SENSUS BEDAH SARAF

Kamis, 19 September 2019

IGD
Total Pasien: 1
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana
1 An. Vina Bamsye 461928 IGD 18-09- EDH frontal temporal (s), IVFD D51/2NS 18 tpm Hb 9,9 Cito cranioktomi
2019 contusio serebri, fractur Ij.Ranitidin 2x17 mg WBC 29,3 decompresi + evakuasi
linier frontotemporal, PCT drip 3x180mg PLT 215 hematom jam 08.00
closed fracture clavicula Ij.Ceftriaxone 2x850mg PT 14,0
(S) Ij.Ondancetron 4mg (kp) APTT 31,7
Ij.Piracetam 2x250mg GDS 69
Ij.Fenitoin 2x85 mg
Ij.Manitol 85cc loading,
maintance 4x43 cc
Cito cranioktomi
decompresi + evakuasi
hematom

RUANG BEDAH WANITA

Total: 9 Pasien
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana
1 Ny. Antonia Raweyai 001266 K1B1 6/9/2019 -Contusio - O2 nasal 3 lpm Konservatif
Temporooccipital IVFD Clinimix 1000 cc/24
Hemoragge Bilateral jam + RL 1000 cc/24 jam
-Encepalophaty -Drip Paracetamol 1x1 gr
-Post Cranioplasty (H-12) (K/P)
-Vulnus Laceratum flank -inj.Ciprofloxacin 2x400 mg
Dextra (H5)
-inj.Gentamisin 2x1 ampl
(H8)
- Inj.Meropenem 2x1 gr
(H7)
-Inj Ranitidin 2x150 mg
-Inj Piracetam 2x1 gr
-Inj Citicolin 2x250 mg
-Inpepsa syr 15 cc/8 jam 1
-Nebu Flexotide + Nacl 1
cc/8 jam
-Cemax 3x4 tetes
 -Sistenol 4x1 tab
-MLP 6x200 cc
Mika miki
Mobilisasi duduk
2 Ny. Simpen 463431 BB12 3/9/2019 Malfungsi VP Shunt - Aff Vemplon Hb 11.1 Konservatif
Hidrochepalus obstruksi - Paracetamol 3x500 mg HCT 31.8
Ensefalopaty (PO) WBC 1.34
-Vitamin B6 1x1 (PO) Plt 126
-Candesartan 1x4 mgt (PO) RBC 4.09
-MLP 8x200 cc PT 9.8
- Mobilisasi duduk APTT 28.2
- Fisioterapi GDP 133
SGOT 20.0
SGPT 29.0
BUN 13.2
Creatinin 0.48
Na 128.50
Kalium 5.10
CL 94.80
Calcium 1.05
3 Ny. Sa’adah 463372 K1B4 9/9/19 Hidrocephalus Obstruksi -IVFD Nacl 0,9% 1500 cc HB 9.2 Pro VP Shunt +
53 tahun Stroke Infark Cerebri 20 tpm WBC 11.80 Debridement
Hemsifer -IVFD RL 500 cc/8 jam Trombosit 600
Temporoparietaloccipital -Inj. Fenitoin 2x150mg RBC 3.58
Ensefalopaty -inj. Dexametason 4x10mg HCT 31.3
-inj. OMZ 1x40mg
-inj. Levemir 0-0-10 IU
-inj. Citicolin 2x500mg
In.paracetamol 3 x 1g(K/P)
-MLP 6x100 cc
- Cek albumin ulang
4 Ny. Lidia Nerotimilen BB13 11/9/2019 -LBP Post Trauma Tumpul - Mecobalamin 2x1caps Konservatif
Lumbal - Primaquin 1x2 tab (H9)
-Susp. Fraktur Lumbal - Ibu profen 400 mg +
-Malaria Tertiana PCT tab 250 mg mfla
da in caps 3x1
- Gabapentin 2x300 mg
- Lactulosa syrup 2 x1 2
- Pasang korset
- Diet tinggi serat
 - Besok BPL

5 Ny.Wartini 465872 B4 11/9/2019 -Akut SDH Temporal - IVFD Tutofusin 1000 cc Hb 13.1 Konservatif
Sinistra : RL 500 cc / 24 jam HCT 37.1
-Brain Decompresi - Manitol 1 x 125 mg WBC 22.41
-Traumatic SAH (H3) stop PLT 191
-Encephalopaty - Fenitoin 2 x 100 (PO) RBC 4.38
-Post Kraniektomy - Piracetam 2x1200 mg GDS 162
Decompresi (H3) (PO) PT 12.7
- Ranitidin 2x 1 tab (PO) APTT 25.0
- Cefixime 2x200 mg
(PO)
- Besok BPL
6 An. Faiza Arya Aziza 466528 RBW 15/9/2019 - Traumatic Cerebral -Paracetamol 3x250 mg
Edem (PO)
- Piracetam 2x400 mg (PO)
-Ranitidin 2x1/2 tab (PO)
- Mobilisasi duduk jalan
- BPL
7 Ny. Yohima Yane RBW 17-09- Fracture kompresi lumbal - Ivfd RL 20tpm+drip
2019 2-3 tramadol 1 amp
- Ij.Ketorolac 3x1 amp(kp)
- Ij.Ranitidin 2x1 amp
- Ij.mecobalamin 2x1 amp
- CT scan lumbosacral+3D
besok
- Pasang korset
- Imobilisasi
8 An.Zahwa Yunita 464328 RBW 16-9- - Epidural hematom Ivfd D51/2Ns 1500cc/24 Post kraniotomy
2019 regio temporal jam evakuasi perdarahan
parietal kiri Ij.Ceftriaxone 2x500 mg
- Brain kompsire + (H2)
traumatic cereberal Ij. PCT 3x250 mg
edem + ensefalopaty Ij. Manitol 3x62,5 cc (H2)
- Post kraniotomy H1 Ij.Fenitoin 3x50 mg
Cek Hb post op
Evaluasi KU/VS/BC
9. An. Josua Pagawak 46 30 28 RBW 13-06- - Traumatic cerebral IVFD d51/2 NS 1150 cc/24 3
2017 edema jam
Manitol 3x35 cc
 Piracetam 2x500 mg (PO)
Paracetamol 3x150 mg
(PO)

RUANG BEDAH PRIA

Total Pasien: 2
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana
1. Tn. Agus Dastra 468171 RBP 6//9/2019 Fraktur kompresi lumbal - IVFD NaCl 0,9 %/6 jam Hb 11,4 - Pro laminectomy
II - Mecobalamin 2 x 1 caps WBC 2.02 decompresi (tunggu
- Ranitidin 2 x 1 tab RBC 4.41 alat)
- Lactosa syrp 3x1 cth PLT 108 - Konsul IPD dan
- Antasida syr 3x1 C DDR (-) Paru
- Inj.Ceftriaxone 2x1 gr (H4) BUN 45,4
- Paracetamol 3x1 tab Cr 2,00
- KSR 2x600 mg (po) Kalium 3,03
Natrium 143
2. Tn. Babel 467526 RBP 14/9/2019 Paraparese ec. Spinal -IVFD RL 500cc/8jam HB 11.8 - Konsul paru
Uropmabin /22 compression -inj. Ranitidin 2x1 amp HCT 34.6
tahun -inj. Antrain 3x1 amp Leukosit 5.04
-Lactulosa syr 3x1 C CL darah
-Inj.Mecobalamin 2x1 amp 110.30
-Bed rest

RUANG Kelas 1
Total Pasien: 2
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana
1. Tn. La Suki 398693 Mambruk 1/9/2019 -Post Craniectomy -IVFD Clinimix 1000 : Hb 12 - Konsul
-Acute SDH, EDH Tutofusion 1000 cc/24 jam WBC 11.3 ortopedi
-Contusio Temporoparietal -Manitol 1x125 cc (H7) HCT 35.3
Sinistra -Inj Piracetam 2x1 gr Plt 22.1
-Fracture Depressesd Os -Inj Antrain 3x1 RBC 4.39
Temporal -Haloperidol n2 mg + THP 1
-Encephalopaty mg 2x1
4
-Hepa Q 3x2 caps
-Inpepsa 4x20 cc
-Nebulizer/8 jam
 -Lactulosa syr 3x1 cth
-Semax 3x4 gtt NDS
-MLP 6x100 cc
2 Ny.Parawati 458436 18/9/2019 GBM residif -IVFD Nacl 2000cc/24 jam -
-Ij.OMZ 2x1 vial
-Ij.Dexametasone 4x1 amp

RUANG ICU
Total Pasien: 2
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana
1 Tn. Jhon Louputty ICU 31/8/2019 - Spontaneus ICH thalamus - IVFD Nacl 0.9 % 20 tpm Post VP Shunt
Umur 51 tahun B1 dengan hidrosefalus + - Inj. Tutofusin /24 jam
encephalopat - Inj. Meropenem 3x1 gr
- Post VP Shunt (H8) - Inj. Piracetam 2x3 gr
- Inj.Paracetamol 4x500mg
- Inj.Levofloksasin
1x750mg
- OMZ 1X40 MG
- Inj. Amlodipin 1x10 mg
(Bila TD sistol> 140)
- Captopril 3x12,5 mg
- Metformin 3x500
- Semax 6x6 tetes
- Diabetasol 4x150 cc / D5
1x 100 cc
- Impepsa 4x20 cc
- Nebulizer / 8 jam
2 Ny. Chadijah A M 423048 ICU 15/9/2019 Spontaneus ICH lib frontal - IVFD Nacl 0,9% 20 tpm Craniotomi
B7 Susp.IVH - Inj. Ceftriaxone 2x1 gr (H5) decompresi + evd
Susp.SAH - Inj.Piracetam 1x3 gr
Encephalopaty - Inj.Manitol 4x125 cc
- Inj.Fenitoin 3x100 mg
- Inj.Ranitidin 2x50 mg
- Inj.Antrain 3x1 gr
- Klonidin 2x0,15 mg
- KSR 2x1 tab 5
- Amlodipin 1x10 mg
 RUANG RES
Total Pasien: -
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana
1 -
2

RUANG RKK
Total Pasien: -
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana
-

RUANG SARAF
Total Pasien: -
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana
-

RUANG ORTHOPEDI
Total Pasien: -

NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana

-

RUANG VIP
Total Pasien: -
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana
-

DAFTAR PASIEN KONSUL

Total Pasien: 1
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana
1 An.Eman 444695 K.V 18-9-2019 Hidrosefalus ec multiple -IVFD D51/2 NS/24 jam Vp shunt
Fredoman tuberculoma -Ij.Ceftriaxone (H3)
-FDC 1x4 tab
-Asparka 3x50 mg
-Vit.B6 1x1 tab 6

DAFTAR PASIEN PULANG

 Total Pasien:
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana

DAFTAR PASIEN MENINGGAL

Total Pasien: -
NO Nama No. DM Ruangan MRS Diagnosis Tindakan Lab Rencana