11102011
1 nl Made Srl MurLlnl/ / 46 Lahun/ 1308687/ harl 2
Ca Cvarlum advenLage sLage + syok hlpovolumlk + uM Llpe 2
2 uewa Cede wlraLama/ L/ 24 Lahun/ harl 2
posL Lrepanasl evacuasl cloL ec SuP fronLoLemporoparleLal S + LuP
Lemporobasal S + edema cerebrl
3 1uklyo/ L/ 33 Lh/ 1313207/ harl 3
posL debrldemenL + exLernal flxasl ec Cl Llbla S 1/3 dlsLal + Cl flbula S
1/3 proxlmal (hr 12) + LeLanus generallsaLa
4 nl kadek MurLlnl/ / 24 Lahun/ 1313264/ harl 3
Ck8 + fr Maxllofaclal le lorL lll + dlsLress napas + braln swelllng + Cl
humerus S 1/3 Lengah
3 CusLl Ayu WldlaLl/ / 30 Lahun/ 01313300/ harl 2
osL v shunL ec hldrocephalus non communlcanL + sol serebrl
6 lda edanda Cde uLu uLra/ L/ 73 Lahun/ 1462313/ harl 9
SP lC8 S
1 nl Made Srl MurLlnl/ / 46 Lahun/ 1308687/ harl 2
Ca Cvarlum advenLage sLage + syok hlpovolumlk + uM Llpe 2
W M8S 7102011 PCu 9102011 darl san[lwanl
W aslen dlkonsulkan oleh 1S obgyn dengan syok dlsLrlbuLlf dd hlpovolumla posL
kemoLerapl paxus karboplamec ca ovarlum advenLage sLage
W aslen mendapaLkan kemoLerapl paxus karboplamserl 2 (8102011) Lemas (9
102011 pk 0200) mual (+) munLah (+) uemam () Lldak sadar selama 3 menlL
kemoLerapl dlsLop
W ulberlkan C2 SM ln[eksl dexameLason 10 mg clmeLldln 3 x 1 amp kalLrofen supp
soclaf 2 x 1
W (9102011 pk 0730) paslen dlkonsulkan ke lnLerna oleh karena mengalaml syok
1u 30/palpasl n 120 x/mnL dlLerapl 8L 300 cc + PALS 6 300 cc 60/palpasl
W Lab (k 833 9/10/2011) W8C 824/ Pb 1478/ PcL 42/ lL 2067/ 81 1/ C1 9/ 1
163 (108) / A11 331 (33)/ ln8 14/ SCC1 608/ SC1 788/ 8un 21/ SC 139/ 8S
342/ na 132/ k 402/
W ACu pP 743/ pCC2 19/ pC2 124/ PCC3 132/ 8L 83/ na 126/ k 38
W Selama perslapan LransporL ke PCu 1u 90/40 mmPg n
W roduksl urlne mlnlmal furosemld 20 mg
8ed 1 Parl 0
88 30 kg/ 1emp 36 C
SS cm
8es 88 30 x/mnL rh / wh / SpC2 99
C2 SM 10 LM
kv 118/76 mmPg n 147 x/mnL Cv 8 cm
P2C
Cl dlsLensl (+) shlfLlng dullness +
uC uk + produksl pekaL 100 cc/3 [am
700 cc/ 7 [am
W8C 108/ Pb 89/ PcL 264/ lL 126/ 8un
1702/ SC 139/ 8S 143/ na 131/ k 41
ACu (pk 1700 1 367 C) pP 742/ pCC2 23/
pC2 113/ 8L 67/ PCC3 162/ SaL 100
ACu (pk 2100 1 36 C) pP 736/ pCC2 28/
pC2 79/ 8L 83/ PCC3 138/ SaL 90
lnLubasl C 20/ rr 14/ fl C2 100 peep 7
SaL 97
ro Lenslon pneumoLhoraks u + efusl
pleura bllaLeral mlnlmal pasang WSu u
W ullL u3 300 cc/24 [am
W 8L 1300 cc/24 [am
W MeLoclopramld 3 x 10 mg
W ClmeLldln 3 x 1 amp
W MeLronldazole 3 x 300 mg
W araceLamol 3 x 300 mg
W PepaLln 2 x 1 Lb
W lenLanyl 23 mcg k/p
W lurosemld 10 mg/[am
W uobuLamln 10
mcg/kg88/menlL
W vascon 03 mcg/kg88/menlL
8ed 1 Parl 1
88 30 kg/ 1emp 38 C
SS cm
8es C 20 88 14 llC2 100 peep 10 rh / wh /
SpC2 99
ro Lenslon pneumoLhoraks u + efusl pleura
bllaLeral mlnlmal pasang WSu u
kv 118/76 mmPg n 147 x/mnL Cv 8 cm P2C
Cl dlsLensl (+) shlfLlng dullness +
uC uk + produksl pekaL 100 cc/3 [am
930 cc/ 21 [am
W8C 198/ Pb 119/ PcL 23/ lL 177/ na 131/ k 43
ACu (pk 0700 1 367 C) pP 734/ pCC2 44/ pC2
133/ 8L 22/ PCC3 237/ SaL 100 C 20 88
14 llC2 70 peep 10
ACu (pk 2100 1 38 C) pP 74/ pCC2 33/ pC2 149/
8L 26/ PCC3 217/ SaL 99
C 20 88 14 llC2 60 peep 10
ro Lenslon pneumoLhoraks u + efusl pleura
bllaLeral mlnlmal pasang WSu u
W ullL dlabeLasol 730 cc/24 [am
W 8L 1300 cc/24 [am
W MeLoclopramld 3 x 10 mg
W ClmeLldln 3 x 1 amp
W Soflram 2 x 1 g
W MeLronldazole 3 x 300 mg
W araceLamol 3 x 300 mg
W PepaLln 2 x 1 Lb
W lenLanyl 23 mcg k/p
W lnsulln sesual gula darah
W lurosemld 10 mg/[am
W Morphlne 20 mg/24 [am
W uobuLamln 10 mcg/kg88/menlL
W vascon 1 mcg/kg88/menlL
2 uewa Cede wlraLama/ L/ 24 Lahun/ harl 1
posL Lrepanasl evacuasl cloL ec SuP fronLoLemporoparleLal S +
LuP Lemporobasal S + edema cerebrl
W M8S 8102011 2012 PCu darl Ck l8u 9102011 pk 330
W aslen ru[ukan 8Suu glanyar dengan Ck8 + cephal hemaLom
W uaLang Lldak sadar
W 8lwayaL operasl 2008 Lrepanasl rawaL PCu dengan CAC11
W MCl paslen Ler[aLuh sendlrl saaL mengendaral sepeda moLor seLelah
mlnum mluman keras kepala membenLur LroLoar
W Lab W8C 273/ Pb 144/ PC1 426/ lL 300
W ermasalah preoperasl
W CCS L1v1M3 pupll klrl sde pupll kanan reflex (+)
W C1 scan focal fronLoparleLal S uk 10868 mm x 91 mm 10 sllce mldllne
shlfL 198 ke kanan
W 8es dllnLubasl dl Lrlage bedah
W uuranLe operasl CAC11
W uurasl 2 [am 23 menlL
W erdarahan 300 cc calran masuk krlsLalold 700 cc/kolold 300 cc/ manlLol
200 cc/ urlne 1300 cc/3 [am
8ed 2 Parl 0
88 33 kg/ 1emp 36 C
SS uC 8 +/ (3 mm/sde)
8es CvC 1v 300 cc 88 12 ll C2 30
LL 3 rh / wh / SpC2 100
kv 132/83 mmPg n 83 x/mnL
Cl dlsLensl () 8u (+) n
uC uk + produksl [ernlh 1700 cc/18
[am
W8C 133/ Pb 123/ PcL 371/ lL 233
SCC1 9603/ SC1 8173/ Alb 34/ 8un
83/ SC 066/ 8S 123/ na 141/ k 37
ACu (pk 0700 1 36 C) pP 739/ pCC2 31/
pC2 273/ 8L 32/ PCC3 188/ SaL 100
CvC 1v 300 cc 88 12 ll C2 40
LL 3
ACu (pk 1400 1 36 C) pP 738/ pCC2 32/
pC2 209/ 8L 33/ PCC3 189/ SaL 100