SENSUS BEDAH SARAF

Minggu, 4 agustus 2019

RUANG BEDAH WANITA

No
Nama Ruangan MRS Diagnosis Tindakan Lab Rencana

Hb : 11,2
HCt 32,4
Leukosit 13,16
Trombosit 451
Eitrosit 4,18
Sel Basofil : 0,2
Sel Netrofil : 23,6
An. Sherlyta Were / 28/07/2 Meningocele Anterior - IVFD D5 – ½ NS 700 cc Sel Limfosit :
1. RBW - Inj Cefotaksim 2x250 mg
454860 019 Post eksisi cele - Pct drip 3x70 mg 67,9
CL darah 112,10
Calcium ion 1,22
PT (Waktu
Prototrombin) :
11,0
APTT : 29,9
HbsAg : NR
 Hb :10.2
HCT: 32.3
Leukosit: 5.90
Trombosit : 151
Eritrosit : 4.71
IVFD tramadol amp dalam RL 500 cc / SGOT : 12.1
Paraplegia Inferior ec 8jam
Ny. Lisbeth 25/07/2 Inj.Ranitidin 2 x 1 ampl SGPT:13.3
2. RBW sus. Burst Fr. Thoracal Inj. Mecobalamin 2 x 1 amp
Nerokop/465780 019 BUN: 13.5
9-10 Inj. Ketorolac 3 x 1 amp (k/p)
Pemasangan korset Creatinine; 0.91
CL darah: 111.10
Calcium ion:1.07
CA 125: 9.26
Iu/mL
LED : 112

- IVFD RL 40 tpm mikro. HB 23,6

29/07/2 - Zinc 1x20mg Hematokrit 65,5
3. By. Melice Kepno RBW Hidraancefali Leukosit 12,28 Pro VP shunt
019 - Liprolac 2x1 sach
Trombosit 94
- Cefixime syr 2x1/2 cth pc
Eritrosit 6,40
 Hb 13,5
Leukosit 9,52
- IVFD Nacl 0,9% DDR negative
PT 11,7
30/07/2 Hemiparesis (D) ec - Citicolin 2x1 amp iv APTT 22,4
4. Ny. Lilis Ermawati RBW GDS 108
019 Abses Temporal (S) - Ranitidin 2x1 amp iv
BUN 9,2
- Ketorolac 3x1 amp iv Creatinin 0,43
Kalium 3,27
Cl 108,70
Calcium 1,12

HbsAg (Rapid) =
Non Reactif

HB 9,0
Hemotokrit 28,3
Leukosit 11,54
- IVFD DS ½ NS 800cc/24jam Trombosit 51
30/7/20 - Inj. Ranitidin 2x8mg iv 3 cc Eritrosit 5,55
5. By. Samuel RBW Hidrocefali Sel monosit 12,1
19 - Asetasolamid 2x80mg
GDS 199
- Aspar k 2x80mg CL Darah 110,80
Calsium Ion 1,00
 - Mannitol 3 x 60 mg
- Phenytoin 2 x 50 mg
1/8/201 Traumatic cerebral
6. An Kristian RBW - Piracetam 2 x 400 mg
9 edem konservatif
- Ranitidine 2 x 25 mg
- Antrain 3 x 250 mg
 RUANG BEDAH PRIA
No Nama Ruangan MRS Diagnosis Tindakan Lab Rencana
- Head lift 30-45o
- IVFD Nacl 0.9% 20 tpm HB: 14.9
- Manitol 3 x 125 cc WBC : 13.01
PT : 9.4
Tn. Briliant A. Traumatik - Inj. Antrain 3x1 ampl (k/p) APTT : 23.3
25/07/ - Piracetam 2x1200 mg(po) SGOT : 32.7
1 Wopari RBP cerebral edem SGPT :21.2
2019 - Paracetamol 3x300mg (po) BUN :14.5
093963/ 23 thn - Ibuprofen 200mg 3x1 (po) Cre : 0.61
Kalium :3.48
- Vit B complex 3x1 (po) Natrium : 137.80
- Betahistin 3x6 mg (po) HbsAg : NR
- Bed rest
- Penurunan
Kesadaran
- RL : aminofluid 2:1 Hb : 8,2
- Inj Dexa 2x10 mg (iv) Hematokrit : 25,2
-Low intake, - Inj Omeprasol 2x1 vial Eritrosit : 3,65
Tn. Armandus 46/08/ hipoglikemia - Inj Fenitoin 2x100 mg Eosinofil : 0,5
2 RBP Neutrofil : 83,1
Ayomi 50 - Inj Meropenem 2x1 gr Limfosit : 6,9
-Hidrosephalus et - Inj Gentamisin 2x1 amp BUN : 27,2
- Pasang NGT Natrium darah : 127,80
causa tumor Fosa CL darah : 97,10
- MLP 6x100 cc
Posterior.

Hb: 19,4
Hct: 55,6
Leukosit 8,08 Pro debridement +
Open fracture - IVFD RL 20 tpm Trombosit 106 koreksi fraktur
depressed os - Inj antrain 3x1 amp
31/07/ - Inj sefotaksim 2x1 gr Eritrosit 6,18
3. Tn. Markus sorabut RBP frontal + closed - Drip metronidazol 3x500 mg
2019 PT 11,7
fraktur scapula - Inj piracetam 2x3 gr
- Inj ranitidin 2x1 amp APTT 29.0
(S)
BUN 7.4
Creatinin 1.01
Cl darah 107.60
 Calvium 1.11

HB : 13,4
Hematokrit 37,3
Leukosit 14,14
Trombosit 236
Eritrosit 4,89
Traumatic
- Mannitol 4x 125 cc PT 11,7
Tn. Sefnat W. 31/07/ cerebral edem - Phenytoin 3x100 mg
4. RBP - Ceftriaxone 2 x 1 gr APTT 24,7
Yaroseray 2019 susp. Fr. Basis
- Piracetam 2 x 3 gr
cranii
GDS 122
SGOT 35,3
SGPT 22,0
BUN 15,1
Creatinin 0,71
Albumin 4,3
 RUANG SARAF

No Nama Ruangan MRS Diagnosis Tindakan Lab Rencana

RKK

No Nama Ruangan MRS Diagnosis Tindakan Lab Rencana

- IVFD KAEN 3B 560

cc/24 jam
- 02 nasal kanul 1-2 lpm HB ; 12,2
- Inj. Ranitidin 2 x 5.6 mg HCT: 38,1
By. NesionWonda Hydrocephalus onset - Inj. Cefotaxime 3 x 187 Leukosit: 16,48 Pro vp-shunt bila acc
1 RKK 25-07-2019
467080 akut + RFA mg Trombosit: 739 dari Sp.A
- Nebuleser Nacl 0.9% Eritrosit : 5,29
/8jam Albumin : 3,5
- Sibital 2 x1 po
- Piracetam 3 x 1 po
 - Diet susu/NGT

RUANG VIP

No Nama Ruangan MRS Diagnosis Tindakan Lab Rencana

 RUANG KELAS 1

No Nama Ruangan MRS Diagnosis Tindakan Lab Rencana

Hb : 15,0
Hct : 44,4
WBC : 14, 79
IVFD RL
PLT :238
Mannitol 4 x 125
RBC : 5,20
cc
Kalium : 3,85
Traumatic cerebral edem Inj.phenitoin 2 x -
1 Tn.Rahmar Latahir/460485 Kelas 1 27-07-2019 Cl : 109,00
Whiplash associated disorder 100 mg
Natrium 138, 60
Inj.piracetam 2 x1
Bun : 19,7
gr
Cr : 1,03
Bed rest
SGOT : 53,6
SGPT 31,8
 IGD

No Nama Ruangan MRS Diagnosis Tindakan Lab Rencana

Obs. Trauma
Maksilofasialis +
1. Tn. Ukum Wenda IGD -
vulnus Eksoriasi regio
wajah

Hb 11.4
Leukosit 14.52
Trombosit 251
Neutrofil 80.8
DDR negatif
Stroke ICH dan IVH GDS 152
spontaneus non BUN 45.2
2. Ny. Yomina Trapen IGD 31/07/2019 Terapi dari Sp.S
trauma faktor resiko Creatinin 2.46
HT emergensi Kalium 2.90
Cl 112.10
Calcium 1.08
PT 10.0
APTT 27.4
HbsAg reaktif
 Hemip[arese sinistra Mannitol 4 x 125 cc
2. 3 Phenytoin 3 x 100 mg
Tn David womsiwor IGD 01/08/2019 ec. Susp stroke infark Ceftriaxone 2 x 1 gr
.
dd hemoragic Piracetam 2 x 3 gr

Pro laminektomi
dekompresi +
stabilisasi
IVFD RL 20 tpm
3. 4 Paraparese inf ec. Kalmeco 2 x 1 amp
Tn. Athala bahasol IGD 02/08/2019 Inj. Antrain 2x 1 amp
. Trauma vertebra
Inj. Ranitidin 2 x 1 amp
 ICU

No Nama Ruangan MRS Diagnosis Tindakan Lab Rencana

Hb : 12,9
Hct : 6,5
WBC : 16, 66
PLT :190
RBC : 4,60
- IvFd nacl 0,3 % 20 tpm
Kalium : 3,82
- Inj ceftazidime 2x1 amp
Fr.dislokasivc 6-7 Cl : 102,20
Tn. Wilius Iv
SCI sompleted type Natrium 132, 70
1 21 tahun ICU 08 / 07 / 2019 - Inj. Antrain 3x1 -
Sepsis Bun : 18,3
467961 - Inj. Omeprazole 2x1 vial
Neurogenik shcok Cr : 0,50
- Inj. Mecobalamin 2x 1
SGOT : 68, 0
ampl
SGPT 203,0

- IVFD D5 ½ NS 2000cc
/24jam
- Mannitol 4x125 cc
Spontaneous ICH - Inj.ceftriaxone 2 x 2 gr
2. Tn. Yanero Apo ICU 25-06-2019 Post craniectomy - Inj.phenytoin 3x100
(H6) - Inj.dexametasone 3 x
5mg
- Inj.kalnex 3x500 mg
- Inj omeprazole 2x2
 Hb : 17,3
Hct : 56,4
Stroke PIS dan IVH Leukosit : 12,25
sistem carotis sinistra Trombosit : 180
Tn. Juniten Kogoya + HT grade 1 + Eritrosit : 7,00
3. ICU Leukositosis Terapi dari Sp.S
467480 Neutrofil : 74,9
Post craniectomy Limfosit : 15,8
dekompresi evakuasi
PT : 12,3
hematom
APTT : 29,6
HBsAg : NR

RES

No Nama Ruangan MRS Diagnosis Tindakan Lab Rencana

1.
-
 DAFTAR PASIEN KONSUL

No Nama Ruangan MRS Diagnosis Tindakan Lab Rencana

Hb: 11,7
Hct: 32,2
Leukosit: 8,73
Neutrofil: 80,7
1 An Orfin Kepno RKK 11-07-2019 Meningoencephalitis
Limfosit: 18,1
DDR: negatif
GDS: 129
Natrium darah: 134,30

POLI

No Nama Ruangan MRS Diagnosis Tindakan Lab Rencana

-
Pasien pulang :
1. By. Efraim /2 bulan/465990/RKK/Hidrosefalus ec. Susp HCP : pulang hari senin 29/7/2019
2. By .Agusta/2 bulan/ 468295/RKK/Hidrocepali d porencephali : pulang hari senin 29/07/2019
3. An. Eman fredoman/464495/RKK/ Hidrocephalus akut ec tumor fosa posterior dd tuberculoma : pulang hari jum’at 03/07/2019

Pasien meninggal:
1. Ny. Dina Mekei/ 41 tahun/ 465385/ ICH spontaneus basal ganglia kiri, hidrosefalus, CKD stage V. Meninggal hari kamis 01/08/2019 jam
18.55 WIT