LAPORAN PASIEN RAWAT INAP

RUANG INAP NEUROLOGI RS H. ADAM MALIK

TANGGAL 2 Mei – 8 Mei 2023

NO DIAGNOSA PRIA WANITA JUMLAH

1. Stroke Iskemik 1 3 4
2. Spasmofilia - 1 1
3. SOL Intrakranial 1 1 2
4. Ensefalopati Sekunder 1 - 1
Jumlah 3 5 8

PASIEN BARU

Usia /
No Nama Tgl Masuk Diagnosa DR Ket DPJP
Kelamin
1. Nur Aisyah 47/PR 05-05-2023 Chronic Vestibular SUS RA 2 SHU
Syndrome ec Vertigo
Sentral ec SOL o/t
Cerebellum
2. Endang Suryani 26/ PR 05-05-2023 Spasme Karpopedal ec SUS RA 2 SHU
Spasmofilia (Hipocalcemia,
Hipomagnesemia)
3. Elpinaria Saragih 54/ PR 06-05-2023 Hemihipestesi Dekstra + GAN SC 3 NAD
Hemiparese Dekstra +
Parese N. VII Tipe UMN
Dekstra ec Stroke Iskemik +
Dislipidemia + Bronkitis
Akut
4. Khairul Ikhsan 49/ LK 07-05-2023 Apatis ec Susp Stroke KRT RITN JUN
Iskemik Rekuren dd
Hemoragik + Covid 19
Terkonfirmasi Derajat Kritis
5. Epril Harianto 42/LK 08-05-2023 Apatis ec Ensefalopati PPS RA 2 DNY
Sekunder ec HIE dd Sepsis
+ Pneumonia Komuniti dd
Viral + Kista Arachnoid
 PASIEN PULANG

UMUR/ TGL TGL

No NAMA JK DIAGNOSIS DR KET DPJP
MASUK KELUAR
1. Nuraini Tgk H 65/PR 03-05-2023 Hemiparese Sinistra + Parese NAD PBJ CAB
M Yusuf NVII. XII tipe UMN Sinistra
ec Stroke Iskemik + HHD +
DM tipe 2 + Pneumonia
Komuniti
2. Linda 59/PR 05-05-2023 Acute Vestibular Syndrome ec SHU PBJ SUS
Nainggolan Stroke Iskemik Rekuren +
HHD dengan Hipertensi Stage
II + Edema Paru
3. Rusdi Saragih 43/LK 05-05-2023 Secondary Headache + Parese SHU PBJ SUS
N. VI OD ec SOL Intrakranial
+ NPC + Hiponatremia
4. Nur Aisyah 47/PR 05-05-2023 Chronic Vestibular Syndrome SUS PBJ SUS
ec Vertigo Sentral ec SOL o/t
Cerebellum
 ,
LAPORAN PASIEN RAWAT INAP VIP
RUANG INAP NEUROLOGI RS H. ADAM MALIK
TANGGAL 2 – 8 Mei 2023

JUMLAH PASIEN
NO DIAGNOSA PRIA WANITA JUMLAH
1. Stroke Iskemik 3 - 3
2. SOL Intrakranial 1 3 4
3. Toxoplasma Ensefalitis - 1 1
4. SOL Medula Spinalis 1 - 1
5. Non Epileptic Seizure - 1 1
6. Epilepsi Idiopatik 1 - 1
7. Meningitis TB 3 - 3
8. Benign Paroxysmal Positional Vertigo - 1 1
9. Ensefalopati Sekunder - 2 2
Jumlah 9 8 17

PASIEN BARU
UMUR/ TGL
No NAMA DIAGNOSIS DR KET DPJP
KELAMIN MASUK

1. Yunidar 52/ PR 04–05-2023 Secondary Headache + ALD RA 6 NN

Chronic Vestibular Syndrome
+ Parese N. VII, XII Tipe
UMN Dekstra ec Brain
Metastase + Ca Cervix Post
Kemoterapi + Ca Paru
Metastase + Hipertensi
Terkontrol
 PASIEN PULANG

UMUR/ TGL TGL

No NAMA DIAGNOSIS DR KET DPJP
JK MASUK KELUAR
 LAPORAN PASIEN RAWAT BERSAMA
RUANG INAP NEUROLOGI RS H. ADAM MALIK
TANGGAL 2 - 8 Mei 2023

No Nama Umur JK Diagnosis DPJP DR KET

1. Lysa Afriani 42 PR Secondary Headache + FII HLM Pavi Lt 7
Hemiparese Dekstra ec
Brain Metastase +
Adenokarsinoma Paru
Kanan T4N2M1a (pleura)
Stage IVA ECOG1 Post
Kemoterapi Siklus 6
2. Eben Ezer 65 LK Paraparese Tipe LMN + FII HLM RB 6
Hipestesi Setentang L1-L2 +
Incontinensia Urin et Alvi
ec Susp. Spinal Metastase +
mCRPC cT2cNxM1b GS
(5+4) + Contracted Ginjal
(R)
3. Ahmad Hidayat 58 LK Apatis + Hemiparese FII HLM RITN - 03
Nasution Dekstra ec Susp. Meningitis
TB dd Bakterial +
Pneumonia ec Klebsiella
Pneumonia et Candida
Tropicalis + TB Paru Kasus
Baru + CKD G5D ec HN +
PSMBA ec Gastritis Erosiva
dd Stress Ulcer + Hipertensi
Terkontrol + Anemia
Normokrom Normositer ec
Penyakit Kronik +
Hiperkalemia + Fistula Ani
dd Fissura Ani +
 Hipoglikemia ec Low Intake
4. Nursinta 65 PR Generelized Onset Motor FII HLM CVCU
situmorang Tonic Seizure ec Non –
Epileptic Seizure + On TPM
a/i Bradikardia Simptomatis
ec TAVB + HHD dengan
Hipertensi Stage I
5. Syafruddin LK 58 Post Stroke Iskemik + DM FII HLM CVCU
Nasution Tipe 2 + Post Primary PCI 1
Stent DES di LAD a/i
STEMI Anteroseptal Onset
40 Jam Killip I TIMI Risk
5/14
6. Ritayani PR 31 Generalize Onset Tonic NN ALD RA 3
Clonic Seizure +
Hemiparese Sinistra +
Parese N. VII Tipe UMN
Sinistra ec Toksoplasmosis
Ensefalitis + HIV Stadium
IV + Oral Candidiasis
7. Jhonson Siregar LK 63 Somnolen + Hemiparese SUS SHU RB 6
Dekstra ec Brain Metasetase
+ Ca Prostat (mCRPC)
T1cNxM1c (Tulang,Otak)
GS (4+4) Post SOB +
Docetaxel Kemoterapi 6
Siklus Abiaterone
8. Baginda Iqbal LK 19 Generelized Onset Tonic SUS SHU RA 4
Guntur Harahap Seizure ec Epilepsi Idiopatik
+ Leukemia Limfoblastik
Akut
9. Ngawang LK 83 Hemiparese Sinistra ec GAN NAD Pavi Lt 7
Sinulingga Stroke Iskemik + HHD
 dengan Hipertensi Stage II +
Pneumonia Geriatri + PPOK
+ AKI dd CKD + Alkalosis
Respiratorik
10. Pahri Amri LK 37 Sopor + Generalized Onset GAN NAD IGD
Motor Tonic Seizure ec
Susp. Meningitis TB dd
Bakterial + TB Milier On
OAT + HIV stadium IV +
Oral Candidiasis + Susp.
PCP + AKI stage 1 dd CKD
+ Anemia ec Penyakit
Kronis
11. Oksin Candra LK 29 Apatis + Generelized Onset KRT JUN RB 1
Motor Tonic Clonic Seizure
ec Susp. Meningitis TB dd
Bakterial + Sepsis ec CAP +
TB Paru Kasus Baru Dalam
Pengobatan OAT Fase
Intesif
12. Yunita Zamrah PR 52 Low Back Pain ec PPS DNY RA3
Spondylosis Lumbalis +
Abdominal Pain ec Kolik
Abdomen + Dyspepsia
Fungsional dd Organik +
Kolelithiasis dd Kolesistitis
+ Nodul Hepar
13. Yuna Syaroh PR 53 Episodic Triggerred PPS DNY RA3
Vestibular Symptoms ec
BPPV + Sepsis ec
Pneumonia Komunitas +
CKDG5D (rabu-sabtu) +
Anemia ec Penyakit Kronis
 + Hipertensi Stage II
14. Nurhayati PR 54 Sopor ec Encepalopati PPS DNY RITN
Harianja Sekunder ec Sepsis ec
Urosepsis + Pneumonia
CAP dd TB Paru + AKI dd
CKD + DM Tipe 2 +
Anemia ec Penyakit Kronis
dd Perdarahan
15. Zul Saad LK 46 Hemiparese Dekstra ec Post PPS DNY CVCU
Stroke Iskemik + Heart
Failure + Post ICD
Implentetion + AKI dd
CKD
16. Karolina Br PR 64 Apatis ec Ensefalopati PPS DNY CVCU
Gurusinga Sekunder ec Susp. HIE +
Post TPM a/i Bradikardia
Simptomatis + CAD post
PCI 2 Stent di RCA a/i
CAD3VD + AKI dd CKD +
Anemia ec Penyakit Kronis
+ Susp. Pneumonia + DM
tipe II