1

REKAP PASIEN BEDAH SARAF 19 JANUARI 2015

Jeumpa 1

NO NAMA/UMUR/ KAMAR/CM

DPJP TANGGAL

MASUK AD

TGGL OP POD

DIAGNOSA LAB

PLANNING

1. M. Daud/69th/1034596/K2B2

dr. Imam 9-1-2015

7

10-1-2015

9 CKS+subdural Hygroma+Negleted Open

Fraktur Supra Condiler Femur S

Hb 13,1

RAWAT ALIH ORTHO

2. FAHMI/31 thn/iso 1/1034540

dr. ISKANDAR 12-1-2015 4

14-1-2015 5 Post Laminotomy ai. HNP L4-

L5 Hb 13,1

mobilisasi

3. Fauzi/38/K6B5/0903310

dr. Iskandar 8-1-2015 9

Tumor intracranial post

removal tumor Hb 15,9

Fisioterapi dilanjutkan (pindahan dari IW)

4. Mukhtar/54thn/1036549 Dr. Bustami 14-1-2015

15-1-2015 4 Post op Vp Shunt ai. Hydrosephalus + tumor

cerebelum

Hb 10,6

Konfirmasi hasil elektrolit

5.

6.

Jeumpa 2

NO NAMA/UMUR/

KAMAR/CM DPJP

TANGGAL MASUK

AD TGGL

OP POD DIAGNOSA LAB PLANNING

1 Alfaizin

/12th/K5B1/1024452 dr.iskandar

26/11/2014

48 11

Post vp shunt ec hidrocepalus 2 kali +ich+postcraniektomy+fr depress

prolapcerebri+closefrhumeruss sin. +close fr. Antebrakii sin.

Hb 10,7 Leu 10,9

2 Manawiyah/46th/k7b3

/1030944 dr.iskandar 30/12 14 -

CRANIECTOMY DEBRIDEMENT, EC. Abses+infected wound ec. Craniotomy

Hb 11 Susul hasil kultur

2

removal tumor ec. meningioma

4. Roslita/25

thn/K6B5/1035616 dr.Iskandar

8 jan 2015

8 14 jan 2015

5 Tumor fossa posterior+hydrosephalus

non cummunican Hb 12,3 Leu 14,5

5. Cut Rosmadiana/25 thn/k3b2/1028063

Dr. Bus 6-1-2015 9

14 jan 2015

5 Tumor IntraCranial GLIOMA pro :

Craniotomy removal tumor Hb 9,5

Leu 13,9 Observasi fungsi neurologis

Jeumpa 3

no Nama/umur/ kamar/cm

dpjp Tanggal masuk

AD Tggl OP POD diagnosa lab planning

1. Sakiran/62 thn/0674442/ /K4B3

Dr. bustami 8-1-2015 3 15/1/201

5 4

Post craniektomi bedah mikro eksisi tumor ec. meningioma

Hb 10,6 Leu 14,4

2. Sakdiah/77

th/1035789/K4B1 dr. bustami 10-1-2015 7

13-1-

2015 5

Post VP SHUNT ec.

ICH+hydrosephalus Hb 13,5

Leu 14,5

3. Ilyas Ben/50th/1034387/k6b6

Dr. Iskandar 30-12-2014 17

Post craniotomy a/i ich a/r temporoparietal dextra

Hb 11,4 Bedah saraf

pbj

4.

Jeumpa 4

no Nama/umur/ kamar/cm DPJP Tanggal masuk AD Tggl OP POD diagnosa lab planning

1 Salwa/32th/1025349/k7b1 dr.

bustami 12/11 46

20/11-2014

31 Post debridement + re-hecting ec

infected wound + post op craniotomy ec intracerebral tumor

Lab 18/1

Hb 11,3 Leu 20,8 Alb 2,5

Cek darah rutin 4 hari

sekali, kultur pus,

albumin

3

Gelima 1

No Nama/umur/

kamar/cm DPJP

Tanggal masuk

AD Tggl OP POD diagnosa lab planning

1. Monizar/41th/8465

83/k7b3 Dr bustami 14/1/2015 4 Metastase intrakranial Hb 12,9

Konsul onkologi

Konsul btkv

2.

Serune 1

No Nama/umur/

kamar/cm Dpjp

Tanggal masuk

AD Tggl OP POD diagnosa lab planning

1. Levisa

Hanum/10thn/K6B4

Dr. Iskandar

31-12-2014 14 - - Abses cerebri a/r ganglia basalis + TOF Hb

17,6 Ct Scan ( )

Seurune 2

No Nama/umur/ kamar/cm

Dpjp Tanggal masuk

AD Tggl OP POD diagnosa lab planning

1. Azkiya agniya/4 bulan. K2b1/1018638

Dr. bus 15-1-2015 16-1-2015

3 Mielokel lumbo sakral Hb 10, 1 Cek luka n produksi urin

2

4

HCU

NO NAMA/UMUR/

KAMAR/CM DPJP TANGGAL MASUK AD TGGL OP POD DIAGNOSA LAB PLANNING

1 Nasruddin/47thn/B3/1034547 dr. Iskandar 5-1-2015

11 7-1-2015

13 Post craniotomy evakuasi ICH+IVH ar.

Ganglia basalis Dex + pneumonia Hb 8, 1

2. Tgk. H Jamaluddin A latif/60thn/1035808/ B2

Dr. Imam 10-1-2015

11-1-2015

7 Post Craniotomy EC. SDH ar.

Temporoparietal + HT stage II Hb 11,6 Rawat luka

3

ICU

No Nama/umur/

kamar/cm DPJP

Tanggal masuk

AD Tggl OP POD DIAGNOSA lab planning

1 Abdullah Isya/70

thn/1035149 dr. Imam 6-1-2015 8 9-1-15 10

CKS+SDH+open fraktur tibia dan fibula sin. 1/3 tengah

Hb 10,3

2. Abdullah/19

thn/1035143/bed 5

dr. Imam 6-1-2015 8 7-1-15 10 Post Craniotomy ec. Diffuse Axional

Injury + evakuasi SAH Hb 10,3

3. Mudawali/14

thn/1036757/bed 4

dr. bustami 17-1-2015

1

Ckb + ich ar. Frontotemporal sinistra +

post wsd a/i pneumothoraks Hb 11,4 Leu 18,6

4.

5

NICU

No Nama/umur/

kamar/cm DPJP

Tanggal masuk

AD Tggl OP POD DIAGNOSA lab planning

1 Nurhasanah/ 5 hari/1034855/lv. 2

dr. iskandar

4/1 7/1/2015

8 Post Reseksi Meningo ensefalokel Hb 12,1

Gv/3 hari rawat Luka

2 By Karlina/13 hari/Level III/1035095

dr. Imam 5 jan 2015

Congenital Hydrosephalus + asfiksia ringan-sedang + NCB-SMK

Hb 16,6 Ct-scan Kepala

PICU

No Nama/umur/

kamar/cm DPJP

Tanggal masuk

AD Tggl OP POD DIAGNOSA lab planning

1

INTERMEDIET

No Nama/umur/

kamar/cm DPJP

Tanggal masuk

AD Tggl OP POD DIAGNOSA lab planning

1 Nurlita/60THN/1035616/b4

Dr. bustami SOL dd : Glioblastoma

Hb 13,2 Hb post op?

2. Dhany,36 thn CKR

PJT

No Nama/umur/

kamar/cm DPJP

Tanggal masuk

AD Tggl OP POD DIAGNOSA lab planning

1. Habsah Ibrahim/49/1034193

Dr. Imam 29-12-2014 12-1-2015

6 Post VP Shunt a/i hidrocephalus ec

tumor intracranial Hb 13,7 Hasil Sitologi LCS

19/1/2015

6

GEURUTE

No Nama/umur/

kamar/cm DPJP

Tanggal masuk

AD Tggl OP POD DIAGNOSA lab planning

1. Surya waldi,1036310/50 thn

dr. BUSTAMI

15 jan 2015

4 Post VP Shunt EC. +hidrosefalus +

ich + AKI

Hb 10,4. Ureum 9,1. Kreatinin 3,6

Konsul interna divisi ginjal hipertensi