LAPORAN PASIEN RAWAT INAP

RUANG INAP NEUROLOGI RS H. ADAM MALIK

TANGGAL 17 Mei – 23 Mei 2023

NO DIAGNOSA PRIA WANITA JUMLAH

1. Stroke Iskemik 4 3 7
2 SOL Intrakranial 1 2 3
3. Tetanus Generalisata 1 - 1
4. PPH 1 - 1
5. Malignant Neoplasm of Spinal Cord 1 - 1
6. Ensefalopati Sekunder 2 - 2
7. Migrain - 1 1
Jumlah 10 6 16

PASIEN BARU

Usia /
No Nama Tgl Masuk Diagnosa DR Ket DPJP
Kelamin
1. Asran Harahap 48/LK 17-05-2023 Kejang Rangsang + Trismus NAD RA 5 GAN
+ Opistotonus + Muscle
Spasm ec Tetanus
Generalisata
2. Yunidar 52/PR 17-05-2023 Somnolen + Hemiparese NAD RA 5 GAN
Dekstra + Parese N. VII, XII
Tipe UMN Dekstra ec Brain
Metastase + Ca Paru Post
Kemoterapi + Ca Cervix
Post Kemoterapi +
Hipertensi Stage I +
Trombositopenia + Anemia
3. Kie Hoa 60/LK 19-05-2023 Tetraparese Tipe LMN ec DNY RA 4 PPS
PPH + Hiponatremia
4. Baik Br Tarigan 76/PR 19-05-2023 Apatis ec Ensefalopati DNY RA 4 PPS
Sekunder ec Electrolyte
Imbalance + Hemiparese
Dekstra ec Post Stroke
 Iskemik + HHD dengan
Hipertensi Stage II
5. Misran 57/LK 19-05-2023 Paraparese Tipe LMN ec DNY RA 4 PPS
Susp Spinal Metastase +
Polineuropathy Sensorik ec
Chemotherapy Induced
Neuropathy + Multiple
Myeloma + Hipertensi
Terkontrol
6. Tumiyah 65/PR 19-05-2023 Apatis + Hemiparese DNY SC PPS
Sinistra + Parese N. VII
Tipe UMN Dekstra ec
Stroke Iskemik Rekuren +
Susp Pneumonia + HHD
dengan Hipertensi Stage II
7. Krisman Tambun 66/LK 19-05-2023 Hemiparese Sinistra + DNY SC PPS
Parese N. VII, XII Tipe
UMN Dekstra ec Stroke
Iskemik Rekuren +
Hipertensi Stage I
8. Rinto Mala 71/LK 20-05-2023 Sopor + Parese N. VII Tipe SHU SC KHS
UMN Sinistra ec Stroke
Iskemik + Hipertensi Stage I
 PASIEN PULANG

UMUR/ TGL TGL

No NAMA JK DIAGNOSIS DR KET DPJP
MASUK KELUAR
1. Sofyan 52 / lK 09-05-2023 Parese N. III, IV, VI ODS + VIA PBJ AF
Lesi N. V Dekstra + Parese
N.VII Tipe LMN Dekstra +
Parese N. IX, X, XII Tipe
UMN Dekstra + Hemiparese
Sinistra ec Stroke
Hemoragik (Pons) +
Hipertensi Stage II
2. Guntur Silaban 58 / LK 12-05-2023 17-05-2023 Hemiparese Dupleks + ALD PBJ ALF
Parese N. VII Tipe UMN
Dekstra ec Stroke Iskemik
Rekuren + HHD dengan
Hipertensi Stage II +
Pneumonia
3. Muhammad 84 / LK 14-05-2023 18-05-2023 Cardiac Arrest + Parese N. SHU EXITUS SUS
Arifin VII Tipe UMN Sinistra +
Hemiparese Sinistra ec
Stroke Iskemik + Hipertensi
Stage II + AF
4. Ponimar Silalahi 58 / LK 14-05-2023 19-05-2023 Secondary Headache + SHU PBJ SUS
Hemiparese Dekstra ec
Toksoplasma Ensefalitis +
HIV Stadium IV + GEA
dengan Dehidrasi Ringan +
Oral Candidiasis
5. Kurnia Wahyu 45 / LK 15-05-2023 19-05-2023 Parese N. VII Tipe UMN ALD PBJ NN
Dextra + Hemiparese Dextra
ec Stroke Iskemik +
Hipertensi Stage II +
Hemofilia A + DM tipe 2
6. Sofia Br 73/PR 15-05-2023 16-05-2023 Koma ec Gagal Nafas + ALD EXITUS NN
Tampubolon Stroke Hemoragik
(SAH+IVH) + Hipertensi
Stage II
7. Yunidar PR 17-05-2023 20-05-2023 Koma + Hemiparese Dekstra NAD EXITUS GAN
+ Parese N. VII, XII Tipe
UMN Dekstra ec Brain
Metastase + Tumor Paru
Metastase + Ca Cervix Post
Kemoterapi + Hipertensi
Stage I + Anemia ec
Perdarahan dd Penyakit
Kronik + Trombositopenia
ec Consumption
Coagulapathy + PSMBA
 ,
LAPORAN PASIEN RAWAT INAP VIP
RUANG INAP NEUROLOGI RS H. ADAM MALIK
TANGGAL 17 Mei – 23 Mei 2023

JUMLAH PASIEN
NO DIAGNOSA PRIA WANITA JUMLAH
1. SOL Intrakranial - 1 1
2. Meningitis TB - 1 1
Jumlah - 2 2

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

1. Ponikem 74/PR 20-05-2023 Focal to Bilateral Tonic SHU RA 6 KHS

Clonic Seizure + Secondary
Headache + Hemiparese
Sinistra ec Susp. Brain
Metastase + Hipertensi Stage
II + Susp. Ca Cerviks + Susp.
CA Recti
2. Yayuk 32/PR 20-05-2023 Apatis + Secondary NAD ICU IGD GAN
Headache ec Susp.
Meningitis TB dd Viral +
Susp Pneumonia dd TB Paru
+ Hiponatremi

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 17 Mei – 23 Mei 2023

No Nama Umur JK Diagnosis DPJP DR KET

1. Selamat 60 LK Hemiparese Dekstra ec Post GAN SHU RA 6
Stroke + Hemoptisis Sedang
ec Tumor Paru Kanan
T3NxMx Stage IIB ECOG1
+ Pneumonia Komunitas dd/
Susp. TB Paru Relaps +
PPOK Stabil Grup E
2. Pamuncak 70 LK Apatis ec Ensefalopati KRT JUN RA 2 ISO
Chaniago Sekunder ec Sepsis ec
COVID 19 Terkonfirmasi
Derajat Berat + Pneumonia
Komunitas + DM Tipe 2
3. Lysa Afriani 42 PR Hemiparese Dextra ec Brain KRT JUN Pavi Lt 7
Metastase (On Radioterapi
Whole Brain ke 6) +
Adenokarsinoma Paru
Kanan T4N2M1a (Pleura)
Stage IV A ECOG1 Post
Kemoterapi Siklus 6 dengan
Regimen Karboplatin dan
Paklitaksel + High Risk
Thrombosis
4. Yogi Arisandi 26 LK Apatis ec Elektrolit PPS DNY RA 4
Imbalance + HIV Stadium
III + PCP dd TB Paru dd
Pneumonia Bakterialis +
Pansitopenia ec Viral
Infection + Hiponatremia ec
 Low Intake
5. Erwin Ritonga 65 LK Parese N. IX, X, XII Tipe PPS DNY RA 5
UMN Dekstra ec Susp.
Brain Metastase + SVKS +
Tumor Paru Kanan
T4NxMib (Pleura,Hepar)
Stage IVA ECOG2 + PPOK
Eksaserbasi Berat Tanpa
Gagal Napas Dalam PPOK
Stabil Grup E + High Risk
Thrombosis +
Hipoalbuminemia
6. Herlina Dewi 56 PR Migrain Without Aura + PPS DNY RA 6
Harahap Anemia Aplastik +
Pneumonia CAP dd HAP +
Dyspepsia Organik dd
Fungsional
7. Mulyadi 48 LK Hemiparese Sinistra ec KHS SHU RA 4
Stroke Iskemik + Susp.
HNP + Trombositosis
Reaktif dd Esensial +
Anemia Hipokrom
Mikrositer ec Defisiensi
Besi dd Penyakit Kronis
8. Evawani 52 PR Hemiparese Dekstra + KHS SHU RB 6
maratlena Parese N. XII tipe UMN
silitonga Dekstra ec Post Stroke
Iskemik + DM tipe 2 + Soft
Tissue Tumor o/t Wall
Abdominal + Kista Ovarium