Ward Report

Thursday, July 13th 2016

D. Patient Move To Other Hospital : (-)

E. Patient Died : (1)
1. Arifin bin Nitikarto /Male/60 years old/days care 5th
Diagnosis : gastricperforation prepyloric + post laparotomy H 5 + Anemia +perifer
cianosis due to suspected adrenal support + hipoalbuminemia
COD : MOF
F. Patient Treated In ICU : (7)
1. BurdanBin CikSamat/Male/31 years old/days care 18th
S: -
O: A: Tracheostomy + SIMV PEEP 6 FiO2 50%
B: RR:18 x/minute SpO2: 100%
C: BP: 118/70 mmHg HR: 108 x/minute
D: GCS: E4MxVT Pupil isochor, ligth reflex +/+

Lab 13/07/2016
Cervical Region: Hb : 11,3
Leuko : 7.700
I: Collar brace (+), Tracheostomy (+) Ht : 34
Plt : 74000
Na : 135
Fluid Balance : K : 3.3
Ur : 28
I : 2035 cc Cr : 0,09
pH : 7,480
O : 1560 cc pCO2 : 60,1
pO2 : 133,8
IWL : 600 cc HCO3 : 45,1
Total : -125 cc/24 hours

A: Spinal cord injury frankle A due to vertebrae C4-C5 dislocation post posterior
stabilization H-18 + Post tracheostomy H-8

P: -IVFD RL gtt xx/minute

- Inj.Meropenem 1 gr/8 hours
- Inj. Paracetamol 1 gr/6 hours
- Inj. Omeprazole 40 mg/24 hours
- N-acetilcystein 200 mg/8 hours
 - Levofloxacin 75 mg/24 hours
- Mecobalamin 1gr/24 hours
- Heparin 2x5000 iu

2. HendraCahyadi/ Male/14 years old/days care 13th

S: -
O: A: O2 10L/m NRM
B: RR: 22 x/m SpO2: 100%
C: TD: 125/69 mmHg HR: 81 x/m
D: GCS: E2M5V1: 8 Pupil isochor, ligth reflex +/+

Lab 13/07/2016
CraniumRegio Hb : 11.5
Leuko : 8.800
I: dry gauze Ht : 35
Plt : 1.017.000
BSS : 103
Ur : 32
Fluid Balance : Cre : 0.5
Na : 137
I : 1840 cc K : 4.5
O : 1870 cc pH : 7.512
pCO2 : 41.6
IWL : 504 cc pO2 : 244,5
HCO3 : 33,7
Total :-534 cc/24hours

A: severe head injury GCS 7T + ICH left frontal lobe post decompretion craniotomy+
duroplasty H-13 + cerebral contution + cerebral edema + fraktur of left orbita

P: - IVFD NaCL0,9% gtt xx/minutes

- Inj.Meropenem 1 gr/8 hours
- Inj. Omeprazole 40 mg/24 hours
- Inj. Paracetamol 1 gr/6 hours
- Inj. Citicoline 500 mg/8 hours
- Inj N Acetyl cistein 200mg/8hours

3. Oki Alexander/Male/17 years old/days care 10th

S: -
O: A: ETT + CPAP PEEP 5 FiO2 40%
B: RR: 26 x/m inutes SpO2: 100%
 C: TD: 124/73mmHg HR: 91 x/minhutes
D: GCS: DPO Pupil isochor, ligth reflex +/+

CraniumRegio
I: dry gauze

Fluid Balance :
I : 2061 cc
O :1660 cc
IWL :504 cc
Total : -103 cc/24hours

A: open severe head injury GCS 6T + right ICH frontotemporal post decompretion
craniektomy + duraplasty H-9 Lab 13/07/2016
Hb : 10,2
Leuko : 18.900
P: - IVFDNaCl 0.9%gtt xx/minutes Plt :705.000
GDS :98
- inj. Paracetamol 1 gr/8hours Ur : 35
Cr : 0.43
- Bisolvon4 mg/ 8hours Na : 139
K : 4,0
- -asetilsistein 200mg/8 hours pH : 7.510
pCO2 : 38,4
- Inj. Forcef 1 gr/8 hours pO2 : 120,6
- Precedex 0,2-0,7 µg/kgBB hours HCO3 : 30,9

- Metoclorpamide, 3x10mg
- New diatab 2 tab

4. martin Akbar/Male/17 years old/days care 1st

S: -
O: A: ETT + SIMV PEEP 5 FiO2 40%
B: RR: 16 x/minutes SpO2: 99%
C: TD: 140/92 mmHg HR: 94 x/minutes
D: GCS: DPO Pupil isochor, ligth reflex +/+
 Fluid Balance :
I : 398 cc
O : 1430 cc
IWL : 315 cc
Total :-1347 cc/24hours

A: severe head injury GCS 4T + depresif frakture of left temporal + cerebral edema
P: - IVFDRL:D51:1gtt xxx/minutes
- Inj. Meropenem 1 gr/8 hours
- Inj. Cefriaxon 1 gr/12 hours
- Inj. Omeprazole 40 mg/24 hours
- Manitol 125 ml/ 6 hours
- Inj. Neurobion 5000 iu/ 24 hours
- Precedex 0,2 mcg/kgBB/hour

5. Roni Agustinus/Male/16 years old/days care 8th

S: -
O: A: O2 10L/minutes NRM
B: RR: 20 x/minutes
C: TD: 139/94 mmHg
D: GCS: E3M5V2
SpO2: 100%
HR: 81 x/minutes
Pupil isochor, ligth reflex +/+

Temporoparietal Region Sinistra:

I: Hematome (+) Lab 13/07/2016
Hb : 12,9
Leuko : 12.600
Plt : 264.000
PeriorbitalRegion Dextra: BSS : 141
Na : 136
I: Hematome (+) K : 4.1
Ur : 28
Cre : 0.63
Fluid Balance :
I : 1980 cc
O : 1530 cc
IWL : 525 cc
Total : -75 cc/24hours
 A: closed severe head injury GCS 5T + EDH retro-orbita lobe+ cerebral edema

P: - IVFDRLgtt xx/minutes
- Inj. Ceftriaxone 1 gr/12 hours
- Inj. Paracetamol 1 gr/8hours
- Inj. Omeprazole 40 mg/24hours
- Inj. Citicolin 500mg/12hours
- Inj. Bisolvon 1 amp/8 hours
- Inf. Dexmetomidine 0,2 µg/kgBB/hours

6. Darul ihsan/Male/17 years old/days care 1st

S: -
O: A: ETT + SIMV PEEP 5 FiO2 40%
B: RR: 18 x/minutes
C: TD: 110/84 mmHg
D: GCS: E4M6V5
SpO2: 100%
HR: 75 x/minutes
Pupil anisochor, left>right, ligth reflex +/+

Fluid Balance :
I : 642 cc
O : 459 cc
IWL : 168 cc
Total : -15 cc/24hours

A: closed severe head injuryGCS 5T + left EDH occipitallobe + cerebral edema + right
closed tibia Frakture 1/3 proksimal transverse displaced

Lab 13/07/2016
P: - IVFDRinger Fundin, gtt xx/minutes Hb : 8,3
Leuko : 16.500
- Inj. Ceftriaxone 2 gr/24hours Plt : 177.000
Ur : 45
- Inj. Paracetamol 1 gr/8hours Cr : 0,53
Na : 136
- Inj. Omeprazole 40 mg/24 hours
K : 4.1
- Manitol 125 ml/ 6 hours pH : 7,485
PCO2 : 34,2
- Inj. Paracetamol 1g/ 6 hours PO2 : 508,7
HCO3 : 26,4
G. Patient treated in PICU: (-)
H. Patient treated in NICU: (1)

1. Baby Rafanda Athalla/Male/8 days old/days care 5th

S: -
O: A: Nasotracheal tube + SIMV PEEP 5 FiO2 50%
B: RR: 50 x/minutes SpO2: 99%
C: HR: 135 x/minutes
D: hipoaktif Pupil isochor, ligth reflex +/+

AbdomenRegion:
9/7/2016
I :flat, ileostomy (+) viabel Hb : 10.9
P :Limp WBC : 28900
Ht : 31
P :Tympani PLT : 221.000
DC : 0//0/68/24/8
A :Bowel (+)

Fluid Balance :
I : 475 cc
O : 315 cc
IWL : 48 cc
Total : 112 cc/24hours

A: Atresia jejuno-ileal Type IIIB post laparotomy + ileostomy H-5

P: - IVFD D10 1/5 NS Kecepatan 14 cc/hours

- Inj.Ampicilin 70mg/8 hours
- Inj. Ceftazidime 135mg/8 hours
- Inj. Metronidazole 70 mg/12hours
- Inf Aminofusin 4.7 cc/hours