LONTARA 2 ORTHOPEDI BAWAH BELAKANG

K9B3
Dawani
MR: 699487
Tanggal Lahir:
01/07/1973
Tanggal MRS:
10/02/2015

S: nyeri kepala
O: KU: baik
GCS 15 (E4M6V5)
A: Susp.
meningioma
sphenoidal

DPJP:
Prof.Dr.dr.A.Asadul I.,
Sp.BS

RL 28 tetes/menit
Ketorolac 30
mg/8 jam/IV
Dexamethasone 5
mg/24 jam/IV
Omeprazole 40
mg/24 jam/IV
Ceftriaxone 1
gr/12 jam/IV

Lab 03/02/2015
WBC: 5.86
RBC: 5.14
HGB: 14.5
HCT: 42.4
PLT: 320
CT/BT: 7'00/3'00
PT/APTT: 10.6/25.8
GDS: 108
Ur/Cr: 19/0.7
SGOT/SGPT: 26/31
Na/K/Cl: 146/3.4/111
HBsAg: nonreactive
MSCT kepala (dengan
kontras) 10/02/2015
Brain swelling
MRI kepala 17/02/2015
Tidak tampak SOL

LONTARA 2 DIGESTIF ATAS DEPAN

K1B1
Irfan Reynaldy
MR: 701665
Tanggal Lahir:
09/03/1995
Tanggal Konsul:
21/02/2015

A: TCS GCS 13
(E4M6V5) + post
laparotomi eksplorasi
+ splenectomy

Citicholin 250
mg/12 jam/IV
Ranitidin 50 mg/12
jam/IV
Sohobion 1 amp/24
jam/IM
Dexamethasone 1
amp/6 jam/IV

CT scan kepala
Tanda-tanda ischemic cerebri
dextra

DPJP:
dr. Willy Adhimarta, Sp.
BS

LONTARA 3 THT ATAS DEPAN

K1B2
Andi Ilham
MR: 696842
Tanggal Lahir:
01/11/1983
Tanggal MRS:
09/02/2015
DPJP:
Dr. dr. Nasrullah, Sp. BS

S: nyeri kepala
O: KU: baik
GCS 15 (E4M6V5)
A: Astrocytoma high
grade

RL 20 tetes/menit
Dexamethasone 1
amp/8 jam/IV
Ketorolac 30 mg/8
jam/IV
Omeprazole 1
amp/24 jam
Citicolin 2x1
Rencana MRI di
RS Awal Bros

Lab 28/01/2015
WBC: 15.1
RBC: 5.64
HGB: 16.8
HCT: 52
PLT: 282
CT/BT: 3'00/2'00
PT/APTT: 9.7/24.4
GDS: 192
Ur/Cr: 21/0.5
SGOT/SGPT: 24/1.1
Na/K/Cl: 140/3.5/99
HBsAg: nonreactive

MSCT scan kepala

12/01/2015
Massa regio temporoparietalis
sugestif high grade
astrocytoma
K1B6
Asis
MR: 701393
Tanggal Lahir:
31/12/1961
Tanggal MRS:
14/02/2015
DPJP:
dr. Andi Ihwan, Sp. BS

S: nyeri luka operasi

O: KU: sakit
sedang/sadar
GCS 15 (E4M6V5)
A: Post craniectomy
sinistra POD-4 e.c
ICH regio frontal
sinistra et dextra

RL:D5= 28
tetes/menit
Ceftriaxone 1 gr/12
jam/IV
Ketorolac 30 mg/8
jam/IV
Ranitidin 50 mg/8
jam/IV
Asam tranexamat
500 mg/8 jam/IV
Takar produksi
drain/ 24 jam

Lab 16/02/2015
WBC: 8.0
RBC: 2.92
HGB: 8.7
HCT: 26.9
PLT: 100
Lab 14/02/2015
WBC: 13.2
RBC: 3.40
HGB: 10.4
HCT: 31
PLT: 131
CT/BT: 8'00/3'00
PT/APTT: 14.5/32.2
GDS: 111
Ur/Cr: 28/0.70
SGOT/SGPT: 41/13
Na/K/Cl: 142/3.8/110
HBsAg: nonreactive
CT scan kepala (tanpa
kontras) 14/02/2015
Intracerebral hemorrhage
regio frontalis bilateral

K2B1
St. Saidah
MR: 701744
Tanggal Lahir:
01/01/1945
Tanggal MRS:
17/02/2015

S: nyeri kepala
berkurang
O: KU: sedang
GCS 15 (E4M6V5)
A: Trauma capitis
ringan GCS 15 + ICH
regio frontal

DPJP:
Dr. dr. Djoko Widodo,
Sp. BS

K2B3
Salmia
MR: 630916
Tanggal Lahir:

S: nyeri kepala
O: KU: sakit sedang
GCS 15 (E4M6V5)

RL 28 tetes/menit
Ceftriaxone 1 gr/12
jam/IV
Ranitidin 50 mg/8
jam/IV
Ketorolac 30 mg/8
jam/IV
Mannitol 100 cc/6
jam bila tensi >
100 mmHg

Lab 17/02/2015
WBC: 26.5
RBC: 3.82
HGB: 11.1
HCT: 33.7
PLT: 339
CT/BT: 7'00/3'00
PT/APTT: 10.1/22.9
GDS: 175
Ur/Cr: 26/0.90
SGOT/SGPT: 38/15
Na/K/Cl: 143/3.1/106
HBsAg: nonreactive

RL 28 tetes/menit
Ceftriaxone 1 gr/12
jam/IV
Ranitidin 50 mg/8

Lab 11/02/2015
WBC: 17.1
RBC: 4.63
HGB: 12.1

31/12/1990
Tanggal MRS:
11/02/2015
DPJP:
Dr. dr. Djoko Widodo,
Sp. BS

A: Post removal tumor jam/IV

intracranial
Ketorolac 30 mg/8
jam/IV
Dulcolax supp 1
tab/12 jam/rectal

HCT: 37
PLT: 195
CT/BT: 8'00/3'00
PT/APTT: 10.9/23.0
GDS: 134
Ur/Cr: 14/0.6
SGOT/SGPT: 15/16
Na/K/Cl: 143/3.6/109
HBsAg: nonreactive

K2B4
Sartina
MR: 701860
Tanggal Lahir:
21/10/2000
Tanggal MRS:
18/02/2015
DPJP:
Dr. dr. Djoko Widodo,
Sp. BS

S: nyeri kepala
O: KU: sedang
GCS 15 (E4M6V5)
A: Trauma capitis
ringan GCS 15

RL 28 tetes/menit
Ceftriaxone 1 gr/12
jam/IV
Ranitidin 50 mg/8
jam/IV
Ketorolac 30 mg/8
jam/IV

CT scan kepala (tanpa

kontras) 11/02/2015
Lesi kistik dengan mural node
di dalamnya yang
berhubugan dengan
ventrikel IV & III disertai
pendarahan intraventrikel
Brain Swelling
VP shunt terpasang pada
ventrikel lateralis kiri
Defect os occipitalis
Cavum septum pellucidum
persisten
Lab 18/02/2015
WBC: 13.1
RBC: 4.20
HGB: 11.4
HCT: 34.5
PLT: 345
CT/BT: 7'00/2'00
PT/APTT: 10.5/24.2
GDS: 100
Ur/Cr: 16/0.5
SGOT/SGPT: 21/9
Na/K/Cl: 142/3.6/107
HBsAg: nonreactive