ICU

Bed 2 S : keluhan sulit Infus RL 20 tetes/menit Foto Thorax (9/2/15)

Mastang dievaluasi Terapi lanjut Ts. Kesan: Pneumothorax
MR : 699916 O : KU : sedang Anastesi dan BTKV Dextra + Emfisema
Tanggal Lahir : GCS : 6x (E4M2Vx) Ceftriaxone subkutis dextra
01/07/1996 1gr/12jam/iv
Tanggal Konsul : Ganti verban
04/02/2015 A : - SOL Foto Thorax (8/2/15)
Intracranial Kesan: Pneumothorax
DPJP : - Post VP shunt Dextra
Dr. dr. Nasrullah, e.c
Sp.BS hydrocephalu Lab 16/02/2015
s
RBC : 3.46
- post
tracheostomi WBC : 12,9
OK HGB : 10,9
CITO(16/2/20 HCT : 32,4
15) PLT : 438
Ur/Cr : 34/0,50
Tgl op (6-2-15)
SGOT/SGPT : 26/49
Na/K/Cl : 146/4,1/112

Lab 04/02/2015
RBC : 4,47
WBC : 11,0
HGB : 14,2
HCT : 42,4
PLT : 268
Ur/Cr : 33/0,80
SGOT/SGPT : 23/17
Na/K/Cl : 141/4,1/108

Foto thoraks (6-2-15)

Edema paru

CT-Scan Kepala Axial

(tanpa kontras) 2/2/2015
Lesi heterogen vermis
cerebella dekstra sugestif
medulloblastoma dekstra
DD/ Astrocytoma disertai
hidrosefalus obstruktif
Bed 4 S :Sulit dievaluasi - Terapi lanjut TS Lab (02/02/2015)
Rustan O :KU : sedang anestesi WBC 12,9
Tgllahir 1/7/1986 GCS 9x (E4M5Vx) - GV/2hari RBC 4,24
(28th) Pupil anisokor - Rawat HGB 12,1
RM 696339 2.5mm/3mm tracheostomy HCT 37,9
MRS 10/1/2015 Tracheostomy (+) GDS 109
A :POH-41 Bil Total 0,55
DPJP Craniotomy ec EDH Bil Direct 0,27
Prof. Dr. dr. Andi Asadul region Alb 2,8
Islam, SpBS temporoparietal SGOT 49
sinistra SGPT 69
(Tgl op 11/1/15) Na/K/Cl 140/4,5/105
CRP 89,5
Bed 5 S: keluhan sulit Terapi sesuai TS Lab 11/02/2015
Bed 1 dievaluasi anestesi RBC : 3.27
Muhammad Yusuf O: KU:sedang Inj. Paracetamol 500 HCT : 32.3
18/7/1970 GCS 8(E1M5V2) mg/8j/IV HGB : 11.3
674967 A: Post lobektomi ec Phenytoin 100mg/8j PLT : 255
MRS 2/2/2015 Astrocytoma residif hari (K/P) WBC : 10.1
VI Ceftriaxone
DPJP -post kraniotomi + 1gr/12jam/iv Lab (3/2/2015)
dr.Nasrullah, SpBS bedah mikro( OK Omeprazole RBC : 3.81
CITO (17/2/2015) 40mg/24jam/iv HCT : 35
PLT : 263
WBC : 10.2
PT/APTT : 14.8/21.7
SGOT/SGPT : 51/46
CT-Scan (3/2/2015)
-Tumor intraaxial region
frontotemporoparietal kiri
- -Defek os temporoparietal
kiri disertai herniasi
cerebri pada region
tersebut
Bed 6 S: keluhan (-) -Terapi lanjut Ts. Lab (7/1/2015)
Muhammad Juhri S. O: KU : sedang Anastesi Kimia Darah
Tgl lahir 31/12/1956 GCS 10x -Head Up 30o pH: 7.409
RM 445570 ( E4M6VX) -Rawat PCO2: 56.3
MRS 16/1/2015 Pupil isokor 2,5/2,5 Luka/GV/2hari SO2: 98.1
Trakheostomi(+)int - Bisolvon PO2: 119.5
DPJP Dr. dr. Nasrullah, ak(+) 1mp/8jam HCO3: 36.0
Sp.Bs BP: Rh-/- - miring kanan
A: post craniotomy miring kiri Foto thorax AP:
ec SDH -rawat Kesan : cardiomegaly
(tgl 17/01/2015): tracheostomy disertai edema paru
36
 Lab (23/1/2015)
(tgl 22/01/2015): WBC 21.48
31 RBC 4.23
HGB 12.3
HCT 38.8
PLT 234
PT 11,4 control 11.1
APTT 28.4 control
25.3
GDS 103
Ur/cr 49/3.17
Bil. Total/Direk
0.89/0.30
SGOT/SGPT 24/20
Albumin 3.1
Na/K/Cl 142/4.1/108

Lab (22/1/2015)
WBC 19.5
RBC 5.37
HGB 16.8
HCT 49.3
PLT 238

Lab (17/1/2015)
Na/K/Cl 143/4.0/108
Ur/cr 24/1.20
GDS 127
SGOT/SGPT 32/24
Ct-Scan kepala
kontrol:
-skull defect region
temporoparietal kiri
-pneumocephal
region frontalis kanan
-encephalomalacia
(dibandingkan foto
tanggal 22-1-2015):
tampak perbaikan
-
Bed 10 S :Kesadaran - Terapi lanjut TS Lab (18/1/2015)
Muh. Rusli menurun Anestesi dan RBC : 3,49
TglLahir 11/11/1981 O :KU: Lemah mata HGB : 10,1
RM 697429 GCS 10x (E4M6Vx) - Awasi TV, GCS HCT : 29,3
MRS 17/1/2015 Pupil anisokor - Rawat PLT : 187
udem/2,5 tracheostomy WBC : 14,2
Tracheostomy (+) - GV + rawat luka/2 GDS : 164
DPJP intake (+) hari Ur/Cr : 56/1,3
Dr. dr. DjokoWidodo, Luka operasi kering Bil.Tot/Direk :
SpBS A :POH-30 0,51/0,17
Craniectomy ec SGOT/SGPT : 101/76
EDH frontobasal Albumin : 2,7
dextra + Post AsamUrat : 5,7
tracheostomy Na/K/Cl :
152/3,95/113
(Tgl op 18/1/15)
CT-Scan kepala
(17/1/2015)
- Pendarahan epidural
region frontalis
dengan fraktur
kominutif os
frontalis sisi kanan
disertai herniasi
subfalcine
- Hematoma subgaleal
dengan emfisema
subcutis pada region
frontalis sisi kanan
VIP 2

VIP 3 S :Kesadaran - Terapi sesuai TS Lab (11/2/2015)

Edward Tamsi menurun anestesi RBC : 3.73
11/06/1969 O :KU : lemah - Ceftriaxone 1 gr/12 HGB : 12.7
RM 331672 GCS 15 (E4M6V5) jam/iv HCT : 35.9
MRS Pupil isokor 2,5 - Ranitidin 50 mg/8 PLT : 24
mm/2,5 mm jam/iv WBC : 12.7
- Paracetamol 1 gr/8
Extrenal drain I : GDS : 55
jam/iv
50 cc Merah Bil.Total/Direk :
- Kalnex 1 ampul/8
Extrenal drain II : 7,54/4,98
jam/iv
40 cc Merah - Vitamin K/8 jam/iv GOT/GPT : 57/36
Takar produksi Albumin : 2,4
drain/24 jam Na/K/Cl : 130/3.6/109
A :POHextrenal
drain hari-6 Lab (20/1/2015)
RBC : 5,59
(Tgl op 11/2/15) HGB : 17,1
HCT : 50,7
 PLT : 65
WBC : 13,9
GDS : 117
Ur/Cr : 28/0,6
Bil.Total/Direk :
7,54/4,98
GOT/GPT : 65/29
Albumin : 3,1
Na/K/Cl : 150/4,6/120

Lab (19/1/2015)
PT/APTT : 14,8/28,8

Lab (18/1/2015)
HBsAg : nonReactive
Anti HCV :
nonReactive

CT-Scan Kepala
(18/1/2015)
- Pendarahan
intracerebri region
frontotemporalis kiri
dan pendarahan
intraventrikel
disertai brain
swelling dan tanda-
tanda herniasi
subfalcine
- Pendarahan
subarachnoid
- Contusio cerebri
region
temporooccipitalis
sinistra
- Fraktur os frontalis
sisi kiri dan os
nasalis disertai
multihematosinus
- Hematom subgaleal
disertai emfisema
subcutis region
frontalis
VIP 4 S :Kesadaran - Terapi sesuai TS Lab
Ibrahim Bayupah menurun anestesi dan WBC 15,71
Tgllahir 29/10/1975 O :KU: Lemah, GCS urologi RBC 3,20
RM 061096 10x (E4M6Vx) - Rawat trakeostomi HGB 9,1
MRS 7/11/2014 Pupil isokor - Glaucon 3x500 mg HCT 29,6
DPJP 3mm/3m GDS 255
Dr. dr. Nasrullah, SpBS Tracheostomi (+) Bil Total : 0,35
intak Bil Direct 0,18
Scrotum = abses SGOT 27
(+) SGPT 29
A :POH 35 VP- Alb 2,9
shunt ec tumor CRP 73,8
intracranial + Na/K/Cl 141/3,3/111
Repair external
drainage ec CT-Scan kepala
hydrocephalus (14/1/2015)
Abses Scrotum - Massa intraventrikel
III
- Hidrocephalus non
(Tgl OP : communicans dg
13/01/2015) VP-shunt terpasang
dengan tip pada
cornu anterior
ventrikel lateralis
kiri

Foto thorax AP
(13/1/15)
Pneumothorax dextra
HCU 1

HCU 2 S :Kel: kesadaran - Terapi lanjut TS Lab (21/1/15)

Massalinri menurun anestesi WBC 9.06
Tgllahir 31/12/1968 O: KU lemah - GV+rawat RBC 2.41
RM 697192 GCS 10x (E4M6Vx) luka/2hari HGB 7.2
MRS 15/1/2015 Pupil isokor - Rawat tracheostomi HCT 22.9
3mm/3mm PLT 181
DPJP Trachestomy (+) Ur/cr 26/0.6
dr. Andi Ihwan, SpBS intake Alb 2.6
A :POH-33 Na/K/Cl 145/3.7/111
Craniotomy ec.
ICH regio Lab (17/1/15)
temporal dextra RBC : 2,86
+ EDH regio HGB : 9,3
frontal + EDH HCT : 24,6
 temporoparietal PLT : 106
sinistra WBC : 7,5
(Tgl op 15/1/2015) PT/APTT : 11,8/38,1
GDS : 147
Ur/Cr : 25/0,8
Bil.Tot/Direk : 0,7/0,32
GOT/GPT : 38/24
Albumin : 2,3
Na/K/Cl : 139/3,6/111

CT-Scan Kepala
(15/1/2015)
- Frakturos frontal, os
parietal, os maxilla,
dan greater wing os
sphenoid sinistra
- Epidural hematoma
region frontal dan
temporoparietal
sinistra dengan
peningkatan
tekanan intracranial
- Pendarahan
intracerebri region
frontotemporopariet
al kanan
- Hematoma subgaleal
region
temporoparietal
bilateral
Multihematosinus