KORAN BEDAH SARAF RABU, 1 OKTOBER 2014

Bed 1
Samintang
01/7/58
681843
MRS : 23/09/2014

DW

BED 2
Vicky
21/6/1999
678975
MRS: 5/9/14

NS

BED 3
Salma Aulia
17/10/13
678549
MRS: 2/9/14

WA

BED 4
Irawati
7/6/1971
678103
MRS: 29/8/14

NS

BED 5
Bahar
681338
01/07/1970
MRS : 20/9/2014
BED 6
Jufri
681217
01-10-1999

WA

LONTARA 3 BEDAHSARAF (KAMAR HCU)

S:Aff drain
O : ku : BAIK/gcs 15
IVFD RL 20 tpm
A:
Ceftriaxone 1gr/12 j/iv
intracerebralhemorage
Ranitidine 50mg/8j/iv
post op craniectomy
Ketorolac 30mg/8j/iv
Awasi KU
S: O: KU: sedang
Pupil isokor 3.0/3.0
RCL +/+
A: POH 11 Craniotomy,
ICH Temporoparietal
Dextra, TCS GCS 10
Afasia
S: kel (-)
O: KU: Sedang/CM
Pupil isokhor
Drain (+) Pus
A: POH 14 External
Drainase ec.
Hidrocephalus +
Empiema
S: Kes.menurun
O: KU: Lemah
GCS 7x (E2M5Vx)
Pupil anisokor 3.0/2.5
RCL +/+
A: POH XIX
Craniotomy e.c SDH
Temporoparietal dextra

Head up 30
Aff infus
O2 4l nasal tracheostomi
Cefadroxyl 125 mg 2x1
Piracetam
Ranitidun 50mg 3x1
Terapi sesui TS gizi
Konsul fisioterapi
Paracetamol 80mg/ 8jam
Cefadroxyl 800mg/12jam
Ikuti instruksi TS gizi anak
Pindah ruangan
Rencana vp shunt

S : (-)
O : KU : sedang GCS
12 (E3M5V4)
A : udem cerebri

IVFD RL 24 tpm
Ceftriaxone 1 gr/12jam/iv
Renitidin 1 amp/8 jam/iv
Ketorolac 1 amp/8jam/iv
Mannitol 100 cc/6jam/drips

S:O : KU sedang
GCS 11 (E2M5V4)
pupil anisokor

IVFD RL 24 tpm
Ceftriaxone 1 gr/12jam/iv
Ranitidine amp/8jam/iv
Ketorolac amp/8jam/iv

Terapi sesuai TS Anestesi

CT-Scan kontrol

Lab. 23/09/2014:
RBC 3.6 WBC 12.6 Hb 11,1
HCT 31.6
PLT 151 Ur/Cr 26/0,80
SGOT/SGPT 37/25 Na/K/Cl
145,3.8,110
Lab (6/9/2014):
HGB:13 WBC:17.1 RBC: 4.36
PLT:231 GDS:186 Ur/Cr:22/0.8
GOT/GPT:50/18
Na/K/Cl:141/4.0/104
Foto Thoraks AP (7-9-2014)
Cor dan pulmo dalam batas
normal
Lab 2/9/14
HGB:10.8 RBC:4.47 WBC:7.9
PLT:354 GDS:94 Ur /Cr:13/0.2
GOT/GPT:28/14
Na/K/Cl:140/5/105

Lab (8/9/2014):
HGB:9.0
WBC:17.40
RBC:3.25
PLT:389000
GDS:91
Ur/Cr:28/0.3
GOT/GPT:58/66
Na/K/Cl:144/4.6/99
CT-Kepala (30/8/14):
- Perdarahan subdural regio
frontotemporoparietal dextra
- Herniasi Subfalcine
- Hematosinus sphenoidalis
bilateral
- Sinusitis maxillaris kanan dan
ethmoidalis kiri
Foto Cervical Lat (30/9/2014)
Tidak tampak kelainan radiologik
pada foto cervical ini
Foto Thoraks AP 8/9/2014
- Pneumonia Dextra
- Fraktur 1/3 lateral Os.Clavicula
Sinistra
ETT di atas carina mengarah ke
main bronchus kanan
Lab (20/9/2014)
RBC 4,62 HGB 12,5 HCT 36,8
WBC 14,7 PLT 245 CT/BT
700/300 Ur/Cr 40/1,30 GDS
147 GOT/GPT 537/517 Na/K/Cl
147/3,4/106
RBC 3,82 HGB 11,5 HCT 34,1
PLT 212 WBC 18,7 CT/BT
700/300 GDS 151 GOT/GPT
60/38 Na/K/Cl 138/3,9/107
1

KORAN BEDAH SARAF RABU, 1 OKTOBER 2014

MRS : 19/09/2014
7

1
2

A : EDH frontalis (D)

STOP manitol
Awasi GCS & TTV
IVFD RL 24 tpm
Ceftriaxone 1 gr/12jam/iv
Ranitidine 1 amp/8jam/iv
Paracetamol 1 gr/12jam/drips
Manitol 100 cc/6jam/drips
IVFD RL 24 tpm
Omeprazole amp/12 jam/IV
Asam traneksamat amp/8
jam/IV

BED 7
Rahmatia
682234
25/07/1999
MRS : 25/09/2014
BED 8
Hariyadi
681697
28/08/1986
MRS : 23/9/2014

AAI

S : (-)
O : GCS 10 (E2M5V3)
A: subdural hematom
temporoparietal (S)
ICH frontoparietal (D)
S : penurunan kesadaran
O : KU : lemah GCS 7
A : Brain injury GCS 7
Post operasi
laparatomi
LONTARA 3 BEDAHSARAF (KAMAR 1)

Bed 2
A.Hidayatullah
28-11-1996
681267
MRS : 22/9/14

WA

S: O: Ku: baik/CM
A: Skull defect regio
supraorbita sinistra

Rencana cranioplasty tunggu

jadwal

Lab (25/9/14)
RBC 4,11 HGB 12,1 HCT 34,6
PLT 271 BT 230 GDS 93 Ur/Kr
16/0,40 GOT/GPT 29/4 Na/K/CL
127/4,4/94
Lab (27/9/2014)
RBC 2.83 HGB 9.5 HCT 25.7
WBC 11,9 PLT 397 Ur/Cr
52/0.30 GDS 51 Na/K/Cl
145/4.8/112

Lab. 19/9/2014
WBC 5500 Hb:14,5 PLT:272000
SGOT/SGPT:16/11 CT/BT
:8/230 GDS:138 Ur/Cr:21/0,6
Foto Thorax PA/AP 19/9/2014:
Tidak tampak kelainan radiologic
pada foto thorax ini
CT scan kepala 19/9/2014:
Tanda-tanda brain swelling

LONTARA 3 BEDAHSARAF (KAMAR 2)

1
2

Bed 2
Drs. Nathan Yunus
19/9/1966
681230
MRS : 19/9/2014

NS

BED 1
Hamria
3-9-1966 (48 thn)
521630
MRS:24-09-2014
BED 2
NurAliah
23-10-2013
656478
MRS: 08-09-2014

NS

BED 3
Syadni aqilah
26-1-2012 ( 2 thn)
537065
MRS: 25-9-2014
Bed 4
Mumtraza tsabita
fayza
12-02-2013 (1 thn)
654835
MRS 17-09-2014

NS

DW

AAI

S : Nyerikepala
Cefadroxyl 2x500 mg
O : KU : sedang, GCS
Ranitidin 3x150mg
15
Tunggu hasil darah rutin
A :POH 11 external
drainage bilateral e.c
subakut subdural
hematom (op. tgl
20/9/2014)
LONTARA 3 BEDAH SARAF (KAMAR 3)
S:kel(-)
O:Ku:baik
Cefadroxil 2x500mg
A:POH 7post lumbal
As. Mefenamat 3x500mg
drainage (24/8/14)

Lab. 19/9/2014
BT: 8.00, CT: 3,00, PT/APTT:
14,6/33,8, Na/K/Cl: 133/4,1/100,
HbsAg: Non Reactive, Anti HCV:
Non Reactive

S: (-)
O: Ku Baik GCS 15
(E4M6V5)
A:Meningoencephaloce
le lumbalis
S: kel (-)
O: KU sedang/GCS 15
A: - hidrocefalus
-POH 5repair vp
shunt (26-9-2014)
S: (-)
O: ku: baik
A: Hydrocephalus post
vp shunt (17-9-14)

Lab 01-09-2014
WBC 9,0RBC 5,01HGB
11,0HCT 35
PLT 470000Na 138K 4,1Cl 106

Tunggu jadwal operasi

Lab 24-9-2014
WBC 8,6 RBC 4,10 HGB 12,6
PLT 245 HCT 36 GDS 95 Ur/Cr
18/0,70 GOT/GPT 26/38 Na/K/Cl
144/4,3/114

Cefadroxil syr 2 x 1 cth

Paracetamol syr 2 x 1 cth

Lab (25-08-2014):
HGB 12,4 HCT 35,2 WBC 5,1
RBC 4,19 PLT 395 GDS 93 Ur/Cr
10/0.19 GOT/GPT 19/16 Alb. 4,3

Cefadroxil syr 2 x 1 cth

Paracetamol syr 2 x 1 cth
Rencana operasi

Lab 17-9-2014
WBC 15,4 RBC 5,04 HGB 13,1
HCT 38 PLT 470 GDS 82 Ur/Cr
16/0,40 GOT/GPT 20/17 Na/K/Cl
142/4,9/106

KORAN BEDAH SARAF RABU, 1 OKTOBER 2014

LONTARA 3 BEDAH SARAF KAMAR 4
1.
Bed 1
Nadyatul adewia
13-5-2009 (5 thn )
682270
MRS 26-9-2014
2.

3.

5.

6.

Bed 2
Arisah
24/04/1982
671844
MRS 15/09/2014

Bed 3
Rahmatia
25/7/1999
682234
MRS 25-9-2014

Bed 5
Adelia agustina
23-8-2006 (8 thn )
316448
MRS: 25-9-14
Bed 6
St. Aisa Ruman
16-05-1999
678529
MRS: 08-09-2014

AAI

WA

AAI

WA

DW

S : (+) nyeri kepala

O : ku: sedang
GCS 15 (E4V5M6)
A : tumor intrakranial

Paracetamol 3x250mg
Tunggu hasil CT SCAN
kontras

Lab 26-08-2014
HGB 11,3 RBC 3,95 WBC 10,7
PLT 360 GDS 93 Ur/Cr 12/0,30
GOT/GPT 20/7 Na/K/Cl
139/3,9/103

S : (-)
O : ku baik
A : fistula carotid
cavernosus
pOH 6 post op. ligasi a.
karotis eksterna
(25-9-2014)

Cefadroxil 2x500 mg
As. Mefenamat 3x500 mg

Lab (13-09-2014):
WBC 6.3 RBC 4.48 HGB 14,5
HCT 41,4 PLT 305 Na 146 K
4,2 Cl 108 Ur 19 Cr 0.61 GOT
35 GPT 36 GDS 114

S : (-)
O : ku baik GCS 15
(E4V5M6)
Pupil isokor 3mm
A : - subdural hematom
temporoparietal (s)
- ICH frontoparietal (D)

IVFD RL 24 tpm
Ceftriaxone 1 gr/12jam/IV
Ranitidine amp/8jam/IV
Paracetamol 1 gr/12jam/drips

Lab 25-9-2014
RBC 4,11 HGB 12,1 HCT 31 PLT
271 GDS 93 Ur/Cr 16/0,40
GOT/GPT 29/4 Na/K/Cl
127/4,4/94

Focal brain injury

Intracranial hematom
region temporal sinistra
S: (-)
O: KU baik
A: POH 20 VP shunt ec
hydrocephalus + tumor
intracranial (16-9-14)

Konservatif dri bedah saraf

Cefadroxyl 2x500 mg
Asammefenamat 3x500 mg
Tunggu jadwal operasi

Lab 25/9/144
RBC 4,6 WBC 11,5 HB 11,7
HCT 33,6 PLT 329 CT/BT
8,00/2,00 HBSag (-)

CT-Scan (01-09-2014):
Pendarahanintracerebri yang
meluaske subarachnoid
danintraventricular
Infarct cerebri parietal dextra
Brain swelling
Subgaleal hematoma dengan
region temporoparietalsinistra
Lab 2-9-14
WBC 14,4 RBC 5,27 HGB 12,2
PLT 423 GDS 96 Ur/Cr 18/0,60
GOT/GPT 19/18 alb. 4,4 Na/K/Cl
143/4,6/105

Bed 1
Fathuddin
27/9/1963
682510
MRS :28/9/2014

WA

LONTARA 3 BEDAH SARAF KAMAR 5

S : Nyeri kepala
IVFD RL 20 tpm
O : KU : sedang
Ceftriaxone1gr/12j/iv
GCS 15 E4M6V5
Ranitidin 50mg/8j/iv
A : Focal brian injury
Ketorolac 30mg/8j/iv
ICH
PSA

CT scan 28/9/2014
-Perdarahan intracerebri region
frontal kanan & temporal kiri
-Perdarahan subarachnoid
-Fraktur os parietal sinistra
Lab 28/9/2014
WBC 14.5 Hb 14.1 HCT 40.3
PLT 265 RBC 4.74
GDS 122
Ur/Cr 35/0.7
SGOT/SGPT 22/13
Na/K/Cl 140/3.7/107
CT/BT 800/300
3

KORAN BEDAH SARAF RABU, 1 OKTOBER 2014

2

Bed 2
Zainuddin
1/7/1954
682403
MRS :20/9/2014

AAI

S:O : KU: sedang

GCS 15 E4M6V5
A: Subarachnoid
Haemorragic

IVFD RL 20 tpm
Ceftriaxone1gr/12j/iv
Ranitidin 50mg/8j/iv
Ketorolac 30mg/8j/iv
Diet susu 3x250ml

Bed 3
Ismail
10/1/2002
678448
MRS : 22/9/2014

DW

S:O : KU : Baik
GCS 15 (E4M6V5)
A : Hidrocephalus post
VP Shunt
Pro repair shunt

Operasi Repair VP Shunt

(selasa, 10/9/2014)

Bed 4
Ahmad Sarjio
672080
1/9/2005
MRS 8/8/2014

DW

S:O : Ku baik
GCS 15 E4M6V5
A : SOL intracranial

Tungggu jadwal operasi

PCT 3x250 (bila perlu)

Bed 5
Nurul Fajrin
681270
16/2/1991
MRS 19/9/2014

WA

Cefadroxil 2x500mg
Ranitidin 2x150 mg
As. Mefenamat 3x500 mg
NonFlamin 3x1
Boleh rawat jalan

Bed 6
Sangkala
636017
14/5/1947
MRS 22/9/2014

AAI

S:O : KU baik
GCS 15 E4M6V5
A : POH 9 Craniotomi
Depressed fracture
OK bone OK scull
Intracerebri hemoragik
S : nyeri kepala
O : KU sakit sedang
GCS 13 (E3M6V4)
A : POH 6 trepanasi
Intracerebral
haemoragic

O2 10 LPM
RL 20 tpm
Ceftriaxone1gr/12j/iv
Ranitidin 50 mg/8j/iv

Lab 26/9/2014
WBC 16.9 Hb 12.1 HCT
34.0RBC 3.47 PLT 180
GDS 118
Ur/Cr 34/1.2 SGOT/SGPT 63/31
Na/K/Cl 145/4/110
HbSAg (+)
CT/BT 600/200
Prot Tot 7.4
Alb 3.3
Lab (19/9/2014)
Hb 13.4 WBC 69
PLT 349
GOT/GPT 21/14
Na/K/Cl 139/4.0/105
Ur/Cr 12/0.5
Lab (2/9/2014)
RBC 4.75 WBC 10.6
Hb 13.2 Hct37.2
PLT 499 GDS 118
Ur 23 Cr 0.63
SGOT 19 SGPT 13
Na/K/Cl 137/3.8/102
Lab (19/9/2014)
RBC 4.04 Hb 11.7
WBC 23.5 PLT 317
SGOT/SGPT 67/31
Ur/Cr 14/0.6
Na/K/Cl 140/4.7/108
Lab (26/9/2014)
WBC 6.85 Hb 7.8Hct 23.5 PLT
189
GDS 30 Ur/cr 61/1.0
Prot tot 4.3
Albumin 2.4
Na/K/Cl 154/3.9/116

LONTARA 3 BEDAH SARAF (KAMAR 6)

Bed 2
Anang Mustalim
8/5/2001
682533
MRS : 29/9/2014

WA

S : Penurunan
Kesadaran
O : KU : Sedang
GCS 12 (E2M5V5)
Pupil Isokor 3mm
A : POH 3 Craniectomy
e.c. EDH Occipital

IVFD RL 20 tpm
Ceftriaxone1gr/12j/iv
Ranitidin 50mg/8j/iv
Ketorolac 30mg/8j/iv

Bed 3
Ervandi
22/5/1995
633313
MRS 22/9/2014

AAI

S :O : KU baik
GCS 15 E4M6V5
A; Scull defect

Rencana
Cranioplasty
(Rabu, 1/10/2014)

Bed 4
Reynaldi M.

WA

S:O : KU : Baik

IVFD RL 20 tpm
Ceftriaxone1gr/12j/iv

Lab 28/9/2014
WBC 13.4 Hb 11.0 HCT 31.7
PLT 259 RBC 3.86
GDS 122
Ur/cr 35/0.7
SGOT/SGPT 25/11
Na/K/Cl 143/4/111
CT/BT 700/200
Lab(22/9/2014)
RBC 5.57 Hb 16.3
WBC 6.0 PLT 268
SGOT/SGPT 22/13
Ur/Cr 27/0.8
Na/K/Cl 146/4.9/107
Lab 28/9/2014
WBC 12.1 Hb 13.1 PLT 221 RBC
4

KORAN BEDAH SARAF RABU, 1 OKTOBER 2014

16/8/1998
682493
MRS : 18/9/2014

GCS 15 E4M6V5
A: Focal Brain Injury
Maxillofacial Injury

Ranitidin 50mg/8j/iv
Ketorolac 30mg/8j/iv
Tunggu hasil 3D wajah

4.6
HCT 37.8
GDS
75
Ur/Cr
SGOT/SGPT 30/18
Na/K/Cl148/4.3/111
CT/BT 800/300

BED 2
ABD. RAUF
1/7/1956
677206
MRS: 25/8/14

AAI

S: O: KU: Lemah
GCS 7x(E2M5Vx)
tracheostomy
Pupil isokor 2.0/2.0
RCL +/+
A: POH XXVIII
Craniotomy e.c SDH
Frontobasal D + ICH

ICU
Diet susu 6 x 200 cc
Manitol 6x100cc
Terapi sesuai TS Anastesi

30/18

Lab (25/9/2014):
HGB:12.2 WBC:19.17 RBC:4.22
PLT:732 GDS:167 Ur/Cr:22/0.30
GOT/GPT:72/141 Albumin:2.9
Na/K/Cl:139/4.5/10
MSCT Kepala (AX + Cor ) Non
kontras : (03/09/2014)
- Defek pada os frontotemporal
sinistra dengan herniasi
meninges dan parenkim cerebri
- Perdarahan intracerebral
frontotemporaparietal dextra
- Herniasi subfalcine
- Hematom subgaleal region
frontotemporoparietal bilateral
terutama kanan
- Fraktur depresi os frontal
- Fraktur os parietal sinistra
Foto Leher AP + Lateral
(25/08/2014)
Tidak tampak kelainan radiologic
pada foto cervical ini

Bed 5
SHADIQUL
MUBIN
3-7-2000
678615
MRS : 2-9-2014

WA

S : (-)
O : Ku Lemah
GCS 10x (E4M6Vx)
Pupil isokor 2.5/2.5
RCL +/+
A : POH XIX
Craniectomy ec. Fr.
Depressed Os. Frontal

Awasi tanda vital dan GCS

Terapi lain sesuai TS
Anastesi

BED 6
NATSIR KADIR
12/6/1980
676380
MRS: 23/8/14

WA

S: O: KU: Lemah
GCS 5x(E1M4Vx)
Pupil Isokor 2,5/2,5
RCL +/+
A: POH XXIX
Craniectomy e.c SDH
Temporobasal S

Meropenem 1 gr/8 j/iv

Diet susu 6 x 200 cc
Terapi lain sesuai TS
Anastesi

Foto thoraks AP asimetris

(12/9/14)
-Tanda-tanda bendungan paru
disertai elongation aortae
Lab 6/9/2014:
HB:9.8 RBC:3.18 WBC:6.4
PLT:103 GDS:127 Ur/Cr:40/0.4
GOT/GPT:48/33
Na/K/Cl:139/4.5/110
Foto Thoraks AP 6/9/2014 :
Suspek kontusio paru sinistra
Foto Cervical AP/Lateral
(7/9/2014) :
Muscle Spam
CT-Scan Kepala 2/9/14:
Brain window : Pneumocephal
regio of frontal
Bone Window: Depressed
fracture of frontal
Lab (9/9/2014):
HGB:12.5 WBC:16.1
RBC:4.15PLT:354000 GDS:169
Ur/Cr:36/0.50 GOT/GPT:43/108
Na/K/Cl:129/3.3/103
Foto thoraks PA (18/8/14):
Tidak tampak kelainan radiologik
pada foto thoraks ini
CT-Kepala (18/8/14):
5

KORAN BEDAH SARAF RABU, 1 OKTOBER 2014

BED VIP 2
Sirajuddin
30/12/1993

Perdarahan subdural regio

temporoparietal sinistra
Foto Thoraks AP (7/9/2014) :
Cor dan pulmo dalam batas
normal
LAB (9/9/2014)
HGB:12,9 WBC:10.3 RBC:4,16
PLT:77 GDS:63 Ur/Cr:35/1.2
GOT/GPT:98/39
Na/K/Cl:153/3.3/116

DW

S: Kel (-)
O: KU: Lemah
GCS 9x (E3M6Vx)
Pupil isokor 2.5/2.5
RCL +/+
A: POH XVII e.c
epidural hemorhage
temporal dextra

IVFD RL 28 TPM
Ceftriaxone 1 gr/12 jam
Ranitidin 1 amp/8 jam
Ketorolac 1 amp/8 jam

S: (-)
O: KU: Lemah
GCS 4x (E1M3Vx)
Pupil anisokor2,0/1.0
RCL +/+
A: POH-X
Craniotomy e.c EDH
regio frontal kiri
S: penurunan kesadaran
O: KU: lemah,
terintubasi
GCS 5x (E1 M4 Vx)
pupil isokor 2,5/2,5 mm
Drain 20cc
A: POH IX craniotomy
ec EDH
temporoparietal D
S: kel (-)
O: KU: Lemah
GCS 5x(E1M4Vx)
Pupil Isokor 2,5/2,5
RCL +/+
A: TCB GCS 6 + ICH
regio temporooccipital
kanan+prolonged
intubation
Post op tracheostomi
dan craniotomi

Head up 300
IVFD RL : DX (2:1) 20 tpm
Ceftriaxone 1 gr/12 jam/iv
Inj.Mannitol 1 gr/ 8 jam
Inj.Omeprazole 6x150cc
Terapi lain sesuai TS
Anastesi

Lab (21/9/2014):
HB:10,7RBC:3.66WBC:14.6PLT:
116GDS:118Alb:3.0GOT/GPT:13
0/35

Head up 30
IVFD NaCl 28 tpm
Ceftriaxone 1gr/12jam
Ketorolc 1 amp/8jam
Ranitidin 1 amp/8jam
Takar produksi drain/hari
Awasi TTV dan GCS

Lab 14-9-2014
WBC:19,6RBC:4,54HB:12,9PLT:
252UR/CR:20/0,7GOT/GPT:27/1
4

Terapi lanjut TS Anestesi

Lab 12-9-2014
HB:10.5
RBC:3.75
WBC:14,8
PLT:210
GDS:77
GOT/GPT:36/34
Alb:2.1
Na/K/Cl:134/2.9/97

679477
MRS: 9/9/14

BED VIP 3
Musfira
5/10/1998
678612
MRS: 2/9/2014

WA

Bed 7
Supriadi dg.Bundu
681142
18/09/1979
MRS 14/9/2014

AAI

BED 8
Hawasia
31-12-1960
472731
MRS: 10-9-2014

AAI

PICU
1

M. Abid Zidan S
681398
23/10/2012
MRS:20/9/2014

NS

S: (-)
O: KU: Baik,GCS 13
A: Hidrocephalus post
VP Shunt

InfusKaen 3B : RL 1 : 2 tpm
Pengobatan lain sesuai TS
pediatric

Lab
BT:6.00 PT:14,3.APTT:31,0
GDS:121 Ur/Cr: 22/0,30
SGOT/SGPT : 23/31 Protein tot :
3,8 Alb:1,9 Na:138 K:3,6 CL:103

MUH. NATHA
NARARYA
17/02/2014
680271
MRS : 13/9/2014

NS

S: Kel (-)
O: KU: lemah
GCS 14 E4M5V5, pupil
isokor 2/2, RC +/+
A:POH-9VP shunt
ec.hidrocephalus

Ceftriaxone 650mg/24j/iv
Lain-lain sesuai pediatri

Lab 15/09/2014
WBC:6,4 RBC:4,64 HB:10,6
HCT:32 PLT:277
Lab 13/09/2014
Ur/Cr:7/0,2 GDS:87
GOT/GPT:183/97
Na/K/Cl:132/3,6/97
CT Scan Kepala non kontras:
- Hidrocephaluscommunicans
6

KORAN BEDAH SARAF RABU, 1 OKTOBER 2014

dg tanda encephalitis
- Brain edema
3
NICU
2

KELAS 2 A
SABRINA
03/09/2014
678792
MRS : 05/09/2014

NS

S: Kel(-)
O: KU:pasif
A:POH-6 VP shunt ec.
Hidrocephalus
communicans

Instruksi post-op:
- Ceftazidime
120mg/12j/iv
- Gentamycin
16mg/24j/iv
- PCT 40mg/8j/iv

Lab (09/09/2014)
CT:800 BT:300
PT : 129 INR:1,07 APTT:37,7
Na/K/Cl: 139/4,2/104
Alb:3,8 GOT/GPT:47/15
Ur/Cr:12/0,32
WBC:10,57 RBC:5,58 HCT:49,4
HGB:17,6 PLT:286

PALEM BAWAH
PALEM ATAS

Jhon Kalvin Rannu

2/3/2014
680878
MRS 23/9/2014
B2/3 bed 1

NS

SITTI
PRAMUKAWATI
10-12-1971
679713
MRS. 12-9-2014

NS

S: O:KU: baik,pupil
isokor,GCS
15,drain:<5cc
A:POH IV wide eksisi
ec tumor parietal Dextra
S:O:A: POH I craniectomy
ec tumor intracranial

-IVFD RL 28tpm
-ceftriaxon 1gr/12j/iv
-ranitidin 50mg/8j/iv
-novalgin 1amp/8j/iv
lanjut terapi TS B.plastik dan
B.onkologi
-IVFD RL 20tpm
-Ceftriaxone 1 gr/12
jam/intravena
-ranitidin50mg/12jam/iv
-ketorolac 30mg/8jam/IV
-phenitoin /8jam/IV
-mannitol 4x100cc

Lab tgl 24-09-2014

Rbc:4,47
ur:15
Hct:38,9
cr:0,80
Plt:391
Wbc:10,7
Gds:107
CT Scan Kepala tanpa kontras :
- Massa intracerebri region
fronto-temporal dextra dg
tanda2 herniasi subfalcine,
sugestif astrocytoma

LONTARA 4 ATAS BELAKANG

1

M. Abid Zidan S
681398
23/10/2012
MRS:20/9/2014

2.

Irfandi
682243
17/04/2010
MRS : 25/9/2014

3.

NS

Alimuddin
682079
31/12/1972
MRS : 25/09/2014

S: (-)
O: KU: Baik,GCS 13
A: Hidrocephalus post
VP Shunt

InfusKaen 3B : RL 1 : 2 tpm
Pengobatan lain sesuai TS
pediatric

Lab
BT:6.00 PT:14,3.APTT:31,0
GDS:121 Ur/Cr: 22/0,30
SGOT/SGPT : 23/31 Protein tot :
3,8 Alb:1,9 Na:138 K:3,6 CL:103

S : Kejang (-)
O : KU : lemah GCS 15
A: Post op VP shunt ec.
Hidrocephalus
Tumor Intracranial
S : (-)
O : KU : baik
GCS 15
A: Focal brain injury

Injeksi Ceftriaxone 3 mg 12
jam/IV
Ranitidin 20 mg /8 jam /IV
Paracetamol tab 250 mg/8
jam /IV
Infus Ringer Laktat 28 tpm
Ceftriaxone
Ranitidine 50 mg 8 jam/IV
Ketorolac 30 mg/8 jam/IV
Farmadol 1gr/drips jika
demam

PT :10.4 APTT 24,6 GDS:76

Ureum, : 19 Kreatinin: 0,30
GOT:29 GPT:13 PROT Total :6,5
Albumin:3,8

RSUH
1

ICU Bed 5
Tn.Ramadhan Lasiny
05/05/1938

WA

S : refleks menelan (-)

O : KU : sedang, GCS 8
(E4M4VX) tracheostomy
A : Post op VP Shunt

- IVFD lanjut
- inj. Gentamycin 1 gr/8 jam/iv
- neurotam 2x1200 mg
- Vip albumin 3x2 caps

LAB Tgl. 03-09-2014

WBC : 15,69
RBC : 3,01
HB : 8,2

KORAN BEDAH SARAF RABU, 1 OKTOBER 2014

024485
MRS : 13/07/2014
DPJP: dr. Willy
Adhimartha, Sp.BS
2

ICU Bed 4
Arwan Aziz
2/8/1961
027270
MRS 16/9/2014
DPJP: dr. Nasrullah,
Sp.BS

NS

KAMAR : 402
Tn.Habib
10/11/1950
023976
MRS : 28/06/2014
DPJP: dr.
Nasrullah,Sp.BS

NS

KAMAR 417
M. Yusuf
25/5/1963
019356
MRS 17/9/2014
DPJP: Dr. dr. Djoko
Widodo, Sp.BS

DW

S; Keluhan (-)
O: K: baik, GCS 15
Luka post op: baik
A: Post VP shunt hari 6 e.c
tumor fossa posterior susp
astrocytoma +
hydrocephalus

KAMAR 319
Adi Abd Majid
15/12/77
027961
MRS 26/9/2014
DPJP: Prof. Dr. dr. Andi
Asadul Islam, Sp.BS

AAI

S; Kel (-)
O: KU: sakit sedang, GCS 15
A;Tumor intracerebral
suspek metastasis pro
radioterapi

KAMAR 304
Rahmat Akbar
10/01/1967
020804
MRS 28/9/2014
DPJP: Dr. dr. Djoko
Widodo, Sp.BS

DW

S: Kel: pusing (+) menurun

KU: sedang GCS 15
Luka di abdomen baik
A: Focal brain injury GCS 15

S: keluhan (-)
O: KU : sedang, GCS 15
(E4M6V5)
Luka post op: baik
Drain: 5 cc/24 jam
A: - post craniektomi hari 4
+ bedah mikro + removal
tumor
S: nafsu makan menurun
O: KU: lemah, GCS 9
(E4M5Vx) tracheostomy
A: Post op eksternal
drainase

EDH + ICH temporal dextra

Hematom subgaleal parietal
sinistra

- inj. omeprazole amp/12 jam

- nebulizer/8 jam
- latih makan
- mobilisasi
- Terapi lain sesuai Ts. Bagian
lain
Terapi lanjut
GV hari ini
Aff drain
Head up 30 derajat
Terapi lain sesuai Ts. Bagian
lain
Mobilisasi duduk
Diet biasa
- pasang ulang infus
- IVFD RL:NaCl 0,9% 1:1
28tpm
- vip albumin 3x2 caps.
- injeksi cermevit 1 amp/24j
- pasang NGT
- latih ulang refleks menelan
- terapi lain sesuai Ts. Bagian
lain
- antibiotik konfirmasi Ts.
Bagian Interna (berdasarkan
hasil kultur sputum)
Lapor Dr.dr. Djoko Widodo,
Sp.BS
Advice:
Aff infus ganti oral
Cefspan 3 x 200mg
Ponstan 3 x 500mg
Neurotam 2 x 1200mg
Zegavit 2x1
Mobilisasi
Diet biasa
GV 3 hari selanjutnya
Awasi peningkatan TIK
(muntah, sakit kepala)
Terapi lanjut Ts. Neurologi
- Infus lanjut
-Mannitol maintenance 100
cc/24 jam
Sistol > 100mmHg
-Terapi lanjut
-Ketorolac amp/8j
-Ondansetron ampul (k/p)
Tunggu konfirmasi atau terapi
lain teman sejawat
dr.Suherman
NaCl 0,9 % 28 tpm
O2 nasal kanul 5 lpm
Ceftiaxon 1gr/12 jam
Ketorolac 30mg/8 jam
Ranitidin 50mg/8 jam
GV hari inj
Awasi TTV dan GCS. Jika
terdapat penurunan 2
lapor
Diet oral biasa
Mika miki / 2 jam
Mobilisasi duduk

PLT : 418
Na/K/CL ; 136/3,6/102

LAB Tgl. 28-8-2014

WBC : 6.24
RBC : 3,27
Hb : 8,7
HCT 26,4
Na/K/Cl 131/3,5/97

MSCT kepala:
- EDH temporal dextra
- ICH frontal dextra
- Cephal hematom parietal sinistra
Lab tanggal 28/9/2014
WBC : 15,20 PLT : 230
RBC : 5,26
Na/K/Cl : 141/3,8/105
HGB : 15,2
CT/BT : 7/3
HCT : 44,4
Ur/Cr : 26/1,2
PT/APTT/INR: 14,2/31,2/1,17
GDS:276

KORAN BEDAH SARAF RABU, 1 OKTOBER 2014

P C C
1

304
Damaris P
1/4/1953
534141
MRS 24/9/2014
DPJP: Dr. dr. Djoko
Widodo, Sp.BS
220
Meti
4/5/1986
590067
MRS 25/9/2014
DPJP: Dr. dr. Djoko
Widodo, Sp.BS

DW

S: Kel: nyeri pada luka post

op menurun
O: KU: sakit sedang, GCS 15
Luka post op: baik
Drain minimal
A: Post laminektomi hari 4
e.c HNP + Spondilosis L4-5

Aff infus ganti oral

Mobilisasi berdiri
-GV
-Mobilisasi duduk
-Diet biasa

DW

S: Kel: nyeri punggung

O:KU: baik, GCS 15
A: Post op hari 1 e.c HNP
L5-S1

202
Malika
4/6/2012
682240
MRS 25/9/2014
DPJP: Prof. Dr. dr. Andi
Asadul Islam, Sp.BS

AAI

S: Kel: nyeri dan bengkak

pada mata
O: KU: baik, GCS 15
A:
-Focal brain injury + TCR
GCS 15
- Fracture depressed os
frontal
-fractur basis cranii

IVFD RL 28 tpm
Ceftriaxon 1gr/12 jam
intravena
Ranitidin amp/12 jam
Ketorolac 30mg/8 jam
Metilprednisolon
125mg/12jam
Metilcobalt/24jam
-IVFD RL 16 tpm
-Novalgin amp/8jm/iv
-Broclad 500mg/12 jam/iv
-Mobilisasi
-Diet biasa