MAPPING BEDAH SARAF

Kamis, 26 JANUARI 2017

TOTAL: 19 PASIEN

Ruangan
Jeumpa 2
Jeumpa 3
Jeumpa 4
NABAWI 1
NABAWI 2
HCU
IGD
PJT

Dr. ISKANDAR, Sp.BS

1 pasien
1 pasien

Dr. BUSTAMI, Sp.BS

2 pasien
1 Pasien
1 Pasien
1 pasien
1 pasien
-

PICU
ICU D
ICUC
JUMLAH

1 Pasien
1 pasien
4 PASIEN

2 pasien
8 PASIEN

Dr. IMAM H, Sp.BS

2 pasien
1 Pasien
1 pasien
1 pasien
2 pasien
7 PASIEN

TOTAL
4 pasien
2 pasien
1 pasien
2 pasien
2 pasien
1 pasien
1 Pasien
1 pasien
1 Pasien
1 pasien
2 pasien
19 PASIEN

JEUMPA 2 TOTAL : 3 PASIEN

Kamar
K4B3

IdentitasPasien
Farid assyraf, 8 bulan, Lk
1088671

DPJP : dr.
1.

Bustami, Sp.
BS

Tgl masuk: 19/01/2017

AD 5
Tgl OP 21/1/2017
POD 4

K4B4
2.

DPJP : dr.
IMAM
HIDAYAT,
Sp. BS

K5B3
DPJP: dr.
BUSTAMI,
Sp.BS

Zahratul Syifa, 2 bulan, Pr

1106860
Tgl masuk: 16/1/2017
AD 7
Tgl OP 17/1/2017
POD 8
Khairul azmi, 6 tahun, LK
1116416
Tgl masuk: 20/01/2017
AD 3
Tgl Op: 20/1/2017
POD 6

LAB
Lab 23/1/2017
Hb/Ht/Er/Leu/Tro
8,3/25/3,8/27,5/462
Diftell: 1/0/0/46/47/6
Na/K/Cl
141/5,5/107
Ur/cr
5/0,10
Lab 16/1/2017
Hb/Ht/Er/Leu/Tro
10,5/32/4,2/26,9/562
Diftell : 0/0/1/75/20/4
Ct/bt: 2/8
Ur/Cr: 24/0,50

Lab 20/1/2017
Hb/Ht/Er/Leu/Tro
10,5/32/4,0/39,1/433
Diftell : 0/0/1/87/5/7
Ct/bt: 2/7
Ur/Cr: 34/0,50

Diagnosa
Malfungsi shunt ec hidrocefalus non
komunikan

Post Vp shunt ec meningoenchefalocel

Elevasi Fraktur depress + Orif

Treatment

Planning
-

Aff cateter
Pasang NGT

-inj.ceftriaxone 2 gr/hari
-inj.ranitidin 1 amp/12 jam
-diet 6x100cc

Rawat luka
Observasi
USG Abdomen Senin
Konsul anak
Konsul anestesi (-)

-iv. Ceftriaxone
- univit syr 2xcth 1
-

Observasi gcs
Rawat luka
GV hari ke 3

-IVFD RL 20 gtt/i

K6B2
DPJP; dr.
Imam
Hidayat , Sp.
BS

Alfi syahri, LK, 9 thn

111.69.20
Tgl op; 25-01-2017
POD 1

Lab 24/1/2017
Hb/Ht/Er/Leu/Tro
11,3/34/4,4/11,5/367
Diftell : 0/1/0/76/16/7
Ct/bt: 2/7
Na/Kk/cl; 143/4,3/107
GDS; 109
Ur/Cr: 25/0,50

EDH a/r pariento occipital S + fr. Linear

a/r pariental S

IVFD Nacl 0,9 % 20 gtt/i

iv. ceftriaxone 1gr/12j
iv. novalgin 50mg/8j
iv. ranitidine amp/12j

Evaluasi tanda perdarahan

JEUMPA 3 TOTAL : 2 PASIEN

NO

Kamar

IdentitasPasien

K4b2

Nurlina, 38th, Pr
1116135

DPJP : dr.
IMAM
HIDAYAT,
Sp. BS
2

Diagnosa
Miningioma ar Frontal

Lab 18/1/2017
Hb/Ht/Er/Leu/Tro
16,4/45/5,3/12,4/335
Diftell : 0/0/0/84/7/0
Ur/Cr: 58/0,70
Na/K/Cl
131/3,9/94

Stroke hemorage (ICH thalamus S +

IVH) + hidrocefalus non comunikan+
post Vp Shunt

Treatment
-

GCS

Planning
Operasi elektif
Konsul anestesi (+)
Hasil ct scan kepala
(+)

IVFD RL 20 gtt/i
Inj. Ranitidin I amp/8jam
Inj. Ketorolac 1 amp/8jam

Tgl masuk: 18/1/2017

AD 8

K5B1

DPJP :
BUSTAMI,
Sp. BS

LAB
Lab 5/1/2017
Hb/Ht/Er/Leu/Tro
13,3/37,8/46,6/11,7/322
Diftell : 1/1/0/80/11/7

Trimo, 76th, Lk
1116254

Tgl Op : 19/1/17
POD 6

GCS
E2M3Vx

IVFD RL 20 gtt/menit
Inj. Cefixime 1gr/12jam
Inj.omeprazol 40mg/12 jam
Amlodipin 1x 10 mg
Valsartan 1x 10mg
Diet sonde 6x200cc

- Observasi GCS
- Aff NGT
- Konsul fisioterapi

JEUMPA 4 TOTAL: 1 PASIEN

NO

Kamar

IdentitasPasien

K5B1

Safrizal, 25th, LK
1116418

DPJP: dr.
BUSTAMI,
Sp.BS

Tgl masuk: 20/01/2017

AD 5

1.

Tgl op: 21/01/2017

POD 4

LAB
Lab 20/1/2017
Hb/Ht/Er/Leu/Tro
15,4/5,31/43,5/12,9/257
ct/bt: 2/10
GDS: 106
Ur/cr: 21/0,9

Diagnosa
CKR+EDH ar temporoparietal Sin + fr.
Linear ar temporal

Treatment
-neurodex 2x1 tab
- sucralfack syr 3xcth 1

Planning
Rawat luka
Mobilisasi

HCU TOTAL: 1 PASIEN

NO

Kamar
B6

1.

DPJP: dr.
ISKANDAR,
Sp. BS

IdentitasPasien
Ridwan Arifin, lk, 51 tahun
Tgl Masuk: 13/1/2017
AD 2
Tg; Op: 13/1/2017
POD 12

LAB
Lab 13/1/2017
Hb/Ht/Er/Leu/Tro
16,4/48/5,6/15,2/233
Diftell: 0/0/0/93/3/4
Ct/bt: 2/8
Na/K/Cl
144/3,2/105
GDS: 127
Ur/cr: 19/0,90
Na/K/Cl/Ca/Mg
144/3,5/112/7,6/1,5

Diagnosa

Treatment

Post Craniectomy evakuasi

ICH+Hipertensi

GCS : E4M4Vx

Planning

Inj.ceftriaxon 1 gr/12 jam

Inj.ranitidin 1amp/12 jam
Inj.keterolak 1 amp/8 jam
Phenytoin 3x1 tab
Diet sonde 6x200cc

Observasi GCS
Rawat luka
Rawat
traceostmi

NABAWI 1 TOTAL : 2 PASIEN

Kamar

IdentitasPasien

LAB

Diagnosa

Treatment

Planning

1.

KB

Amiruddin, LK, 51thn

Penurunan kesadaran ec stroke iskemik

+ post vp shunt dgn malfungsi shunt

DPJP: dr.
Imam
Hidayat, Sp.
BS
2

K2B5
DPJP: dr.
Bustami,
Sp.BS

M. Rehan, Lk, 7 thn

1116635
Tgl op : 23/01/2017
POD 2

Lab 22/1/2017
Hb/Ht/Er/Leu/Tro
9,9/30/3,6/15,9/380
Diftell: 0/0/0/81/12/7
Ct/bt : 2/7
Na/K/Cl ; 138/4,8/107
GDS; 64
Kr ; 0,30

CKR + open fr. Depress frontal D +

leakage LCS

RL 20 gtt/i
Iv. Ceftriaxone 750 mg/8 j
Iv. Novalgin amp/ 8j
Iv. Ranitidine amp/ 12j
Head up 30%

Rawat luka
Kamis GV

NABAWI 2 TOTAL : 2 PASIEN

Kamar
1

K3B4

DPJP : dr.
IMAM
HIDAYAT,
Sp. BS

IdentitasPasien
Hasyem Rusli, Lk, 38 thn
1114601
Tgl masuk: 04/01/2017
AD 20

DPJP: dr.
BUSTAMI,
Sp.BS

Lab 4/1/2017
Hb/Ht/Er/Leu/Tro
14,4/42/5,0/13,7/286
Diftell : 0/1/0/75/17/7
Ct/bt: 2/7

Diagnosa
Post removal tumor a.i Cephalgia ec
SOL Intracranial

Treatment
-

Planning

Vestigo 2x1
Coditam 3x1
Ranitidin 3x1
Duragesic path 25 mg

Observasi gcs
Rawat luka
GV hari ke 3
Alih rawat neuro
CT angiografi (rabu)

- sesuai TS intensive
-inj.ceftriaxone 2 gr/hari
-inj.ranitidin 1 amp/12 jam
-inj.ketorolac 30mg/8jam
-diet 6x100cc

Rencana craniotomy
elevasi fr.depres
elektif
Konsil anestesi (+)

Tgl Op: 12/1/2017

POD 13

K6B5
2

LAB

Rustam, 24th , Lk
1116403
Tgl masuk: 19/1/2017
AD 6

Lab 19/1/2017
Hb/Ht/Er/Leu/Tro
14,5/41/4,8/10,0/246
Diftell : 2/0/0/73/18/7
Ct/Bt: 2/7
Na/K/Cl
143/3,6/121
Ur/cr: 20/0,80

Close fr.depres ar frontal Sin

PJT TOTAL: 1 PASIEN

NO

Kamar
K7B1

1.

DPJP : dr.
ISKANDAR,
Sp.BS

IdentitasPasien
Marlina abdullah, PR, 43 tahun
Tgl masuk: 17/01/2017
AD 6
Tgl op:
POD

LAB
Lab
Hb/Ht/Er/Leu/Tro
12,3/36/4,2/6,4/226
diftell: 1/0/0/70/24/5
ct/bt: 2/7
albumin: 4,37
Na/K/Cl
147/3,8/109
GDS: 224
Ur/cr: 32/0,80

Diagnosa
Meningioma

Treatment
-

Diet MB
PCT 3x1 tab
Ranitidine 2x1 tab

Planning
Persiapan operasi
Konsul kardio (+)
MRI

IGD TOTAL: 2 PASIEN

NO

Kamar

IdentitasPasien

LAB

Diagnosa

Treatment

Planning

F
IGD

Nurlela, PR, 44thn

111.69.18

DPJP: dr. Imam

hidayat Sp. BS

Tgl op: 25/1/17

POD 1

IGD

Safrizal, LK, 24thn

111.69.44

DPJP: dr. Imam

hidayat Sp. BS

Tgl masuk; 25/1/17

AD 1

1.

Tgl op: 25/1/17

POD 1

Lab 24/1/2017
Hb/Ht/Er/Leu/Tro
14,1/44/5,6/17,1/315
Diftell: 0/0/0/80/14/6
Ct/bt; 2/7
Na/K/Cl : 154/3,0/111
Ur/cr : 56/1,60
GDS : 139

ICH + IVH + hidrocephalus ec stroke

hemoragik

Lab 25/1/2017
Hb/Ht/Er/Leu/Tro
12,5/38/4,5/22,1/236
Diftell: 0/0/0/89/4/7
Ct/bt; 2/8
Na/K/Cl : 141/4,2/106
Ur/cr : 30/0,70
GDS : 184

SDH a/r tempero pariental S

F
IVFD Nacl 0,9% 20 gtt/i
iv. ceftriaxone 1gr/12j
iv. ketorolac 30mg/8j
iv. ranitidine 50mg/12j
F

ICU D TOTAL : 1 PASIEN

Kamar

B4
1.

IdentitasPasien

Nazariah, 41th, Pr
1077544

DPJP : dr.
ISKANDAR,
Sp. BS

Tgl masuk: 15/01/2017

POD 10

LAB
Lab 14/1/2017
Hb/Ht/Er/Leu/Tro
14,5/42/5,3/14,9/241
Diftell: 2/1/0/69/16/12
Na/K/Cl
12/4,8/96
Ur/cr
42/0,70

Diagnosa

Treatment

SOL intracranial + Hidrocefalus non

comunican + post op Vp Shunt

Planning
-

-IVFD RL 20 gtt/i
-inj. Ondansetron 1 amp/ 8jam
-inj. Ranitidin 1 amp/ 8jam
-inj. Tramadol 1 amp/ 8jam
-drip PCT 1gr/ 12jam

Observasi
Konsul kardio (+)
Konsul anestesi (+)

PICU TOTAL : 1PASIEN

NO
1.

Kamar

IdentitasPasien

Bed 4

M. Farid Arsyad, 4 bulan

DPJP: dr.
ISKANDAR
, Sp. BS

Tgl op: 12/01/2017

POD 13

LAB
Lab 20/1/2017
Hb/Ht/Er/Leu/Tro
11,6/38/4,8/10,6/350
Diftell: 4/1/0/40/46/9
Pt/aptt: 9,9/42,7
d-dimer: 739,38
Na/K/ClCa
131/5,2/98/8,9

Diagnosa
SDH kronik + infark serebri
Post burhoel drainase

Treatment
-

Inj.novalgin 50 mg/8 jam

Lanjut terapi sesuai SP.A

Planning
Observasi
Rawat luka

GCS : E3M4Vx

ICUC TOTAL : 2 PASIEN

NO
1

Kamar

IdentitasPasien

Bed 1

Moh. amin, lk, 63 thn

1116582

DPJP :
BUSTAMI,
Sp. BS

Tgl OP 22/1/2017
POD 3

Bed 2

Fakhriah, 47th, pr
1116294

DPJP :
BUSTAMI,
Sp. BS

Tgl OP 20/1/2017
POD 5

LAB

Diagnosa

Treatment

Planning

IVFD 20 gtt/i
Inj. Ceftriaxone 2 gr/24 jam
Inj. Novalgin 1 amp/8 jam
Inj. Ranitidine 1 amp/8 jam
Phenitoin 1 amp/8 jam
Diet sonde 6x100 cc

Stroke Hemorage (ICH basal ganglia

Sin.) + craniectomi evakuasi ICH

GCS : E1M1Vx

IVFD 20 gtt/i
Inj. Ceftriaxone 100 mg/12
jam
Omeprazole 1 amp /8jam
Sucralfack syr 3xcth 1
Pyracetam 1gr /8jam
Phenitoin amp /8jam
Diet sonde

Lab 22/1/2017
Hb/Ht/Er/Leu/Tro
15,6/46/5,7/20,9/244
Diftell:0/0/1/80/11/8
Pt/apt : 10,6/35,4
Na/K/Cl ; 146/2,9/113
Ur ; 40
Albumin ; 3,52

Stroke hemoragik (ICH +IVH) +

Hydrocephalus non communicant

Lab 22/1/2017
Hb/Ht/Er/Leu/Tro
8,7/32/3,9/12,2/152/
Diftell:0/0/1/80/11/8
Ct/bt: 2/8
Na/K/Cl
154/4,0/129
Ur/cr: 37/1,00

GCS : E1M3Vx

Rawat
luka
GV(+)
Observasi
AFF drain