List pasien 29/11/19

IRINA A ATAS
A1.2 Tumbol Jeremiah/L/25th/708910 Kista kongenital Lab : 23/11/2019 Oksigenasi
frontal dekstra
MRS: 24/11/219 Leu : 12,3 Elevasi kepala 30
Fr. Clavicula derajat
DPJP: Prof. Dr. dr. Eko Prasetyo SpBS(K) dekstra 1/3 media Eri : 5,31
Analgetik
Fr. Zygoma Hb: 15,8
dekstra Antibiotik
Ht: 45,3
Mobilisasi
Tro: 251
Rencana APS
MCH: 29,8

MCHC : 34,9

MCV : 85,2

SGOT : 23

SGPT : 11

CI : 101,7

K : 3,99

Na : 143

A8.5 Agow Sandy/L/ 19 th/1707346 Vulus skizum Lab : 25/11/2019 Mobilisasi

 MRS : servikal + Ruptur Leu : 15 belajar duduk
duramater + Fr.
DPJP: Dr.dr. Eko Prasetyo,SpBS(K) Servikal II + Eri : 4,88 Antibiotik

S : Kelemahan anggota gerak kanan Ulkus dekubitus Hb: 14,9 Analgetik

grade.I
O: KU Cukup Kes E4V5M6 Ht: 41,5 Rawat luka

Tro: 318 Aff drain

MCH: 30,5

MCHC : 30,5

MCV : 85,1

SGOT : 29

SGPT : 34

CI : 99,1

K : 4,68

Na : 138

A9.4 Tumbol Noel/ L/ 5 th/708922 Fraktur Os Lab 24/11/19 Observasi

Frontal Dextra kesadaran
MRS: 24/11/2019 Leukosit 20.5
Antibiotik
DPJP: Prof. Dr. dr. Eko Prasetyo SpBS(K) Eritrosit 4.37
Analgetik
Hb 12.4
 S: Nyeri kepala Ht 34.9 Rawat
lukandebgan
O: Trombosit 446 salep
KU Baik GCS E4V5M6 MCH 28.5

R Frontal: Luka terawat MCHC 35.6

MCV 80

SGOT 40

SGPT 14

Ureum 26

Cr 0.3

PT12.9/14.2

INT 1,03/1,17

APTT 29/34.5

Na 141

K 3.29

Cl 99

A11.1 Mamuaya Risca/P/4th/709551 EDH regio Lab 28/11/19 Observasi tanda

temporal Sinistra peningkayan
MRS:28/11/19 Leukosit 10 TIK
DPJP Dr. dr. Maximillian Oley , SpBS(K) Eritrosit 4,33 Head of bed 30

Hb 12 Antibiotik

S: Nyeri kepala + Ht 33,6 Analgetik

O: GCS E4V5M6 Trombosit 251

Kepala : CA(-), pupil bulat isokor o 3mm, RC MCH 27,7

(+)
MCHC 35,7

MCV 77,6

SGOT 59

SGPT 39

Ureum 20

Cr 0.3

PT 12.6/15,4

INT 0,94/1,15

APTT 38,1/36.0
 IRINA A BAWAH
B3.1 Korompot Feraldi/L/15th/709038 Fr.depressed temporo Lab:25/11/2019 Oksigenasi
occipital dextra
Dr.dr. Eko Prasetyo,SpBS(K) Leu: 15,5 Elevasi head of bed
Vulnus laserasi 30
r.temporoparietal dextra Eri: 5,00
Rawat luka
S: Penurunan kesadaran Hb: 14,4
Antibiotik
O: Ht: 41,2
Analgetik
KU Cukup Kes E2V2M5 Trombo : 238

Pupilbulat isokor 3/3mm MCH : 28,9

R.temporooccipital dextra : Hematoma uk MCHC: 35,0

5x6cm
MCV: 82,5

Cl : 98,6

K : 3,79

Na: 138

B3.2 Sobarik Ateng/L/25th/708516 EDH Parietal Sinistra Lab:20/11/2019 l Elevasi Head of Bed
30O
 MRS: 20/11/2019 Fr. Basis cranii media Leu: 19,8 Oksigenasi

DPJP : Dr. dr. Maximillian Oley , SpBS(K) Pneumatocele Eri: 4,64 Rawat luka

S: Nyeri Kepala – Hb: 14,9 Antibiotik

O: KU: Baik Ht: 42,5 Analgetik

Kes E3V5M6 Trombo : 313 Mobilisasi

Pupil bulat isokor 3mm/3mm, RC +/+ MCH : 32,1

Reg. auricula dextra : Luka terawat + MCHC: 35,0

MCV: 91,7

Cl : 97,4

K : 3,17

Na 130

1 B3.3 Hendrik Takalumang/ L/21th/ 705482 Post craniectomi ec Lab:28/11/2019 Elevasi Head of Bed
EDH temporoparietal 30O
MRS : Dextra Leu: 17,3 Cek Hasil
CT Scan Oksigenasi via
DPJP: Dr. dr. Maximillian Oley , SpBS(K) Multiple ICH Eri: 3.55 kontrol trakeostomi
Hb: 10,8 Rawat luka
S : Penurunan kesadaran, Ht: 31 Antibiotik
O: Trombo : 552 Analgetik
 KU: berat MCH : 30,,6

GCS: E2V1M3 MCHC: 35,0

Pupil bulat isokor 3mm/3mm, RC +/+ MCV: 87,3

Region temporoparietal D: luka terbuka +, Cl : 91,3

teraba tulang +
K : 4,36
Region colli: trakeostomy +
Na : 133

2 B3.4 Makalunsenge Muhammad EDH Temporaparietal Lab 22/11/19 Oksigenasi

Fahrul/L/9th/708709 Dekstra
Leukosit 19,2 Elevasi head of bed
MRS: 22/11/19 Fr. Os. Temporal 30°
Sinistra Eritrosit 4,11
Dpjp: Dr. dr. Eko Prasetyo SpBS (K) Antibiotik
Hb 10,3
Analgetik
Ht 30,6
S: Nyeri kepala + Rawat luka
O: KU: cukup, ks: CM, GCS : E4M5V6 Trombosit 349

Pupil bulat isokor 3-3mm, RC +/+ MCH 25,1

R, temporal dextra : Hematoma MCHC 33,8

MCV 74,3

SGOT 35

SGPT 11
 Ureum 23

Cr 05

GDS 158

PT 15/15,2

INT 1,26/1,28

APTT 30,5/35,2

Na 129

K 4,01

Cl 95,7

7 B7.2 Rumeen Wiliam/ L/ 84 tahun/708362 SDH temporoparietal Lab 23/11/19 Observasi kedadaean
occipital Dextra + Fr.
MRS: 19/11/2019 Collum femur sinistra Leukosit 8,1 Oksigenasi

DPJP: Prof. Dr. dr. Eko Prasetyo SpBS(K) + parkinson Eritrosit 3,9 Antibiotik

Hb 12,5 Analgetik

S: nyeri kepala Ht 33,8 Terapi sesuai TS

orthopedi
O: Trombosit 178

KU;Cukup Kes E4V5M6 MCH 32,1

Pupil bulat isokor 3/3mm MCHC 37,0

 R.Supraorbital : Luka terawat MCV 86,7

R.Frontoparietooccipital :Luka terawat SGOT 23

SGPT 21

Ureum 61

Cr 1,1

GDS 242

8 B7.6 Raden Virlan/L/15th/709525 Cedera otak Ringan Lab 28/11/19 Cegah secondary
brain injury
MRS: 28/11/2019 Multiple Vulnus Leukosit 18,0
Ekskoriasi Atasi nyeri
DPJP: Dr. dr. Maximillian Oley , SpBS(K) Eritrosit 5,01
Rawa luka
Hb 14,5

Ht 42,6

Trombosit 256

MCH 29

MCHC 34,3

MCV 84,4

SGOT 30
 SGPT 22

Ureum 27

Cr 0,7

GDS 99

PT 13,5/15,4

INT 1,00/1,15

APTT 32,4/36

Na 129

K 4,

7 B8.3 Derek Tobias/L/65th/709530 Subdural Hygroma Lab 28/11/19 Perbaiki KU

Frontoparietal sinistra
MRS: 28/11/2019 Leukosit 9,,5 Oksigenasi

DPJP: Dr. dr. Maximillian Oley , SpBS(K) Eritrosit 3,02 Antipiretik

S: penurunan kesadaran akibat KLL Hb 8,5 Antibiotik

O: GCS E3V5M6 Ht 24,3

TD: 120/70 N:73 R:20 SB: 36,5 Trombosit 164

 Pupil bulat isokor 3/3mm MCH 28,3

R. Frontal sinistra : Hematom uk 5cm MCHC 35,2

Luka terjahit uk 4cm MCV 80,4

SGOT 52

SGPT 16

Ureum 22

Cr 0,9

8 B9.7 Wenur Hokta/ L/ 48 tahun/708902 SDH Frontotemporal Lab 23/11/19 Rawat luka
sinistra
MRS: 24/11/2019 +Pneumatocele + Leukosit 21,5 Oksigenasi

DPJP: Prof. Dr. dr. Eko Prasetyo SpBS(K) Fr.segmental os Eritrosit 4,58 Antibiotik
frontal + Fr.
Zygomamaxillary Hb 13,0 Analgetik
complex
S: nyeri kepala Ht 39,2 Elevasi head of bed
30°
O: Trombosit 337
Debridement
KU;Cukup Kes E4V5M6 MCH 28,4

Pupil bulat isokor 3/3mm MCHC 33,2

R.Supraorbital : Luka terawat MCV 85,6

 R.Frontoparietooccipital :Luka terawat SGOT 30

SGPT 15

Ureum 30

Cr 0,8

GDS 101

PT 14,5/14,2

INT 1,21/1,17

APTT 29,7/34,5

Na : 137

8.1 Laoh Nuordin/65th/L/709633 CKR + Vulnus Eksoriasis Lab 29/11/19 Rawat luka

MRS: 29/11/2019 Leukosit 12,9 Oksigenasi

DPJP: Prof. Dr. dr. Eko Prasetyo SpBS(K) Eritrosit 5,48 Antibiotik

Hb 16,4 Analgetik

S: Penurunan Kesadaran ajibat terjatuh, Ht 49,5 Elevasi head of bed

riwayat hipertensi (+) 30°
Trombosit 302
O: Cegah cedera otak
MCH 30,0
 KU;Cukup Kes somnolent GCS E3V5M6 MCHC 33,2

Pupil bulat isokor 3/3mm MCV 90,3

Kepala: Luka lecet 2cm SGOT 30

SGPT 15

Ureum 41

Cr 1,3

GDS 105

IRINA A TERATAI
1 Kls 2 Legoh M Yulius/L/37th/709684 Higroma sub Lab 30/11/19 CT scan kepala: rencana op
bed 5 dural elektif (NS)
MRS: 30/11/19 Leukosit 23,7 Higroma
Fr Sinus Frontal subdural
DPJP : Posterior Eritrosit 4,6
Fr. Sinistra
Dr. dr. Maximillian Oley SpBS(K) Fr zygomatica Hb 15,0 frontal posterior
Dr. dr. Mendy H. Oley SpBP (K) RE Sinistra Pars Ht 41,7
Maxilatis os
 Frontalus Trombosit 283

old Fr MCH 32,6

dentoalveolar
superior dextra + MCHC 36,0
avulsi ginggiva MCV 90,6
incisivius I-II
Dextra superior SGOT 41

SGPT 30

Ureum 73

PT 14,2/15.2

INR 1,06/1.13

APTT 34,4/37,2

Na 144

K 3.91

Cl 104,5

ICU BAWAH
1 ICU Bed Tampah Joseph/L/71 th/705266 Post craniectomy Lab 22/11/19 -analgesik
8 MRS: 18/09/19 decompresi ec Leu 17.7
SDH Eri 3.55 -antibiotic
Hb/Ht : 12.4/37.2 Mobilisasi
DPJP: Dr.dr. Eko Prasetyo,SpBS(K)
Netro.Bat : 5
Rawat luka
MCV 104.7
S: Penurunan kesadaran Elevasi head of bed
O: KU: sedang, GCS : E1M2V2 Trombosit 412 30°
MCH 34.8

MCHC 33.3

2 ICU bed Fano Rindengan /L/43th/707928 Post kraniektomi 25/11/2019 Observasi TIK
12 ec ICH Frontal + Leu : 18.9
MRS :16/11/2019 SDH regio Eri : 2.81 Antibiotik
temporal Hb : 8.9 Analgetik
Ht : 24,7
DPJP: Dr.dr. Maximillian Oley, SpBS(K)
Tro :480

S: - MCH 31,7

O : GCS :E2M3V5 MCHC 36,1

MCV 87,8
3 Bed 3 Egbert mansye/P/66thn/708887 Post craniectomi Leukosit 13,2 Rawat luka
dekompresi ec
MRS:23/11/2019 SDH Eritrosit 3,16 Antibiotik
frontoparietotemp Hb 10,2 Analgetik
oroocipital sinistra
Dpjp: Dr. dr. E. Prasetyo, SpBS (K) Ht 28 Oksigenasi

Tromboit 228

MCH32,1

MCHC 36.2

MCV 88.7

SGOT 712

SGPT 638

Albumin2,77

PICU
Potabuga EDH 25/11/19
Ersa/L/16th/709022 Frontal
Dekstra Leukosit
MRS: 25/11/19 15,7
SAH
DPJP : Dr. dr. Eko Eritrosit
Prasetyo SpBS (K) Fr. Zygoma 4.14
D
Hb 11,6
Fr.
S: Penurunan Semental Ht 33
Kesadaran Mandibula Trombosit
O: E1M3B2R1 166

MCH 228

MCHC 35

MCV 79

SGOT 1,998

SGPT 1,035

Ureum 23

Cr 0,9,

GDS 187

PT 25,1/12,5
 INT 2,5/0,99

APTT
27,1/35,4

Na 144

K 2,91

Cl 102,0

HCU
1 2.14 Sondakh Joshua Wuisan/L/ 17 th/709099 Post Craniotomy Lab 28/11/19 Cek Lab lengkap
Decompression +AGD
MRS : 25/11/19 e.c Epidural Leuko: 10,3 (terlampir)
DPJP: Dr.dr. Eko Prasetyo,SpBS(K) Hematoma regio Eritrosit 3.08
frontoparietal Konsul rehab
S : On Sedasi sinistra hari ke-II Hb 9,0 medik

O: Regiofrontroparietal sinistra : Tampak luka Ht 25,3 Antibiotik

terawat Antipiretik
Trombosit 221
Drain: 75cc Hemorargik Ts lain sesuai ts
MCH 29.4
Kes : HCU
MCHC 35,7
MCV 82,2

SGOT 39

SGPT 18

Ur 33

Cr 0.9

Gds : 139

Cl : 100,1

K : 3,69

Na : 139