NS 24 Desember 2015
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Transcript of NS 24 Desember 2015
LIST PASIEN DIVISI NSKamis, 24 DESEMBER 2015Irina A BawahNo.KamarIdentitasDiagnosisPemeriksaan PenunjangTerapi
1.B3 Bed 1Suluh NaftaliP / 18 th / 40.49.32
MRS 08/12/2015HP ke-12
DPJP:dr. Eko Prasetyo, SpBS(K) EDH frontobasal \ SDH temporal \ Contusio cerebri Fr. Metacarpal sinistra Fr. Zigoma sinistra Hifema sinistra18/12/2015Leu 5300 Eri 3,95Hb 11,1Ht 33,3Tro 262SGOT 17SGPT 8MCH 28,1MCHC 33,3MCV 84,4Ur 16Cr 8Na 141K 4,20Cl 102,9
18/12/2015X foto thorax: Terlampir
21/12/2015PT: 12,9APPT: 27,3 Tidak ada penanganan lebih lanjut dibidang bedah saraf TX lain sesuai ts Bedah KL
2.B3 Bed 2Thomas JeryL / 54 th/ 36.11.74
MRS 20/12/2015HP ke 4
DPJP:dr. Eko Prasetyo, SpBS(K) ICH r. parietal S ICH r. frontal S Multiple vulnus laceratum Multiple vulnus ekskoriasi20/12/2015Leu 12000Eri 4,34Hb 13,2Ht 41,1Tro 276SGOT 30SGPT 39MCH 30,4MCHC 32,1MCV 94,6Ur 40Cr 1,4GDS 138Na 141K 3,4Cl 106,0 IVFD asering O2 2-4 lpm Ceftriaxon 2x1gr IV Antrain 3x1 amp IV Ranitidin 3x1 amp IV Brain Act 3x1amp IV Rawat luka (Sudah tanda tangan pulang paksa)
3B3 Bed 3Neni Kakarang /17thn/46.22.12
MRS 23/12/2015HP ke 1
DPJP dr. Maximilian Oley, SpBS-ICH parietal dekstra
-Susp Fraktru basis cranii23/12/2015Leu 11500Eri 4,68Hb 13,0Ht 41,4Tro 247MCH 27,8,3MCHC 31,4MCV 88,4Ur 19Cr 0,6Na 139K 3,70Cl 106GDS 110
CT Scan: di keluarga. O2 2-4 lpm IVFD Nacl 0,9% + ketorolac 3 amp + neurobion 1 amp 20gtt/m Ceftriaxon 2x1gr iv Ranitidine 2x1amp
4B8 Bed 5Jeremi PangauL/14th/46.17.62
MRS 17/12/2015
HP ke 8
DPJD:dr. Maximilian Oley, SpBS SAH region ocipital V. laceratum r. pedis dextra17/12/2015Leu 20400Eri 5,16Hb 15,8Ht 47,3Tro 414MCH 30,6MCHC 33,4MCV 91,7Ur 27Cr 0,9GDS 84Na 140K 4,7Cl 104
17/12/2015Urinalisis: terlampir Rawat jalan kontrol poli bedah
5.B8 Bed 6Mamile MaulanaL/48thn/46.19.70
MRS 21/12/2015
HP ke 4
DPJP:dr. Eko Prasetyo, SpBS ICH temporoparietal Sinistra EDH temporal dextra Fr. Basis crani17/12/2015Leu 6600Eri 4,62Hb 13,8Ht 41,4Tro 173MCH 29,9MCHC 33,3MCV 89,6Ur 20
Cr 0,9GDS 148Na 137K 3,70Cl 107 Elevasi head of bed 300 O2 4lpm IVFD asering 5% 20 gtt/m Ceftriaxon 2x1 gr Antrain 3x1 amp Brainact 2x500mg iv Ranitidine 2x1 amp
ICU 1 pasienNo.KamarIdentitasDiagnosisPemeriksaan PenunjangTerapi
1.Bed 3Robinson KundimangL/15thn/45.19.02
MRS
HP ke
DPJP:Dr. Maximilian Oley, SpBS
ICH parietal sinistra SAH Fr.clavicula19/12/2015Leu 9700Eri 5,75Hb 17,7Ht 53,8Tro 251MCH 30,8MCHC 32,9MCV 93,5Ur 26Cr 1,0
GDS 132Na 141K 3,60Cl 107
19/12/2015Urinalisis:terlampir Elevasi head of bed 300 IVFD NaCl 0,9% + 3amp ketorolac + neurobion 5000 1 amp 20 gtt/m IVFD Ringer fudin 12 gtt/m Ceftriaxone 2x2 gr iv Fenitoin 2x100mg PO Ranitidine 2x1 amp Neurolin 2x500 iv Diet cair via NGT Terapi lain sesuai Anestesi Neurologi
RR 1 pasienNo.KamarIdentitasDiagnosisPemeriksaan PenunjangTerapi
1Alese HeskielL/20/46.22.02
MRS 23/12/2015HP ke 1
DPJP:dr. Maximilian Oley, SpBS Contusio Cerebri + susp Fr basis cranii Multiple vulnus eksoriasi
IVFD Ringer fudin 12gtt/m Nacl 0,9% + ketorolac 3 amp + neurobion 1 amp Ranitidin 2x1 amp Ceftriaxon 2x1gr Citicolin 2x1 IV Pasang kateter Cephactam 2x1 IV