstra
ICH oarietal Dextra

Cefadroxyl syr 3x1 cth

Piracetam syr 3x1 cth
Novalgin syr 3x1 cth

19

Khansa Nafisa Zahra

21/6/2013
RM 641586
MRS 18/12/2013
JKM
Bed 6

AAI

Hidrosefalus

Tunggu jadwal operasi

Lab 16/12/13
RBC 4,33 HB 12,6
HCT 37,6 WBC 11,8 PLT 379
Na/K/CL 138/5/110 GDS 119
UR/CR 13/0,39 GOT/GPT 42/3
4 Anti HbsAg non reaktif anti H
CV non reactive

20

Sari
1/6/1971
RM 624729
MRS 11/11/2013
JKM
B.4

Ca. Thyroid CT3N0M1 (metastasis tulang bela

kang) std IV karnofsky 60-70%

Tunggu jadwal laminectomi

+ pedikal screw

LAB 5/9/13
WBC 11,3 RBC 4,43 HB 13,3
HCT 39,7 PLT 367 FT4 0,651
TSHs 0,664 CEA <0,50 GDS 11
4 UR/CR 18/0,5 GOT/GPT 33/3
9
LAB 28/11/13
Ca 10 Na/K/Cl 134/4,3/104

Lab 07/12/2013
Ur/Cr 28/0,3 SGOT/SGPT 49/1
13 Prote. Total 5.3 Alb 2.7 CT/
BT:7/3 Na/K/Cl: 140/4,96/111

Lontara 3 Bedah Saraf (Kamar 5) (Febri)

21

Amir A
Laki-laki
18/03/1983 (30 tahun)
RM 631297
MRS 28/10/2013
Jamkesmas
Bed 1

WA

Tetraparese ec spinal cord injury

Anemia ec
Ulkus dekubitus

Ranitidin 3X1
Cefadroxyl 500 mg 2x1
GV/hari
fisioterapi

Lab 13/12/2013
WBC 7.6 RBC 3.18 HGB 9.5 H
CT 28.7 PLT 464 Ur/Cr 20/8.42
SGOT/SGPT 17/22 Prote. Total
5.3 Alb 2.7
Lab 7/12/113
WBC 14,2 RBC 3,09 HGB 9,3
HCT 28,6 PLT 359
Lab.27/11/2013
WBC 13,8 RBC 2,85 HGB 8,8
PLT 3 GOT/GPT:26/111 prot to
tal :4,45 albumin:2,6
Lab.14/11/2013
CT/BT:7/2; PT:12,3; APTT:24,3
; GDS:127; UR/CR:10/0,3; GO
T/GPT:31/83; Prot.Tot:4,5; Alb:
2,4; WBC:9,21; RBC:3; Hb:9,2;
HCT:27,2; PLT: 248
Lab. 11/11/2013
Biakan dan resistensi: tidak ada
pertumbuhan bakteri aerob
Lab.7/11/2013
Na/K/Cl: 126/3.5/103
Lab.2/11/2013
CT/BT:8/3; PT:14,3kontrol9,8; I
NR:1,18; APTT:33,8 kontrol25,
5; GDS:95; UR/CR:33/0,7; GO
T/GPT:32/50; Prot.Tot:4,4; Alb:
2,7; Na/K/Cl: 116/3,4/91
WBC:10,8; RBC:3.17; Hb:10,0;
HCT:29.3; PLT: 188
MRI 30/10/13
Kesan: reverse spondylosisthesi
s CV C4 terhadap C5
Hematoma spinal cord setinggi
CV C4-C5
Lab. 28/10/2013

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

WBC 8,99 RBC 3,58 HGB 11,1
HCT 29,0 PLT 143 Na/K/Cl 115
/3,7/9,1 GDS 94 Ur/Cr 41/0,8 H
bsAg (-), Anti HCV (-)

22

Ilham lallo
7/4/2013
603969
18/12/2013
Jamkesmas

AAI

Pro cranioplasty

tunggu jadwal operasi

Lab 10/12/2013
WBC 6,2 RBC 4,37 HB 13,2 HCT3
9,1 PLT 291 BT/CT 4/8 PT 14,2 I
NR1,18 APTT 31,9 Na/K/Cl 134/
4,1/107 anti HbsAg (-) anti HCV
(-) GDS 100 UR/CR 18/0,97 GOT
/GPT 22/22 ALB 4,4

Bed 2

23

Paulus Biri
Laki-laki
RM 630215
22/4/1950
MRS 17/12/2013
Bed 3

NA

Post cranioplasty

IVFD RL 20 tpm
Ceftriaxone amp/12jam
Ranitidine amp/8jam
Ketorolac amp/8jam

Lab 17/12/2013
WBC 10 RBC 4.97 HB14.6 HCT 4
2.9 PLT 301
Na/K/Cl 138/4.1/111
CT/BT 600/200 PT 10.1 INR 0
.86 APTT 20.1 GDS 134 Cr/Ur 31
/1.1 GOT/GPT 20/9

24

Rafaluddin DG gassing
31/12/1969
RM 639760
MRS 20/12/13
JKM
BED 4

NA

Tumor medulla spinalis

Rencana operasi

25

Hasbullah
11/9/1982
642290
MRS 17/12/13
JKD
Bed 5

DW

POH 4 Cramectomy ec EDH temporal Dextra

IVFD RL 20 tpm
Ceftriaxone amp/12jam
Ranitidine amp/8jam
Ketorolac amp/8jam

Lab 29/12/13
WBC 8,5 RBC 4,66 HB 12,3
HCT 37,5 PLT 425 GDS 121
UR/CR 22/0,91 GOT/GPT 28/47
ALB 3,8 BT/CT 300/800 PT 11,9
INR 0,99 APTT 27,2 HbsAg (-)
HCV (-) NA/K/CL 137/4,6/103
MRI L-SPINE 21/11/13
Intramedullary lesio
n setinggi CV Th 8-1
2 dengan stenosis pa
rsial di beberapa titik
pada level tersebut
suspek Astrocytoma
DD/ Myelitis
Degenerative disc di
sease
Lab 20/12/13
WBC 10,13 RBC 3,53 HB 10,9
HCT 30,7 PLT 167

26.

Anshar
Laki-laki
31/12/1977 (35 tahun)
RM 639182
MRS 26/11/2013
Jamkesmas

AAI

Paraparese ec spondilolistesis C4-C5

POH 2 fusi korpus vertebra approach posterio
r

IVFD NaCl 16 tpm

Cefotaxym amp/12jam
Ranitidin 25gr/8J/IV
Ketorolac 15gr/8J/1V

LAB 26/11/2013
WBC : 8,36, RBC ; 5,50, HGB:
18, HCT :47,1, PLT :162, PT/A
PTT ; 11,2/10,2, INR ; 0,95, GD
S 113, UR/CR : 28/0,8, GOT/G
PT : 50/82, ALB : 4,1, Na/k/Cl :
136/3,2/113.

Bed 6
Lontara 3 Bedah Saraf (Kamar 6) (Nila)
27

Ahmad Akram
Laki-laki
15/11/2009
RM 640841
MRS 06/12/2013
Umum

WA

TCR GCS 13
POH 8 Craniotomy ec. Fr Depressed Tempor
al S

Cefadroxyl Syrup 2 x 2 cth

Paracetamol Syrup 3x2 cth

Lab 12/12/13
WB : 6,71 RB : 3,37 HGB : 8,5
PT : 12,6 APTT : 21,3 HCT : 25
,0 PLT: 246 CT :800 BT :300
Na : 144 K : 3,7 Cl : 107 GDS :
94 Ur : 15 Cr : 0,32 GOT : 54 G
PT : 34
Foto Thorax 12/12/2013
Depressed fracture frontotempor
al kiri disertai pneumocephal da
n hematom subgaleal region ters

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

ebut
-Brain swelling
Lab 6/12/2013
WBC:13,00 RBC:4,39PLT:321
HGB:11,21 HCT:32,8
CT scan kepala tanpa kontras
6/12/2013
Depressed fraktur frontotempor
al kiri disertai pneumocephal &
hematoma subgaleal region ters
ebut
Brain swelling
Susp hematosinus ethmoidalis b
ilateral
28

Aris
Laki-laki
01/01/1992
RM 596418
MRS 16/12/08
JKM

WA

Post cranioectomy ec. Skull defek

Tunggu jadwal operasi berik

utnya

TCR GCS 15 E4M6V5

ICH Temporal Sinistra
SDH Temporoparietal Sinistra

IVFD RL 20/tpm
Ranitidin 50 gr 8/j/iv
Ceftriaxon i gr 12/iv

Bed 2
29

30

Andi Salsang
Laki-laki
31/12/1953
RM 642264
MRS 16/12/2013
Jamkesda
Bed 3
I Nyoman Subagia
Laki-laki
25/12/1966
RM : 641923
MRS : 14/12/13
Umum

Ketorolac 30 gr 8/j/iv
Piracetam 3 gr/8/j/iv
Mannitol 100cc/6J/IV
Kateter Urin
WA

TCS GCS 15 + EDH

temporal D/ minimal

Bed 5

31

Ny. Sari
Perempuan
01/06/1971 (42 tahun)
RM 625724
MRS 11/11/2013
Jamkesmas
Tgl konsul : 21/11/13
Kamar 8 Bed 1
Apriadi
14/04/1984
RM 641982
MRS 15/12/2013
Umum
KM 7 Bed 7
Mardia
09/07/1933
641371
MRS 11/12/2013
JAMKESDA
KM6 Bed

AAI

O2 10 Lpm
Ceftriaxone 1 gr/12/iv
Novalgin /8j/iv
Ranitidin /8j/iv
Ceremax 2,5 cc/j/SP
Necroton 3 gr/8/iv
Awasi tanda vital dan keluh
an utama

TITIPAN ( erwin dan eka)

LONTARA 1
LONTARA 2 ONKOLOGI ( erwin )
Ca Tiroid c T3NoM1 (metastasis tulang
Tunggu jadwal laminectomy
belakang) std IV
dari TS pediatri
Karnofsky 60-70 %

TCR GCS 14 (E3M6V5)

Susp. Spinal cord injury

RL 28 TPM
Ceftriaxon 1gr/12j/iv
Ranitidin 1gr/12j/iv
Ketorolac 1gr/8j/iv

TCR GCS 15
Contusio cerebri Dextra

Head up
IVFD RL 20TPM
Inj.ceftriaxon1gr/12j/
iv
Inj.Ranitidin
1amp/8jam/iv
Inj.Ketorolac
1amp/8jam/iv
Inj.piracetam 3
gr/8jam/iv
Terapi sesuai
TS.Ortopedi

Lab 14/12/13
CT : 730 BT : 200 Ur : 25 Cr
: 0,7 GOT : 58 GPT : 47 Albumi
n: 3,7 Na : 140 K : 3,82 Cl : 110
WB :22,8 RBC : 4,41 Hgb: 13,
5 HCT : 41,0 PLT :282

Lab 28/11/2013
Na/K/Cl 134/4,3/104 Ca 10
Lab 5/9/13
RBC 4,43 HGB 13,2 HCT 39,7
PLT 367 GDS 114 As.Urat 3,6
Ur/Kr 18/0,5 Kol.Total 197 HD
L 30 LDL 107 TG 273 GOT/GP
T 33/39 FT4 0,651 TSHS 0,664
Na 139 K 3,8 Cl 102
Lab
RBC 4,91 HGB 15,2 HCT 43,8
PLT 216 GDS 133 Ur/cr 19/1,
0 GOT/GPT 67/36 Na 137 K
5,63 Cl 112 alb 4,1 PT/APTT 1
0,5/13,7 CT/BT 8/3
Lab
WBC 16,00 RBC 4,69 HGB 1
3,6 HCT 38,6 PLT 247 GDS 1
32 Ur/cr 20/0,8 GOT/GPT 32/
22 Na 143 K 4,0 Cl 101 alb 4,
1 PT/APTT 10,2/24 CT/BT 8/2
3

LONTARA2(Bawah Depan) Urologi ( erwin )

LONTARA 2 (ATAS DEPAN) Digestif ( erwin)

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

34

Naira Najwa
Perempuan
5/5/2013 (6 bulan)
RM 635913
MRS 26/11/2013
Dikonsul dari B.anak 6/
12/2013
Jamkesmas

Soft tissue massa subcutis regio lumbal di pos

terior processus spinosus setinggi CV Th L2L3

Tunggu jadwal operasi

Terapi sesuai TS.Interna

Lab 5/12/2013
WBC:9,1 RBC:3,99 HGB:10,7
HCT:32,4 PLT:374 Ur/Cr:20/0,2
GOT/GPT:58/55 GDS:80 PT/A
PTT:11,9/27 CT/BT:3/8INR 0,9
9 HbsAg (-) anti HCV (-) Total p
rot 6,4
MRI Thoracolumbal spine tan
pa kontras 7/11/2013
Soft tissue mass pada subcutis re
gio lumbalis di posterior process
us spinosus setinggi CV Th12-L
2 yang tidak berhubungan denga
n canalis spinalis; kemungkinan
dari komponen otot

Astrocytoma

Tunggu jadwal operasi

Head up 30
Terapi sesuai TS neurologi
Biopsy tumor

POH 8 Post VP shunt ec Hydrocephalus non

communicans

Ceftriaxone 1 gr/12j/iv
Ranitidin amp/8j/iv
Ketorolac amp/8j/iv
Diet biasa
Terapi lain sesuai TS neuro
Mobilisasi duduk
GV/rawat luka

Meningioma intracranial

Tunggu jadwal operasi

Terapi sesuai Ts Neuro

CTscanKepala dgnkontras
22/11/2013
Massa region frontalis sesuai
gambaran low grade astrocytoma
dgn tanda herniasi subfalcin
Lab 26/11/2013
Protein total 5,6 Albumin 3,1
Lab 20/10/2013
WBC14 RBC 5,55 PLT 326 HB
15 CT/BT 7/2,5, PT/APTT
12,3/31,2, Ur/Cr 16/0,7,
GOT/GPT 31/29, Na/K/Cl
148/3,7/109
CTscanKepalatanpakontras
20/10/2013
Susp. Astrocytoma
Lab 11/11/2013
WBC 6.8 RBC 3.08 HGB 9.1
HCT 26.3 PLT 402
Prot tot 5.1 Alb 2.8
Lab 13/12/2013
WBC 6,5 , RBC 3,52, HGB 7,5 ,
PLT 682
CT scan kepala 12/12/2013
Massa intraventrikel susp
ependymoma
Hydrocephalus non
communicans
Lab 12/12/2013
GDS 98, ur/cr 25/0,16,
GOT/GPT 17/8, PT/apTT
11,9/22,7 ,INR 1,00, As. Urat
5,2, Na/K/Cl 145/4,05/104
HGB 14,1, RBC 4,59, HCT 42,4,
PLT 243, WBC 8,2
Kol tot 175, HDL 44, LDL 113,
TGR 98
CT
angiografi
cerebral
9/1/2012
Susp
meningioma
planum
sphenoidalis 33,5 x 28,5 mm &
os sphenoid kanan uk 34,7 x
35,9 mm dengan edem fokal +
midline structure shift ke kiri 4,7
mm + hyperostosis ringan os
sphenoid kanan
Tidak tampak aneurisma a.
cerebri media
Lab 4/11/2013
CT/BT 800/230 PT/APTT 9,3
control 9,6/19,1 control 25,5
GDS
104
ur/cr
37/0,6
SGOT/SGPT 26/119 Na/K/Cl
138/4,8/109 WBC 16,99 RBC
4,85 HGB 13,3 HCT 39,3 PLT
458
Kol.Total 240 HDL 40 LDL 155
Trigisirida 350
Lab 14/12/2013
CT/BT 800/300 PT/APTT
10,5/23,7UR/CR
2,8/0,5
SGOT/SGPT 16/36 Na/K/Cl
144/4,12/109 WBC 15,67 RBC
4,90 HGB 13,6 HCT 41,7 PLT

(Soft tissue tumor regio lumbalis)

Kamar 12 Bed 1

LONTARA 3 NEURO (Eka)

35

Manija
Perempuan
14/2/1975 (38 th)
RM 633310
MRS 19/10/2013
Umum

NS

HCU Bed 3

36

Ny. Sutanti
1/08/1983 (75 th)
RM 641565
MRS 12/12/2013
HCU bed 4

37

Nadirah
Perempuan
5/5/1963 (50 tahun)
RM 635735
MRS 4/11/2013
Jamkesmas
Kamar 3 Bed 1

DW

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

544
38

Ny. H. Suriani
perempuan
05/09/1967(46 th)
RM 635701
MRS 04/11/2013
Jamkesmas
Tgl konsul :13/11/13

WA

Meningioma intracranial

Tunggu jadwal operasi

Sesuai TS Neurologi

DW

POH 14 external drainage ec tumor kistik

ventrikel lateral sinistra

GV + rawat luka hari ini

Asam mefenamat 3x1
Cefadroxil tablet 2x1
Ranitidin tablet 2x1
Analisa liquor
serebrospinal
Aff hecting selang-seling

DW

Post removal tumor craniofaringotomi

Lapor prof AAI

Boleh rawat jalan
Rencana radioterapi

K3 Bed 6

39

Herman
Laki-laki
5/4/1984 (29 tahun)
RM 637466
MRS 14/11/2013
Jamkesmas
Kamar 4 Bed 5

40

Saiful
Laki-laki
5/11/1986 (26 tahun)
601772
MRS 6/8/2013
Jamkesmas
K 4 Bed 2

Foto thorax 26/11/13

Cardiomegaly
Elevasi diafragma (susp.proses
intrahepatik)
Lab 14/11/2013
HBsAg (-) Anti HCV (-)
SGOT/SGPT 19/70, Albn 3,4
Lab 6/11/2013
WBC 15,3 RBC 5,00 PLT 161
HGB 12,6 HCT 36,7 Na/K/Cl
138/4,3/107; SGOT/SGPT
29/108; Ur/Cr 32/0,7; Kol.Total
238 HDL 66, LDL 156, As. Urat
2,8 CK 23, GDS 105 LDH 406
MRI 8/11/2013
Massa
selladansupraselladenganinfiltras
ikenervus opticuskiridenganatopi
oculisinistrasesuaidenganmening
oma.
USG Abdomen Atas
15/11/2013
Tidak Tampakkelainanpada
USG abdomen
Lab 14/12/2013
GOT/GPT 19/70
Alb 3,4 anti HCV (-), HbsAg (-)
Lab 16/12/2013
WBC 14,83 RBC 6,30, HGB
15,4, HCT 44,6, PLT 354
Na 139, K 3,4, Cl 106, GDS 116,
UR/CR 14/0,50, CT/BT
8,00/3,00, PT 11,2, INR 0,93,
APTT 23,2
CT Scan kepala (tanpa
kontras) 20/11/2013
Massa di ventrikel lateralis
sinistra
Brain swelling
MSCT kepala dengan kontras
25/11/2013
Massa kistik ventrikel lateralis S
Brain swelling
Lab 15/11/2013
WBC 12,34 RBC 5,28 HGB
16,0 HCT 43,3 PLT 302 CT/BT
7/3 PT/APTT 11,0/27,6 INR
0,9 GDS 103 Ur/Cr 37/1,2
GOT/GPT 14/9
Kol.tot/HDL/LDL/TG
255/54/170/68 As urat 5,2
Lab 7/11/2013
Na/K/Cl: 142/4.1/107; GDS: 50;
UR/CR: 11/0,9; GOT/GPT:
17/12; Alb: 3,8;WBC: 7.0;
RBC:3.8; Hb:9,8; HCT:28.3;
PLT: 446
Lab 31/10/2013
Kolestrol.Tot:215;
HDL:21;
LDL:153; TGL:149;
UR/CR: 12/0,7; GOT/GPT: 14/9;
Prot. Tot: 7,4; Alb: 3,6;
WBC:8,6; RBC:3.9; Hb:9,8;
HCT:29.4; PLT: 676
Lab 17/10/2013
CT/BT
:
8,00/3,00
;
PT/APTT:13,5/28,9;
Lab (AGD)17/10/2013
pH: 7,46; pCO2: 42; sCO2: 99,9;
pO2: 316,6; HCO3: 30,3; ct:
17,4; BE: 6,5
PA 17/10/2013
Karsinomasel
squamous
differensiasibaik
Lab 16/10/2013
CT/BT
:
7,00/3,00
;
PT/APTT:10,8/29,5;
GDS:71;
ur/cr:15/0,6 ;GOT/GPT:17/26;
alb:3,4

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

Na/K/Cl:139/4,5/107;
WBC:14,3;
RBC:4,37;
HGB:11,3 HCT:34,8; PLT:540
Foto thorax 15/10/2013
Tanda-tanda edema paru
Dilatasi et aortae
Susp. Efusi pleura (s)
MS CT kepaladgnkontras
20/9/2013
Massa supracella
Susp. Craniopharyngioma
Hydrocephalus
non
communicans
MRI
brain
dgnkontras
20/9/2013
ambaranCraniopharyngioma
DD/ adenoma hipofise
LONTARA 3 MATA (erwin)
LONTARA 3 THT (eka)
41

Riska
Perempuan
Tgl konsul: 11/12/13
RM: 640519
Jamkesda

DW

Abses fossa posterior

Post op masteidectomi bilateral canal wall d
own day 5

AAI

Hidrosefalus

Rencana operasi setelah

THT

K2 Bed 3

42

Muslimah
Perempuan
Tgl konsul 19/12/2013
RM: 642762
Tgl lahir 24-07-2009
K7B1

LONTARA 4 ATAS BELAKANG

Rencana VP shunt jika kelu
arga setuju

Lab 11/12/13
WBC: 12,1; RBC: 3,47; HGB:1
1; HcT:32; PLT: 159; BT/CT:8
00/300; PT/APTT: 11,7/20; I
NR: 0.98/GDS: 134; Ur/Cr: 45/0
,6
Na/K/Cl: 140/3,3/104
GOT/GPT: 26/48
Prot. Total: 6,1; Alb:3;
Foto Thorax 5/12/13
Kesan: Normal
CT tanpa kontras 5/12/13
Koleosteatoma dengan abses
cerebelli.

Lab 19/12/13
GDS 94. Na 143, K 4,9, Cl 116
WBC 13,19, RBC 4,61, HGB 13
,1, HCT 38,6, PLT 368

Lontara 3 KULIT KELAMIN

43

Ny. Damaris Pasa

Perempuan
12/10/1953 (60 tahun)
RM 636948
MRS 27/11/2013
Askes

DW

LONTARA 4 (Bawah Depan) OBGYN

LONTARA 4 (Bawah Belakang) NIFAS
LONTARA 4 (Atas Belakang) ANAK
PAKIS
ICU (RUSWATI)
Post laparotomi eksplorasi
ec perforasi gaster

Lab (8/12/2013)
RBC 4,08 HGB 11,0
PLT 64 WBC 15,4

Post Tracheostomi hari ke 9

Bed 4
44

Fitria
Perempuan
20/5/1989 (24 tahun)
MRS 27/11/13
RM 639460
Bed 1

WA

POH 23 craniectomy
EDH temporoparietal dextra

IVFD RL 28 tpm
Inj.
1g/8j/iv
Awasi KU, TTV & GCS
Rawat luka
Aff Hecting

Lab (11/12/2013)
BT/CT: 800/300
PT/INR; 12,9/1,09
APTT; 24,3
GDS: 174; Ur/Cr:
24/0,2;
GOT/GPT;
35/42
WBC: 10,25; RBC:
3,43; HGB: 10,2; HcT:

10

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

29,4; PLT: 332
Lab (10/12/2013)
CRP kuantitatif 149
Lab (8/12/2013)
WBC 26,4 RBC 4,341
HGB 12,8 PLT 445
ALB 3,2
Lab 4/12/13
CRP 96,1 GDS 93; Ur/
Cr 15/0,92; GOT/GPT:
61/69; Alb 2,8; CT/B
T 7/ 23; INR 1,09 W
BC 9,3; RBC 3,84; Hb
11; PLT 182
Lab 3/12/2013
GDS 117 Ur/Cr 22/0,4
9 GOT/GPT 34/57 Na/
K/Cl 135/3,5/101 WB
C 6,2 RBC 2,68 HGB
7,8 HCT 23,2 PLT 147

45

Tn A.Subair
Laki-laki
31/12/1945 (67 tahun)
RM 640388
MRS 3/12/13
Jamkesda

WA

ICH parietal dextra

POH 15 craniotomy

IVFD RL 28 tpm
Inj.ranitidin 1 gr/8j/iv
Terapi sesuai Anestesi
Diet susu personde
Awasi KU, TTV & GCS

Bed 8
Aff hecting semuanya

Lab 30/11/13
AGD alkalosis metabol
ic, GDS 89, Ur/Cr 21/0
,4, GOT/GPT 86/88, A
lb 3,2, WBC 10,07, RB
C 2,8, HGB 8,3, HCT
24,2, PLT 143
Lab 29/11/13
AGD alkalosis respirat
orik, CRP 95,7
PT/APTT 16,3/28,3, I
NR 1,35
Lab 28/11/13
GDS
101,
Ur/Cr
24/0,81,
GOT/GPT
63/80, Alb 3,0, WBC
11,93, RBC 3,04, HGB
9,0, HCT 25,6, PLT
151, As. Laktat 38,8,
CRP kuantitatif 62,8,
Na/K/Cl 145/4,1/119
Lab (12/12/2013)
Ur/Cr 74/1,4
Alb 2,7 GOT/GPT
108/77
Na/K/Cl
151/3,8/106 WBC 4,0
RBC 3,89 HGB 11,4
PLT 127 HCT 33,5
Lab 4/12/13
Lab (8/12/2013)
CT/BT
230/730
PT/APTT
9,3/29,4
INR 0,80 GDS 114
Ur/Cr
57/1,3
GOT/GPT
170/45
Na/K/Cl 153/3,9/115
WBC 4,2 RBC 3,871
HGB 11,51 PLT 84
Lab 4/12/13
AGD: Alkalosis metab
olic terkompensasi sem
purna
CT/BT: 630/3 PT/A
PTT: 11/19,8; INR: 0,9
: GDS: 109; Ur/Cr: 36/
1,4; GOT/GPT: 29/14;
Na/K/Cl: 139/3,91/12
0; WBC: 9,2; RBC: 4,1
8; Hb: 12,6; HCT: 35,3
; PLT: 158;
Lab 3/12/13
CT/BT: 6/3
INR:
0,9;
GOT/GPT:37/29;
Na/K/Cl: 144/3,6/116;
WBC: 12,39; RBC:
4,96; Hb: 15,1; HCT:
40,2; PLT: 196

11

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

46

Ny.Hadina
Perempuan
05/07/1977
RM 6402028

SDH Temporal Dextra

POH 5 Cranioctomi

Jamkesda

Ny. Nurleli
Perempuan
05/01/1997
RM 642571

Lab 17/12/2013
Wbc 4,4 Rbc 3,24
Hct 27,3 Plt 86 na 140
k 3,5 cl 111 GOT 37
GPT 22

Awasi KU, TTV & GCS

Rawat luka & GV
Aff drains

Bed 9
47

IVFD RL 28 tpm
Inj. Meropenem 1g/8j/iv
Inj.mannitol 100 cc/6j
Terapi sesuai TS Anestesi

DW

POH 3 Craniotomi
EDH temporal Sinistra

Jamkesmas

IVFD RL 28 tpm
Inj. meropenem 1 g/8j/iv
Inj.asam traneksamat 1g/8j
Terapi sesuai Anestesi
Diet susu & bubur
Ganti botol Drain
Awasi KU, TTV & GCS

Lab18/12/2013
WBC 49,21
RBC 3,92 HGB 11,5,
HCT 33,8 HCV 86,
PLT 332

Bed 7

48

Gede Krisna
6/4/2013
641904
Dikonsul tgl 14/12/2013

DW

PICU (RUSWATI)
Trauma cantis GCS 11 (E3M5V3)
Subdural Higroma frontal sinistra

DW

Hydrocephalus post VP- shunt 14 hari

Awasi TTV,KU & GCS

Rawat luka & GV
Diet susu personde
Terapi lanjut sesuai TS anes
tesi

Hidrocephalus

Rencana Joint TS THT

Tunggu jawaban perioperasi
TS anestesi

Post Op Cranioktomi hari 2

IVFD RL 20 tpm/mnt
Meropenem 1 gr/12j/iv
Ranitidin 1amp/8j/iv
Asam Traneksamat 1/2/8j/iv
Sesuai TS pediatric
Diet susu

Lab10/12/2013
GDS 116 Ur 17 kreatinin 0,60 A
lbumin 4,6 Na 144 k 5,0 Cl 103
SGOT 32 SGPT 13

Hidrosephalus
Post op Vp shunt 3 hari

Terapi Lanjut
Sesuai TS pediatric
Rawat luka & GV hari ini
Awasi tanda vital KU & GC
S

Lab18/12/2013
Na 155 k 4,0 Cl 126 Wbc 5,1
RBC 2,56 HGB 7,9 HCT 22,3
MCV 07 MCHC 35,6
MCH 30,9

Tunggu jadwal operasi

Lab 03/12/13
WBC 11,5 RBC 4,2 HGB 12,5
HCT 37,9 troponin <0,02 CK

Konsul perioperatif anestes

i
Rencana operasi

Bed 2

49

Arjun
Laki-laki
12-8-2002
RM 637061
MRS 12/11/2013
Jamkesmas
Bed 10

50

Fathin Shidqia
15/6/2013 (5 bulan)
Tgl MRS 1/12/2013
Tgl konsul : 11/12/13
RM 619608
ASKES
Bed 9

51

Muh. Faris
01/11/2007
RM637431
JAMKESMAS

AAI

Bed 12
52

Naura Azzahra
25/06/2013
RM636293
JAMKESMAS

Lab 8/12/12
GDS: 119; Na/K/Cl: 138/3,6/10
7;
RBC: 4,24; HGB; 11,6; HcT;35,
5; PLT: 570
Lab 7/12/2013
WBC: 12,97 RBC:4,38 Hb:11,7
PLT:6,8 Hct:33,5
Na/K/Cl : 137/4,0/110
Lab 11/12/13
D dimer: 3,1
PT/APTT/INR: 15,4/1,27/36,3
Lab 10/12/2013
Na/K/Cl 136/2,8/99 TSHS 5,95
FREE T4 1,87 ALB 3,7 ALP 25
4 COL. TOTAL 162
Lab 7/12/2013
WBC 18,16 RBC 3,51 HGB 9,5
HCT 27,4 PLT 34
MSCT (2/8/2013)
KESAN : meningioencephaloce
le nasal

Bed 4
NICU (RUSWATI)

Palem atas (ERWIN)

53

Martinus Rante Pasos

O
TGL Lahir 01/01

DW

Gangguan FKL e.c susp meningioma dd/

abses cerebri

12

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

RM640312
MRS 03/12/13
Askes
B1/3

54

Massakirang BA
25/06/1939
RM 641738
MRS 13/12/2013
B2/2

NS

55

Manuara Nurdin
Tgl Lahir 31/12/1950
RM 641157
MRS 13/12/2013
ASKES
B2/3

WA

Post Ventrikulostomy day 1

PALEM BAWAH
POH 7 removal tumor

RL 28 TPM
Ceftriaxon 1gr/12j/iv
Ranitidin 1gr/12j/iv
Ketorolac 1gr/8j/iv
Piracetam 1gr/8j/iv
-Rencana VP-shunt kamis
19/12/2013

MB 43 CK 5280 Na/K/Cl 41/3,

43/120
Kol total 156 HDL 38 LDL 10
5 TG 64 Ur/Cr 38/1,0 GDS 12
2 PT 12,6/11,4 CT/BT 8/3
CT scan tanpa kontras (03/12/
13)
Kesan : masa intracranial extr
a axial susp meningioma diser
tai hormone subfalcine dan hy
drocephalus non communican
s
Lab 03/12/13
WBC 6,41 RBC 3,73 HGB 11,
7 HCT 32,7 Na/K/Cl 139/3,4/1
02
Prot.total 4,4 Ur/Cr 25/0,8 PT
11,6/36,5 CT/BT 830/2,30

IVFD RL28 TPM

Meropenem 1gr/8jam/iv
As.Tranexamet 1gr/8jam/i
v
Dexametason 2 amp/6jam/
iv
Brainact 1gr/12jam/iv
Vit K 1amp/24jam/iv
AFF kateter
Diet lunak

Lab 16/12/13
WBC 12,0 RBC 7,0 HGB 13,8
HCT 50,2 PT/APTT 11,8/24,9
CT/BT 730/2,00

Terapi lanjut sesuai TS neur

o dan EM

Lab 14/12/13
GDS : 91, GDP : 184, G2PP : 2
04, sedimen urin : dalam batas n
ormal. Urin rutin : Protein : 10,
VitC : 10. Lainnya : DBN
Lab 07/12/2013
RBC : 7,66. WBC : 3,66. HGB:
9,6. HCT : 29,5. PLT: 550. CT/
BT: 9/ 3. PT/APTT: 15,5/30,5.
Lab 26/11/2013
CT/BT 830/230 PT/APTT 1
1,3/29,0 INR 0,90 GDS 146 Ur/
Cr 61/1,1 GOT/GPT 21/24 Prot.
tot 4,54 Alb 4,7 CK 47 CKMB
1,3 HBsAg (-) Na/K/Cl 130/4,8/
107 WBC 6,94 RBC 2,96 HGB
8,2 HCT 23,9 PLT 489
Lab 27/11/2013
HbA1C 7,2% (N = 4-6)
MRI thoracalis T1WI (2/12/20
13)
Lesi posterior vertebra setinggi
CV T5-T6 yang menekan thecal
sac, pergeseran alur liquor & sp
inal cord serta menyebabkan ste
nosis parsialis canalis spinalis
Spondylosis tjoracolumbalis

PCC (FARADILA)

56

Hj. Kurniah
Perempuan
1/1/1962 (51 tahun)
RM 248936
MRS 26/11/2013
Askes

AAI

RSUH (FARADILA)
A/ Post epidurolisis

Lantai 4 kmr 424

57

Ny Harmoni
Perempuan
25/12/1969
RM 016106
Lantai 4 K405 A

Post op removal tumor

PA : glioblastoms multiforme

- IVFD NaCl 0,9 % : RL. 3

: 1/ 28 tpm
- Cernevit amp/ 24j/drips
- cefadroxil 500 2 x1
Terapi lain sesuai TS Neuro
dan gizi klinik

Lab 15/12/2013
WBC : 15,63. RBC : 4,87. HGB
: 14,5. PLT : 123. HCT : 42,5
Hasil pem.mikrobilogis :
kultur bakteri (-).
Lab 14/12/13
Na : 130, K : 3,1. Cl : 95
Lab 9/12/13
Na/K/Cl: 140/2,7/98; GOT/GPT
; 18/18; Prot. Total; 7,1; PT/AP
TT; 16,8/28,6; GDS; 139; Koles
trol total; 242; Ur/Cr; 27/0,6
Hasil CT scan
- Defek os frontoparietal kiri dis
erta herniasi otak pada level tsb
Encephalomalacia
Lesi slight hiperdens susp. Mass

13

KORAN BEDAH SARAF SABTU, 21 DESEMBER 2013

a residu

58.

Muhajirin
Laki-laki
6/8/1982
MRS 7/11/2013
RM 015603

AAI

EDH frontal (D)

Postcranioplasty
Post tracheostomy
GCS 15

Terapi lain sesuai TS intern

a (pulmo), mata.
Boleh rawat jalan dari beda
h saraf.

Lantai 3 K313

59

Anak. A.Radhi
Laki-laki
Tgl lahir : 01-12-2006
RM : 016726
Tgl masuk : 14-12-2013

NS

A/ TCR GCS 10 dalam perbaikan

GCS 15 post debridement hari ke 8

-Cefadroxil syr 3 x 1
-PCT syr 3 x 1
Terapi lanjut sesuai TS Neu
ro.

Lab 6/12/2013
Ur/Cr: 35/0,8
CT Scan kepala
Kesan:
-defect pd os frontalis dengan en
chepoalomalacia region frontali
s
-fraktur dinding anterior & later
al sinus maxilaris bilateral disert
ai multi hematosinus
Lab 10/12/2013
WBC 7,85 RBC 4,03SGOT 32
SGPT 34 HB 12,1 HCT 37,1
PLT 282
Lab 14-12-2013
WBC : 19,38, RBC : 3,97. HGB
: 10,6. HCT : 32,2. PLT : 385.
GOT : 68, GPT : 48. GDS : 81

Lantai 3 kamar 326

60.

Ny. A Amiratna
Perempuan
Tgl lahir : 13/12/1953
RM : 0155770

WA

A/Post Gamma knife surgery

AVM Cerebellum

LANTAI 4 406

-IVFDNacl 0,9 %/ 28tpm

-Cernevit / 24 jam/ drips
-Hexilon 125 mg/ 12 j
-Torasic tab 3 x 1(klo perlu)
- omeprazole 1 vial/24 jam
-lain-lain sesuai TS Pulmo

Lab 17-12-2013
WBC : 9,41. RBC : 6,54.HGB:
19,5. HCT: 53,7. PLT :119. Na :
130. K : 3,6. Cl : 95. Ct: 3. BT:
6. PT : 12,9. INR : 1,03. APTT :
28,7. GOT : 57. GPT : 127. GD
S :102. Ur : 18. Cr : 0,5

UGD
61

62

63

64

Nasrul
Laki-laki
12/3/1991
RM 642409
MRS 17/12/2013
Jamkesda
Rika Ananda
Perempuan
27/10/1998
RM 642262
MRS 16/12/2013
Umum

TCS GCS 10 E3M4V3

DW

02 Masker NRM
IVFD RL 20/tpm
Ranitidin 50 gr 8/j/iv
Ceftriaxon i gr 12/iv

Ketorolac 30 gr 8/j/iv
Piracetam 3gr/8J/IV
NS

TCS GCS 11 E3M5V3

ICH Frontotemporal Sinistra

Lab 15/12/2013
CT 8 Bt 3 PT 10,1/10,5 INR 0,8
09 APTT 21,4/2,7 GDS 133 Ur
/cr 19/1,0

IVFD RL 28/tpm
Ranitidin 50 gr 8/j/iv

Ketorolac 30 gr 8/j/iv
Ceftriaxon i gr 12/iv
Neck Collar
Mannitol 100cc/6J/IV

Andi Salsang
Laki-laki
31/12/1953
RM 642264
MRS 16/12/2013
Jamkesda

TCR GCS 15 E4M6V5

ICH Temporal Sinistra
SDH Temporoparietal Sinistra

Nyomba Dg. Ngitung

Laki-laki
1/1/1943
RM 642420

Abses Regio Zygomatikum D

Abses Regio Temporal D
Abses Regio Parietal D
Abses Regio Occipital D

IVFD RL 20/tpm
Ranitidin 50 gr 8/j/iv
Ceftriaxon i gr 12/iv

Ketorolac 30 gr 8/j/iv
Piracetam 3 gr/8/j/iv
Mannitol 100cc/6J/IV
Kateter Urin
IVFD RL 20/tpm
Ranitidin 50 gr 8/j/iv
Ceftriaxon i gr 12/iv

Ketorolac 30 gr 8/j/iv
Metronidazole 5mg/8J/IV

14