TITIPANLONTARA 2 BAWAH BELAKANG

K4b1nIrma70857922-8-1989MRS: 15-4-2015DR. Andi ikhwan, Sp.BsS: nyeri O: sAdara GCS 15A: TCR: GCS 15 FRAKTUR PALATUMDIGITI 1 PEDIS DEXTRARL: 28 TPMCeftriaxone 1gr/12 jsam/ivRanitidine 50 mg/8jam/ivKetorolac 30mg/8jam/ivPiracetam 1mg/8jam/ivO2 nasal kanulKonsul ortopedi

K8b2Ridwan7085781781986MRS 15-4-2015DR ANDI .IKHWAN SP.BsS: NYERI KEPALAO: ku baik GCS 15A: tcr gcs 12RL: 28 TPMCeftriaxone 1gr/12 jsam/ivRanitidine 50 mg/8jam/ivKetorolac 30mg/8jam/ivPiracetam 1mg/8jam/ivO2 nasal kanul

K9B5LARASWATI70882521-10-1990Mrs 17-4-2015D.dr DJOKO WIDODO,SPBsS: keluhan nyeri kepala O: ku sedang gcs 13A: tcr gcs 11CeftriaxoneKetorolacRanitidine

LONTARA 3 BAWAH BELAKANG

K3B1Abd. Muhai1-1-1972708235MRS 13-4-2015Dr. Dr. Nasrullah Sp.BSS : O: Ku: sedang, GCS 15AInfus RL 28 tetes/menitCeftriaxone 1 gr/12 jam/intravenaKetorolac 30 mg/8jam/intravena17-4-2015na/k/cl: 140/3.7/109 13-4-2015WBC 9.3 SGOT/SGPT: 14/25RBC 5.8 PT/APTT 10/22.6HGB 17.8 GDS 84HCT 49 PT/APTT: 10/22.6BT 3.00CT 8.00

K3B6M. Said31/12/1949479757MRS: 7-4-2015Dr. Dr. Nasrullah Sp.BSS : lemah pada kedua tanaganO : sadar , GCS 15, A: tumor medulaa spinalisOmcal 1x1MRI T spine (dengan kontras )-Multiple lsi intra osseus yang melibatkan pedikel dan prosesus spinosus pada CV T1 s/d T12, L1 s/d L3 sesuai metasstasis ke vertebra- Destruksi dan lesi intra osseus CV T5 dn T8 disertai destruksipdikel sisi kiri, mendesak techal sac dan spinal cord dan menyebakkan stenosis parsial kanalis vertebralis- Destruksi dan lesi intraosseus CV Th12 disertai detruksi pedikel sisi kanan kir, mendesak thecal sac dan spinal cord yang menyebabkan stem=nosis total kanalis spinalis- spondylosis Thoracolumbalis- Degenerative Disc DiseaseMR Myelography : stenosis parsial level CV Th 5 dan stenosis totalis Level CV Th 1218-4-2015WBC 12.6 RBC: 3.17HGB 8.8 HCT 26MCV 81 PLT: 176GDS: 113 UR/CR 73/11.15SGOT/SGPT 45/18 Na/K/CL 139/3.2/10613-4-2015PSA >100.0

Lontata 3 atas depan

K1b3Syamsuddin4-9-1986697720MRS: 17-4-2015Dr. djoko widodo, SPBsParese otomastoiditis kronik dextraS: nyeri telinga kiriO: ku baik

19-4-2015Ur/Cr : 17/0.909-4-2015wbc: 7.6 RBC: 5.50HGB 17.3 HCT 52MCV 95 PLT 312GDS 107 Ur/Cr: 15/0.80

msct kepala dgn kontras 20-4-2015Klinis otomastoiditis dextraUraian kesan pemeriksaan:Cerebritis region temporal dextraOtomastoiditis

K1B6Mustari708963mrs 19-4-201531-12-1954DR.dr. djoko widodo, SPBsS: nyeri kepLaO ku sadar gcs 15A trauma capitis sedang gcs 12

Rl 28 tpmCeftriaxone KetorolacRanitidine mannitol9-4-2015wbc 7.6 rbc 5.50hgb 17.3 hct 52mcv 95 plt 312ur/cr 15/0.80 gds 107

LONTARA 3 ATAS BELAKANG

K5b4Ashar27/10/1971707407

MRS : 07/04/2015DR.dr. Djoko Widodo, Sp.BSS: nyeri kepalaO: status generalis SS/Gizi cukup?composmentisGCS 15 (E4M5V6)Pupil isokor 3mm/3mmRC +/+IVFD RL 20 tpmKetorolac 30mg/8 jam/ivRanitidin 50 mg/8jam/ivLab 7/4/15WBC 14.9 RBC 4.25HB 12.5 HCT 38PLT 587CT/BT 900/300PT/APTT 10.6/27.8GDS 129Na/K/Cl 128/4.6/92Ur/Cr 17/0.50GOT/GPT 28/66

Foto lumbosakral AP lateral 7/4/15-Kurva lordotik kesan melurus (muscle spasm)-spondylosis lumbalis

MRI 09/04/2015 :Facet joint edema CV L2-L3, dan CV L3-L4Ekstrusio Disc Cv L4-L5 yang menekan thecal sac dan kedua nerve root, menyebabkan stenosis totalis canalis spinalis pada level tersebut. Facet joint edema kanan dan penebalan ligamentum plavum pada level tersebut,Protrusio disc CV L5-S1 yang menekan thecal sac dan menekan kedua nerve root, menyebabkan stenosis totalis canalis spinalis pada level tersebutDegenerative disc disease

K3b2Rahman708967MRS 19-4-20156-6-1996Dr.dr. djokowidodo, SpBsS: nyeri kepala GCS 15A: tcr gcs 15Terapi sesuai teman sejawatWbc 18.7Rbc 5.11Hgb 14.9Hct 45Mcv 88Plt 283Pt/apt 10.9/26.4Ur/cr 19/0.90Sgot 37

K4b1708992mrs 19-4-2015Novita indah29-11-1985Prof DR dr andi asadul islam SPBsTrauma capitis ringan gcs 15Epidural hematom frontal dextraRl 28 tpmCeftriaxone RanitidineKetorolacO2 nasal kanulHead up 30 derajatWbc 10.1Rbc 3.89Hgb 11.1Hct 34Mcv 86Plt 293Ur/cr 10/0.56Sgot 15Sgpt 10

Nicu

Kamar IIBBy. Ny. Syahra19-03-2015705393

MRS 19/3/2015

DR.dr.Djoko Widodo,Sp.BSS: kepala membesarO: Lingkar kepala 33,5 cmA: HidrocephalusRencana VP shunt hari senin 13 april 2015Lab 09/04/15CT/Bt 900/300PT/APTT 10.5/33.4

Lab 08/4/15WBC 16.8RBC 3.58HB 13.2HCT 39 PLT 358GDS 74Ur/Cr 16/0.57Got/Gpt 28/10Na/K/Cl 130/4.6/102

CT scan kepala (07/4/15)Kesan: -hidrocephalus-suspek meningitis

Foto thorax PA/AP-terpasang gastric tube dengan tip berada pd rongga abdomen-Gambaran hyaline membrane disease grade 1

By ny suryanti70921320-4-2015Hydeocephalus communicansCt scan kepala-Dandy waters-perdarahan subdural regio parietoocipital dextra dan intraventrikel-subdural hygnoma frontotemporal kiri-hydrocphalus communicAns-cavum septum pellucidum ersisten

Icu

Bed 1HermanRM: 70-58-4824-08-1965

MRS: 23/3/2015

DPJP:Dr. Willy Adhimarta,Sp.BSS: keluhanO: KU: lemah, sadarGCS 10x(E4M6Vx)Pupil isokor 25mm/25mmDrain: 50cc/24j

A:-Post Op craniotomiec ICH+IVH-post op eksternal drainage +ICP-post tracheostomyMeropenem 1gr/12j/ivTerapisesuaiTsanestesiTakar drain/24jamLab 23-03-015Wbc:3,85Rbc :5,75Hgb :9,3Hct: 25,1Plt :240GDS: 157SGOT/SGPT: 24/22Na/k/cl:148/3.3/112Ur /Cr:51/1.40HBsAg:non reactive

Foto Thorax AP 25-3-2015-CVC terpasangdengankedudukanbaikpadahemithoraxkanan-Cardiomegaly-Elevasidiafragmakanan

MSCT Kepala (AX+ Cor) Non Kontras(12/03/2015)Kesan : -Pendarahan volume 15,5cc thalamus kanan,midline structure shift kekiri minimal denganpendarahanintraventrikel-Sugestifinfark lama batangotakkanan-Kista arachnoid di sisterna magna

Bed 2Mastang69991601/07/1996

TanggalKonsul :04-02-2015

DPJP :Dr. dr. Nasrullah, Sp.BSS : kesadaran menurunO : KU : lemahGCS : 5x (E1M4Vx) Pupil isokor 25mm/25mm

A : -Post op VP shunt e.c hydrocephalus-Tumor intracranial-Post eksternal drainage ec. SDH-Post TracheostomyTerapilanjut TS. Anastesi/Neurologi

Lab 1-04-015Wbc:9,2Rbc :5,75Hgb :15,2Hct: 45,1Plt :284GDS: 87SGOT/SGPT: 21/34Na/k/cl:148/3.3/112Ur / cr:26/1.40HBsAg:non reactive

BED 5Herman21/4/1994707605

MRS: 21/3/2015

DPJP :Prof.DR.Dr Andfi AsadulS : Keluhan : sulit dinilaiO : KU : lemasGCS 9x (E4M5Vx)Pipil isokor dimeter 2,5/2,5A : POH 15 ec ICH temporo parietal STerapi Ku sesuai TS anastesiAwasi TV dan GCS

Lab 2/4/2015WBC : 8,0RBC : 2,77HGB : 7,7HCT : 24,1%PLT : 261,000GDS : 87Na : 144K : 4,5Cl : 110Ct scan kepala (2/3/2015)Perdarahan intra cerebri regio temporoparietal kiri disertai contusio cerbriFraktur os schenoid kanan dan frontalis kiriMultihematomasinus

BED 7 SUGIYANTI20/2/1952

MRS: 3/3/2015

DPJP: dr.Nasrullah Sp.BSS : Keluhan : keasadarn menurunO : KU : lemasGCS 9 (E4M5Vx)Pipil isokor dimeter 2,5/2,5A : POH 2cranioctomy + External drainase ec ICH + SDHTerapi Ku sesuai TS anastesiTakar produksi drain/ 24 jam

Foto thorax 7/3/2015Kesan :Kardiomegali dnegan tanda-tanda bendungan paru disertai dilatsi aortaMSCT SCAN kepala 23/3/2015Skull defec regio temporoparietal kanan, tidak nampak harniasi parenkim paru.Enchepalomalacia regiotemporoparietal dekstraHygromn regio frontal bilateral terutama sinistra.

Bed 8Baharudin

70646730-3-1966mrs 29-3-2015DR.dr. djokowidodo, SPBsS: nyeri kepalaO: sadar gcs 15A: post removal tumor cerebellum hari ke 1Rl 28CefrtiaxonKetorolac\cRanitidineDrip mannitol20-4-2015wbc 9.4rbc 5.09hgb 14.7hct 44mcv 86plt 234ur/cr 18/0.40sgot/sgpt 19/9

Bed 6H muh hatta709163MRS 20-4-201524-6-1962PROF dr. DR andi asadul islam SPBsS; kesadaran menurunO gcs 7Terapi sesuai ts btkv21-4-2015LBUMIN 1.9GDS 91UR/CR 41/1.56BIL TOTAL 3.67BIL DIREK 3.24SGOT/SGPT 108/592

Picu

Bed 2Wira70793612-05-2012

MRS 10-04-2015Dr.A. Ikhwan Sp.BSPost operasi VP shunt Hari-1 ec HidrocephalusIVFD Kaen 3 B 62.5 cc/jamCeftriaxone 750 mg/12 jam/iv dlm Nacl 0.9% 100 ccRanitidin 25 mg/8jam/ivKetorolac 30 mg/8jam/ivAwasi ttv dan GCSLab 10-04-15WBC 7.58RBC 3.97HB 11.2HCT 31.2PLT 231Lab 11-04-15CT/Bt 800/300Pt 10.5 APTT 21.8GDS 314Ur/Cr 9/0.20GOT/GPT 62/23Albumin 3.8Na/K/Cl 125/2.9/94

JIHANBed 4Mrs 16-4-20151-12-2012708707S: kejangO ku sedang/gizicukup/sadarA: hidrocefalus ec tumor intracranialVp shuntTunggu optimalisasi KULAB: 16-44-2015WBC 8.1rbc: 4.74hb:12.9plt;:33.7bt/ct: 3/8pt/apt: 12.9/27.1sgot/sgpt: 32/14ur/cr:54/0.11

BED 3NEILONMrs: 14-4-201525-11-2015708177Prof.dr.dr. andi asadul islam ,SpBsS: Ku: kejangO: A: subdural nigroma parietal dextra Brocho pneumonia dextraTunggu rencana operasiIvfd asering 20 tpmFennitoin 20mg/6jam/drips dalam nacl 0.9% 20 tpmParacetamol 500 mg

21-4-2015NA/K/CL 137/4.7/10617-4-2015WBC 8.0\RBC 3.94HGB 9.0HCT 28PLT 217

Alif6-1-2013709377mrs 21-4-203Dr.willy adhimarta,spbshidrocephalusRencana vp shunt

RPK

BED 4NURBAETY707647MRS 9-4-20151-1-1956Dr. andi ihwan, SpBsS: DEMAMKu lemah GCS 8XA: tumor intracranialOptimalisasi KU11-4-2015kolestrol total 204kol. Hdl 21kol. Ldl 147

10-4-2015kimia laktat darah 42.3imunoserologi 0.38