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L3 ATAS DEPAN
Kamar/ bed
1.
Identitas
JUNUS JAMA
07-07-1954
(61 tahun)
731333
L3 AD
THT
K4 B3
MRS
21/02/2016
Dpjp:Dr. dr.
Djoko
Widodo,Sp.BS
Diagnosis
S: Gelisah, makan dan minum baik
O: status generalis
Tampak lemas / gizi cukup/sadar
Status vitalis
Td 110/80, n 80x/menit, p 20x/menit, s
36.6*C
GCS 15 E4M6V5
Pupil isokor 2.5/2.5mm
RC +/+
Motorik 5/5/5/5
A: Tumor intrakranial
2.
HARNAWATI
07-01-1976
(39 tahun)
740629
L3 AD
THT
K5 B1
S:
O:
A: Skull defect
MRS
02/02/2016
Laboratorium
Lab 26-22016
FT4 : 1,50
TSHs : 0,88
CEA : 70,70
Lab (tgl 2102)
WBC: 14.3
RBC: 4.27
Hb: 13.3
Hct: 40
PLT: 314
GDS: 94
UR/KR
36/0,66
SGOT/SGPT
28/45
NA/K/CL
138/3,2/102
Lab 24-22016
FT4 : 1,50
TSHs : 0,88
CEA : 70,70
Lab (tgl 2102)
WBC: 7.8
RBC: 4.49
Hb: 13,1.
Hct: 42
PLT: 384
PT/APTT :
10,2/29,6
HBSAG : NR
GDS: 99
UR/KR
18/0,85
SGOT/SGPT
26/21
NA/K/CL
144/4,4/109
PemeriksaanPenunjang
Penatalaksaan
Menunggu jadwal
operasi
L3 ATAS BELAKANG
Kamar/ bed
1.
L3 AB Kulit
Identitas
ADIEL ROLLO
01-11-2008
(7 tahun)
743130
Diagnosis
S : tidak ada keluhan
O: sakit sedang/gizi
ckup/sadar, GCS 15
pupil bulat isokor, RC +/
Laboratorium
Lab ( 27-022016)
WBC: 16.0
RBC: 5.91
PemeriksaanPenunjang
Foto MRI Brain tgl 27-12016:
- Massa hemisfer cerebellum
sinistra
Penatalaksaan
- infus ringer laktat 10tpm
-ceftazidime 150mg/12jam/iv
-dexametason
amp/6jam/iv
K2B4
MRS: 4-2-2016
DPJP:
dr. Andi Ihwan
Sp.BS
2.
L3 AB Kulit
K2B2
M. NASIR
13-03-1974
(41 tahun)
747447
MRS: 29-02-2016
DPJP:
Prof.Dr.dr.Andi
Asadul Islam, Sp.BS
3.
L3 AB kulit
K5B5
SM HABIBI
HAEDAR
11-11-1999
(16 tahun)
747453
MRS 29-02-2016
+
A: - POH 23 vp shunt
ec Hidrocephalus non
communicans
-Tumor cerebellum
Hb: 13.7
Hct: 45
PLT: 667
Lab (24-02-2016)
PT/APTT:
11.7/26.8
INR: 1.11
GDS: 101
UR/KR 18/0.45
SGOT/SGPT
60/68
NA/K/CL
134/3.8/98
- Hydrocephalus non
communicans dengan tandatanda hipertensive
hydrocephalus
- Sinusitis maxillaris bilateral
S : Nyeri kepala
O: sakit sedang/Gizi
cukup/sadar, GCS 15
(E4M5V6), pupil buat
isokor, RC +/+
A: Traumatic brain
injury GCS 15
-multiple vulnus
laceratum
-Perawatan hari ke 3
Lab 29-2-2016
WBC 13.9
RBC 5.11
HCT 40.9
HGB 14.4
PLT 234
PT 10.7
APTT 22.2
UR/C 30/0.6
NA/K/CL
139/4.0/104
Lab 29-2-2016
WBC 22.7
RBC 5.38
HCT 45.8
HGB 15.3
PLT 301
PT 11.4
APTT 23.6
INR 1.10
UR/C 30/0.82
GOT/GPT 68/47
NA/K/CL
142/4.1/108
Diagnosis
S : Tidak ada
O : KU : lemah
Sakit sedang/gizi
cukup/sadar TD:100/70,
HR:132 x/menit
GCS 15 (E4M6V5)
Pupil bulat isokor,
refleks cahaya +/+
Chamber kontrol
A : POH 2 Vp Shunt e c
hydrocephalus
Laboratorium
Lab (tgl 24-022016)
WBC: 9.56
RBC: 4.00
Hb: 10.8
Hct: 33.4
PLT: 719
UR/KR : 7/0.76
SGOT/SGPT
28/10
NA/K/CL
146/5.1/117
PemeriksaanPenunjang
CT kepala (tanpa kontras) tgl
21-02-2016
-Massa fossa posterior sugetif
medulloblastoma disertai
hypertensive hydrocephalus
Penatalaksaan
-Infus kaen 3b 16tpm
Ampicilin 300mg/6jam/iv
-Awasi KU dan gcs, komtrol
chamber
+terapi sesuai ts. Pediatri
-GV/ 2hari
DPJP:
Prof.Dr.dr.Andi
Asadul Islam, Sp.BS
L4 ATAS BELAKANG
Kamar/ bed
1
Identitas
AISYAH NUR
ASYSYIFA
L4 AB K6B2
Mrs: 25/02/2016
Tgl konsul:
24/02/2016
DPJP :
Dr. Andi Ihwan
Sp.BS
2.
JIBRAN
L4AD K2B6
Mrs :24-02-2016
Tgl konsul :
27-02-2016
DPJP :
Dr.dr. Djoko widodo
Sp.BS
S : nyeri kepala
O : sakit sedang/gizi
cukup/sadar, GCS 15
(E4M5V6), pupil bulat
isokor RC +/+
A: Gliomathalamus dd/
policystricitoma
-Hidrocephalus non
communicans
Laboratorium
Lab 26-1-2016
Wbc 38,6
Rbc 4,69
Hgb 13,6
Hct 42
Plt 314
Pt/aptt 11,2/25,1
Gds 103
Ur/cr 22/1,16
Sgot/sgpt 13/10
Hbsag
Nonreaktive
Na/k/cl
148/4,5/113
Lab 18-2-2016
Protein total: 6,1
Albumin: 3,6
Globulin: 2,5
PemeriksaanPenunjang
MSCT kepala (28-1-2016)
- Gambaran meningioma reg.
frontotemporalis kiri
- Tribrous dysplasia
Penatalaksaan
-Menunggu jadwal operasi
elektif
-as.mefenamat
500mg/8jam/oral
-ranitidin 50mg/12jam/oral
-neurodex 1 tab/24 jam/oral
- Optimalisasi keadaan
umum
- tekan chamber vp shunt 30x
pagi,30 x sore
- anjuran : Radioterapi
L3 BAWAH BELAKANG
Kamar/ bed
1.
L3BB K4B6
Identitas
LE'LENG DG
PU'JA
742801
1-1-1973
Mrs : 12-2-2016
Diagnosis
S: Keluhan tidak ada
O: ku baik/ sakit
sedang /sadar
A: - susp. Meningioma
-Hiperostosis sphenoid
sinistra
2.
L3BB HCU bed 7
MARYANA
719322
10-02-1971
Konsul ke BS:
13/2/2016
Dpjp: dr. Andi
Ikhwan, Sp.BS
S: kesadaran menurun
O: ku: baik/gizi cukup/
tidak sadar gcs 9
(E4M4V1)
Pupil bulat, isokor,
diameter 3mm/3mm,
refleks cahaya +/+
normal
A: -hidrocephalus on
vp shunt lingkar
-Tumor intracranial
Lab 17/2/2016
WBC 15.78
RBC 4,60
HB 13,5
HCT 42,2
PLT 256
GDS 91
UR/CR 32/0.49
GOT/GPT 27/51
NA/K/Cl
137/3.9/107
L2 BAWAH BELAKANG
Kamar/ bed
1.
L2 BB K9 B3
Identitas
ATI BACO
747422
7-3-1974
Mrs : 28-02-2016
DPJP: Prof Dr. dr.
Andi Asadul Islam,
Sp.BS
Diagnosis
S: Nyeri kepala dan
wajah
O: sakit sedang , GCS
15 (E4M6V5), pupil
bulat isokor RC +/+
A: - Traumatic brain
ijnury GCS 15
(E4M6V5)
-Fractur anterolateral
os maxillaris dextra
-ICH temporo parietal
sinistra
-Multiple vulnus
Laboratorium
Lab 29-2-2016
WBC 12.78
RBC 43.02
HGB 8.9
HCT 26.5
PLT 101
PT/APTT
12.6/24.9
GDS 123
UR/CR 26/0.55
SGOT/SGPT
27/13
HBSAG
PemeriksaanPenunjang
CT scan Kepala (28-02-2016)
- Fraktur dinding anterior dan
dinding anterolateral os
maxilaris kanan
-Fraktur wing of sphenoid kiri
-Perdarahan intracerebi regio
temporo parietais kiri
-Multihematosinus
-Brain swelling
-hematom subgaleal
Foto kepala posisi waters
-Fraktur os maxillaris dextr
Penatalaksaan
-O2 6 liter permenit/ NRM
-Ceftazidime 1gr/12jam/iv
-Ranitidin 50mg/8jam/iv
-Ketorolac 30mg/8jam/iv
laceratum
NONREAKTIVE
NA/K/CL
138/3.4/111
maxilaris dextraa
-Suspek hematosinus
Lab (02-03-2016)
WBC 3.9
RBC 3.55
HB 8.1
HCT 28.0
PLT 150
GDS 75
UR/CR 21/1.1
GOT/GPT 20/18
NA/K/Cl
141/3.5/108
Protein tot 7.8
Albumin 4.0
INFECTION CENTRE
1.
L3BB HCU bed 7
AIMO KIWO
730324
21-06-1995
Mrs : 02-03-2016
DPJP:
Dr.dr.Nasrullah
Sp.BS
- Neurodex 1x1
JURANAH
QAULIYA
673585
09-10-2011
konsul : 03-03-2016
DPJP:
S:
O:
A: -Hidrocephalus
communicans
-Infeksi Hiv
Lab (02-03-2016)
WBC
RBC
HB
HCT
PLT
GDS
UR/CR
GOT/GPT
NA/K/Cl
Protein tot
Albumin
- Neurodex 1x1