HCU L3BD

No IDENTITAS KELUHAN DIAGNOSIS HASIL LAB RADIOLGI PLANNING DPJP

PASIEN
1 HCU 1 TBI GCS 15 25-01-2019 Foto Pelvis /Panggul AP -Infus NaCl 0.9% 28 tpm WA

MUHAMMAD WBC : 23.4 Kesan: -Ceftriaxone 1gr/24/iv

SAAD
RBC : 4.30 -Fraktur Kominutif sisi lateral - Ranitidine
871176 acetabulum dextra 500mg/8jam/iv
HGB : 13.4
12-09-1963 -Coxitis Sinistra -Metronidazole
PLT : 181 1gr/8jam/iv
55Tahun CT KEPALA (TANPA
PT/APTT : KONTRAS) -Rawat sama TS BTKV
11.4/23.1 - Tidak tampak lesi
hipo/hiperdens patologik
MRS 25-01- GDS : 160 intracranial
2019 - Hematosinus spenoidalis
UR/CR : 22/0.57 dextra
- Mastoditis dextra
SGOT/SGPT : 57/26

Na/K/Cl :
134/3.5/102

HBsAg : Non
reactive
2 HCU 2 -TBI GCS 15 21-01-2019 Foto Thorax PA/AP :21-01- -O2 4 LPM via NC AAI
2019
AWALUDDIN -Fracture costae WBC : 12.300 -Infus NaCL 0.9% 28
multiple + Flail Chest Kesan : TPM
870666 Dextra RBC : 4.570.000
-Kontusio pulmo, -Cefotaxime 1
05-12-1978 -Fracture clavicula 1/3 HGB : 13.9 hematothorax dextra gr/12jam/IV
medial dextra -Fracture costae II-VI dengan
40Tahun PLT : 161 -Ketorolac 30mg/8jam/iv
flail chest
MRS: 21-01- PT/APTT : -Flail costa VII-IX posterior
- Ranitidine
2019 10.2/20.0 dextra
50mg/12jam/iv

GDS : 120 - Neurobion 1

USG Abdomen Whole
 UR/CR : 32/1.05 Abdomen 21-01-2019 amp/12jam/iv

SGOT/SGPT : Kesan : -Boleh pindah perawatan

130/243
-Efusi pleura bilateral
Na/K/Cl : -Ascites
138/4.4/106 -Organ-organ intra abdomen
lain yang terscan dalam batas
HBsAg : Non normal
reactive

CT Scan Kepala
(TanpaKontras) 21-01-2019 :

-Tidak tampak lesi

hipodens/hiperdens patologik
intracranial
-Haematomastoid dextra
-Multihaematosinus
-Frakturos mastoid dextra
-Deviasi septum nasi
-Concha bulosasinistra
-Soft tissue swelling disertai
emfisema subkutis region
temporal dextra
3
TRAUMATIC BRAIN
HCU 3 INJURY GCS 15

DG SIKKI

845469

25-09-1963

55 TAHUN

MRS 29-01-
2019

4 HCU 4 -TBI GCS 15 25-01-2019 CT KEPALA (11/1/19) AAI

MAX -Intracerebral - perdarahan intracerebri pada

 ALKADRI Haemorragik WBC: 10.300 lobus frontotemporalis kanan. -O2 NC 2-4 LPM
TAGOE
-ICH Frontotemporal HGB : 9.9 -perdarahan intercerebellum - NACL 0.9% 28tpm
869385 sinistra bilateral
HCT: 30 -Cefotaxime 1gr/12jam/iv
(10/6/1961) -Subarachnoid - perdarahan subarachnoid
Haemorragik PLT : 733.000 region temporalis dextra, -Metronidazole
MRS: parietoocipital bilateral dan 1gr/8jam/iv
-Fraktur os. Occipital GDS:122
frontalis bilateral serta falx
Sinistra -Omeprazole
Ur/Cr : 31/0.64 cerebri
4mg/24jam/iv

SGOT/SGPT : 58/94 -perdarahan subdural region

occipitalis dextra
Albumin : 3.1
-Brain swelling
Na/K/Cl :
131/4.5/99 -sinusitis maxillaries dextra

21-01-2019 -Fraktur OS occipital sinistra

GDS : 135 - Subgaleal hematom region

occipital bilateral terutamas
Ur/Cr : 30/0.73 inistra.

Na/K/Cl : Foto Thorax (11/1/19)

132/3.0/100
-kontusio pulmo dextra
30-01-2019
Na/K/Cl: -dilatatio et elongation aortae
128/4.2/98
-tulang-tulang intak.
5 HCU 5 TRAUMA BRAIN 27-01-2019 FotoKepalaAP+Lateral (18- - Infus NaCl 0.9% DW
INJURY 01-2019) :
MUH.ISHAK WBC -Cefotaxime 1 gr/12
871242 -Tidak tampak kelainan jam/IV (Skin Test)
17-01-2004 RBC 3.61 radiologic pada foto skul ini
-Metamizole 1gr/8jam/IV
MRS 27-01- HB 10.3 CT Kepala (TanpaKontras)
2019 -Ranitidine 50
27-01-2019 :
HCT 30.4 mg/12jam/IV
- Perdarahan epidural
PLT191 -Diet lunak/hari
region frontal sisi
GDS 149 dextra dan parietal
-Mobilisasi duduk
sinistra dengan
estimasi volume
 UR/CR : 20/0.51 perdarahan -/+ 17 HU -Infusconnecta
- Perdarahan
SGOT/SGPT : 49/13 intraventrikel lateral -Betadine kumur / 8 jam
sinistra cornu
HBsAg (ICT) : Non
posterior
Reactive
- Brain edema
Anti HCV : Non - Subgaleal hematom
Reactive regio
frontotemporoparietal
Na/K/Cl : bilateral
135/4/1/103

6 HCU Bed 6 POH 6 aff VP Shunt 24/1/2019 20/10/2018: -rawat luka AAI
DARAH RUTIN: -terapi sesuai TS Plastik
NUR ALISYAH WBC:12.4 CT SCAN KEPALA (DENGAN
AZZAHRA RBC: 3.84 KONTRAS)
HGB:9.9
860192 HCT:31 KESAN:
PLT:150
12-09-2018 - Hydrochepalus
communicans
30-01-2019 - Lesi hypodens region
4 bulan
WBC: 17.0 frontalis bilateral suspek
RBC: 2.99 infeksi DD/ focal edema
HGB: 7.4 19/1/2019
MRS 18-01-2019 GDS: 86
UR: 9 FOTO THORAKS PA/AP:
CR:0.19
- Terpasang VP Shunt
SGOT: 63
- Cor dan pulmo normal
SGPT:48
NA/K/CL: 101/4.2/83

7 HCU 7 HEMIPARESE 23/1/2019 - Ranitidine DW

DEXTRA et causa FOTO THORAX PA/AP 50mg/12jam/iv
A.NIRWAN SUSPECT DARAH RUTIN: (23-01-2019) - Cefotaxime
DEWI GLIOBLASTOMA - Pneumonia Dextra 1gr/12/jam/iv
MULTIPLE DD WBC: 10.6 - Dilatatio Aorta - NAC
868331 ABSES CEREBRI 200gr/8jam/oral
RBC:3.38 - Pracetamol
30-12-1958 1gr/8jam/iv
(60TAHUN) HGB:9.4 - Nebu combivent
/ 8jam
HCT: 28 - NAC
200mg/8jam/oral
MRS 08-01- PLT:380 \
Pantau kesadaran dam
 2019 NA/K/CL: tanda vital
133/3.5/101

8 HCU 8 FOTO THORAX PA/AP -Infus NaCl 0.9% DW

- Cord an Pulmo normal
SYAMSUDDIN TRAUMATICBRAIN 26-01-2019 -Tulang-tulang intak -Ceftriaxone 1gr/12jam/iv
BIN JUMA INJURY GCS 14 EC
EDH WBC : 13.1 -Ranitidin 50mg/12jam/iv
871225 PARIETEMPORAL
RBC : 4.26 - Metamizole 1gr/8jam/iv
SINISTRA dan ICH
04-02-1969
TEMPORAL HGB : 13.3 - Rawat luka
49 TAHUN DEXTRA
PLT : 261
Poh 4
PT/APTT :
MRS 26-01- 10.5/25.4
2019
GDS : 155

UR/CR : 35/0.31

SGOT/SGPT : 31/22

Na/K/Cl :
134/3.8/102

HBsAg : Non
reactive

30-01-2019
WBC: 11.6
RBC: 3.64
HGB: 11.2
Na/K/Cl:
133/3.6/107
9 HCU 9 -POH 9 REVISI VA 27-01-2019 FOTO THORAX PA/AP -NaCl 0.9% 20tpm NAL
SHUNT EC
RAHMATAN WBC : 11.2 - Bronchopneumonia -ceftriaxone 1gr/8jam/iv
MALFUNCTION VA bilateral
SHUNT - Cardiomegali disertai
850295 RBC : 3.73 -citicolin 250 mg/8jam/iv
dilatatioaorta
-ULCUS PEPTICUM
20-04-1975 HGB : 11.5 -neurobion 1amp/8jam/iv

43 TAHUN PLT : 502 - VIP Albumin 2

CT KEPALA (TANPA tab/8jam/via sonde NGT
 HCT: 34 KONTRAS) -Ondansentron 4mg/12
jam/iv
MRS 15-01- - Hydrochepalus
communicans
2019 - Terapi nutrisi sesuai TS
- Brain Edema
- Terpasang VP shunt dengan tip Gizi Klinik
pada cornu posterior ventrikel
lateral dextra -mobilisasimiring kanan
dan kiri/ 2jam

-
10 HCU 10 Tumor suprasellar DD/ 20-01-2019 -Primary bone tumor pada -Asam mefenamat 3x DW
Meningiaoma WBC 12,3 sphenoid bone meluas ke sinus 500mg/ oral
MARTINUS RBC 3,12
842974 sphenoidalis dan ethmoidalis -Ondansentron
HGB 9,3
11/01/1957
PLT 268 bilateral kena sopharynx dan 8mg/12jam/iv
61 tahun
13-01-2019 posterior cavum nasi serta -Metamizol 1gr/8jam/iv
MRS 13-01- Wbc 11.83
mendestruksi os ethmoid dan -Alprazolam
2019 Hb 10.9
Plt 421 clivus suspek chordoma DD/ 0.5mg/24jam/oral
Rbc 3.85 meningioma -Antasida syrup 2cth/
Pt/apt 10.9/21.8
-Deviasi septum nasi 8jam/oral
Gds 121
Ur/cr 25/ 0.85 - Rhinitis chronic
Sgot/sgpt 38/24 hypertrophycans
Na/k/cl 137/4.6/104

11 HCU 11 PARESTESIA 26-01-2019 FOTO THORAX PA/AP -Meropenem 1gr/8jam/iv DW

EXTREMITAS (20-01-2019)
HALIA BILATERAL POST WBC 24.9 - Metronidazole
SYRINGECTOMY -Cardiomegali 1gr/8jam/iv
814108 RBC 4.36
-Pulmo dalam batas normal -OMZ 4gr/12jam/iv
17-11-2019 HB 13.8
MRI C-SPINE (TANPA
PLT 446 KONTRAS) (14-01-2019)
MRS 20-01- PT/APTT Hemiparese Sinistra
2019
INR

GDS 99

UR/CR 24/0.53
 SGOT/PT 26/33

Na/K/Cl
134/4.0/102

HBsAg: non-
reactive

Anti HCV: non-

reactive.

12 HCU 12

MUHAMMAD
RISWAN