S (K)
No Nama Umur RM
14 Mr. X 50 21014410
Trauma 1 Infeksi
Onkologi 5 Nyeri
Behaviour 0 Epilepsi
Movement 1 Opthalmologi
Geriatri 0 Otologi
Autoimun 2 Vaskular
LAPORAN KEGIATAN JAGA RESID
22 April 2021
L/P Kamar
L Angsoka 103.6
L Angsoka 108.3
P Angsoka 306.2
P Angsoka 307.1
P Angsoka 307.4
P Angsoka 307.6
L Bakung Timur 1.1
P Mahottama 310.1
L RTI Timur 9
L RTI Timur 10
L Ratna Bawah 3B
L Ratna Bawah 4B
L Ratna Bawah 6A
P IW PJT Bed 6
L MS 203 A
P MS 203 B
L MS 206C
P MS 210A
P MS 210B
L MS 209 D
L MS 210 D
L MS 211 C
L MS 212 A
P MS 212 B
L MS 212 C
4
0
0
15
LAPORAN KEGIATAN JAGA RESIDEN
22 April 2021
SH (ICH+IVH) e.c susp ruptur mikroaneurisma (H26), post evd kocher H24 Pneumonia Aspirasi, Hiperglikemi e.c susp dru
SNH berulang ec suspek kardioemboli dd tromboemboli onset Hari ke -9, CHF FC II ec RHD
Parkinson Disease modified Hoen and Yahr grade IV, Rheumatoid arthritis dd lupus syndrome, Obs pansitopenia ec susp dr
stabil
Status epileptikus ec suspek epilepsi simptomatik ec suspek infiltrasi KNF dd tumor serebri metastase
observasi general onset motor tonic clonic ec susp acute simtomatic seizure dd epilepsi simtomatik dd epilepsi idiopatik, DM
obs.general onset motor tonic clonic ec susp acute simtomatik seizure dd epilepsi simtomatik dd epilepsi idiopatik, DM type
SNH ec susp thrombus onset H6, DM Tipe II, Hipertensi stage II susp HHD
SOL serebri ec suspek tumor serebri metastasis (primer adenocarcinoma paru) dd SOL infeksi (abses serebri), Epilepsi simto
Tetraparesis tipe LMN et causa suspek GBS tipe AIDP ( kelemahan onset H-17 , hari rawat ke 14)
DOC ec sup enselopati septik dd/metabolik (CO2 Narcose), Meningoensefalitis bakteri dd/TB, Mielopatikompresi ec fraktu
medula spinalis intradural ekstramedullar., HAP susp sepsis gagal nafas type II, DM tipe II susp Polineuropati DM susp PAD
SOL sereb ri ec susp tumor serebri metastase (primer tumor paru dekstra) dd SOL infeksi (toxo, tuberkulosis)
obs bangkitan general onset motor tonik klonik ec susp acute symptomatic seizure ec susp npsle dd epilepsi simptomatik, Su
SH serebelum + IVH ec susp ruptur mikroaneurisma onset H6 (post craniotomy evakuasi ICH H0, Hidrosefalus non komun
Hipokalemia.
Complete Stroke (SNH Batang Otak), Hipertensi grade I, Penumonia aspirasi, Hiponatremia kronik asimtomatik, Obs Hiper
Guillain-Barre Syndrome tipe AIDP varian facial diplegia and paresthesia dd GBS related Covid, HT stage II, Hipokalemia
SH (ICH) ec susp ruptur mikroaneurisma dd AVM onset H7, post kraniektomi dekompresi H5, susp HHD + CAD
Meningoensefalitis ec susp tb (grade III) dd aseptik - sepsis, tb paru tuntas pengobatan (Bed Adherence), transaminitis ec su
SOL Serebri ec susp tumor serebri primer ec susp low grade glioma dd SOL infeksi, DM tipe II, HT Stage I
DOC ec susp enselopati global hipoksik dd metabolik dd septik, SNH ec susp hipoperfusi dd trombus onset H2, NSTEMI, R
LBP Non spesifik ec susp paralumbal muscle spasme dd syndrome nyeri myofacial, polineuropati DM, UAP dd NSTEMI, D
Obs.bangkitan ec susp.acute symptomatic seizure (hiperglikemia), obs DOC ec susp. Ensefalopati septik dd metabolik (hipe
SNH berulang ec susp thromboemboli dd trombus onset H4, Hipertensi stage 2, Hponatremi akut simptomatik (112), susp.is
SNH ec suspek tromboemboli dd kardioemboli onset H5, CAP CURB 65, Hipertensi St I
Sol Serebri ec suspek tumor sererebri metastase dengan intracranial bleeding dd tumor serebri primer ec HGG, Status epilep
DOC ec susp ensefalopati septik + hipoksik iskemik + metabolik, obs syok ec suspek septik dd hipovolemik, DM tipe II, AC
Meningoensefalitis ec susp bakteri partially treated dd TB, Epilepsi simptomatik, riwayat status epileptikus, hiperglikemia e
SDH kronis bilateral, Post boorhole D et S H1, DM Tipe 2, Pneumonia, Bradikardia asimptomatik, susp. HHD
Moclonic Jerk ec susp.Metabolik (uremikum), SLE on treatment, ACKD on CKD ec susp GNC, Sindroma Nefrotik, obs.me
SNH ec susp kardioemboli dd tromboemboli onset H5,HHD, HT st II, susp CAD, iskemik anteroseptal, EF 60%, Hiponatrem
SNH ec susp.trombus dd tromboemboli onset H2, CAD, Omi Inferior, Hipertensi stage I
Sub Bagian
Infeksi
Vaskular
Vaskular
Movement
Epilepsi
Vaskular
Vaskular
Epilepsi
Epilepsi
Vaskular
Onkologi
Autoimun
Onkologi
Onkologi
Epilepsi
Vaskular
Vaskular
Autoimun
vaskular
Infeksi
Onkologi
Vaskular
Nyeri
Epilepsi
Vaskular
Vaskular
Vaskular
Onkologi
Infeksi
Infeksi
Trauma
Epilepsi
Vaskular
Vaskular
###
No Nama Usia No. RM L/P
4
14
Diagnosis
Motor Tonis seizure -->Temporalis Lobus Epilepsi suspek epilepsi simptomatik dd/bangkitan non
Susp Perinaud syndrom ec susp vaskula event berulang dd/ SOL vaskular
DOC ec enselopati global hipoksik dd/intrakranial (metastasis)
Divisi Keterangan
Infeksi
Vaskular
infeksi
Onko
No Nama
2 Mr. X
3 Ni Made Narti
84 21014416 P MS 210B
SOL serebri ec suspek tumor serebri metastasis (primer adenocarcinoma paru) dd SO
SOL sereb ri ec susp tumor serebri metastase (primer tumor paru dekstra) dd SOL inf
SOL Serebri ec susp tumor serebri primer ec susp low grade glioma dd SOL infeksi, D
Sol Serebri ec suspek tumor sererebri metastase dengan intracranial bleeding dd tumo
Onkologi
Onkologi
Onkologi
Onkologi
Onkologi
INFEKSI
1 Muhammad Fauzan Najmi 27 18046999 L
AUTOIMUN
Ratna Bawah 6A
MS 209 D
MS 210 D
Ratna Bawah 3B
Sefalgia Redflag suspek infeksi intracranial (meningoensefalitis)
Infeksi HIV stadium IV (WHO) pre HAART: CNS TB, Meningoensefalitis TB (thwaites score 0, Lancet score 12),
CKD
Meningoensefalitis ec susp tb (grade III) dd aseptik - sepsis, tb paru tuntas pengobatan (Bed Adherence), transaminit
Ringan, Hiponatremia, SH, Riw.CAD
DOC ec susp ensefalopati septik + hipoksik iskemik + metabolik, obs syok ec suspek septik dd hipovolemik, DM tip
Meningoensefalitis ec susp bakteri partially treated dd TB, Epilepsi simptomatik, riwayat status epileptikus, hipergli
Guillain-Barre Syndrome tipe AIDP varian facial diplegia and paresthesia dd GBS related Covid, HT stage II, Hipok
Infeksi
Infeksi
Infeksi
Infeksi
Infeksi
Autoimun
Autoimun