MAPPING BEDAH SARAF

Rabu, 19-12-2018
ICU-C
Suharlan, lk, 61th Lab 17/12/2018
B1 1194307 Hb/Ht/E/L/T :
11,1/33/3,7/16,3/164
POD 2 Dx. ICH ar ganglia basis dextra

dr. Imam Hidayat, SpBS

B2 Caribulan, pr, 89th Lab 14/12/2018
1194309 Hb/Ht/E/L/T :
POD 3 14,5/47/5,7/8,6/291
Dx. IVH+ICH+Edema serebri GDS: 97
Ur/Cr : 115/2,27
Na/K/Cl : 138/4,4/99
dr. Imam Hidayat, SpBS
Nurmala Sari, Pr,44th, Lab 16/12/2018
B3 1049632 Hb/Ht/E/L/T : 10,6/32/
3,8/21,6/248
POD 2 Dx. EDH a/r temperopariental Ur/Cr : 15/0,64
dekstra+edema serebri+ruptur sinius Na/K/Cl : 141/4,0/105
sigmoid+ V.laseratum a/r frontal dex

dr. Imam Hidayat, SpBS

B4 Darmansyahputra, lk, 19th Lab 17/12/2018
1194375 Hb/Ht/E/L/T :
POD 2 14,9/45/5,3/19,8/474
Dx. ICH ar Frontal Sin + Fr a.r Ur/Cr : 28/0,88
Frontal sin + Fr a.r rima orbita sup Na/K/Cl : 142/4,2/106
sin + Fr zigoma sin + Fr Nasalis

dr. Imam, Sp.BS

ICU-D
Alamsyah ibrahim, lk, 65th Lab 17/12/18
1194305 Hb/Ht/L/Tr : 12,5/37/153/7,1
B4 PT/APTT : 9,8/35,2
POD 2 Dx. Penurunan kesdaran e.c stroke Ur/Cr : 77/1,14
hemoragic post craniotomy evaluasi Na/K/Cl: 145/4,3/115

dr. Imam Hidayat, SpBS

B5 Muhammad M Hamzah ali, lk, 46th Lab 16/12/18
0696926 Hb/Ht/E/L/T :
POD 1 15,1/45/6,1/5,2/347
Dx. Tumor ar thoracal 3-4 + Ur/Cr : 29/0,90
spondiolisi Na/K/Cl: 143/4,5/104

dr. Imam Hidayat, SpBS

PICU
B1 Zahratul jannah, pr, 2th Lab 16/12/2018
1194336 Hb/Ht/E/L/T :
POD 3 10,6/30/3,9/12,9/198
Dx. EDH ar frontal dekstra + Fr GDS: 174
liner ar frontal dextra post Ur/Cr: 15/0,27
craniotomy evakuasi EDH Na/K/Cl: 139/3,1/115

dr. Imam Hidayat, SpBS

RAUDAH 2
K6B4 Riyudi Saraman, lk, Lab 26/11/18
AD 1 1184765 Hb/Ht/L/Tr : 14,1/41/8,0/220
CT/BT “ 7/2
dx. Skull Defect GDS : 100
Ur/Cr : 14/0,71
Na/K/Cl : 147/4,4/104
RAUDAH 3
Rusmini, 68 thn, pr, 119-19-07 Lab 12/12/18
K2B1 Hb/Ht/L/T : 12,5/37/11,0/151
dx. post op removal tumor Ur/Cr : 25/0,64
POD 6 intrakranial Na/K/Cl: 143/3,0/108

dr. Iskandar, SpBS

op 12/12/2018

K2b2 Fitri Wahyuni, 30 thn, pr, 116-22-99 Lab 13/12/2018

Hb/Ht/E/T/L:
POD 4 Dx. Malfungsi shunt post VP Shunt 12,9/ 38/4,2/357/7,5
a/I hydrosefalus non kommunikans Ur/Cr: 15/0,52
 HbsAg negatif
dr. Iskandar, SpBS
K5B1 Salbiah adam, pr, 63 th Lab 05/12/18
POD 12 Dx. Hidrosefalus non comunicas Hb/Ht/E/L/T :
tumor intracranial +ec post VP shunt 10,8/29/3,7/8,3/171
Ur/Cr : 69/1,06
dr. Bustami, SpBS Na/K/Cl: 138/4,8/95
Tgl op 5-12-2018

K5b3 Nurlaili M Ali, pr, 40 thn, 1190702 Evaluasi GCS Lab 12/12/18
Rencana Op Na/K/Cl/Ca/Mg:
POD 6 Dx. Meningioma post craniotomy kembali 140/4.1/106/7.4/1.9
removal tumor + hidrocepalus post
Vp shunt Lab 5/12/18
Hb/Ht/E/L/T:
dr. Iskandar, SpBS 10.5/31/3.8/6.3/274
Ur/Cr: 17/0.73
Tgl op 11-12-2018 Na/K/Cl: 139/2.6/101

Lab 15/11/18
Hb/Ht/E/L/T: 11.1/31/4/19/138
Ca: 7.9
Na/K/Cl: 143/3.9/98
K5b4 Ainun Sati, 41 thn, pr, 1190786 Rencana Op Sabtu, Lab 12/12/2018
15/12/2018 Hb/Ht/E/T/L: 11/33/3.8/14.9/248
POD 6 Dx : Tumor a.r calvaria + post Ur/Cr: 16/0.55
craniotomy removal tumor Na/K/Cl: 142/4.1/110
Ca/Mg: 8.4/1.9
dr. Iskandar, SpBS Albumin: 3.62
Tgl op 11-12-2018
K6b1 Susana Rita, Pr, 44 thn, 1191155 Mobilisasi Lab/06/12/2018
Konsul RM Hb/Ht/E/L/T
POD 13 Dx. Tumor ar temporal base + post 10,3/28/3,6/20,5/224
craniotomy removal tumor

dr. Iskandar, SpBS

tgl op 5-12-2018
K6B4 Sasdalila m nuh arwy,pr,49thn, Lab 14/12/2018
1189926 Hb/Ht/E/L/T :
POD 5 9,5/28/3,3/16,9/263
Dx: Post Abcess Drainage+Post HbsAg : neg
Craniotomy
Lab 04/12/2018
dr. Imam Hidayat, SpBS Hb/Ht/E/L/T :
11,6/32/3,9/12,3/317
Ur/Cr : 13/0,55
Na/K/Cl : 137/3,9/96
K7B5 Juairiah, Pr, 45th Lab 04/12/2018
1194374 Hb/Ht/E/L/T :
AD 2 11,0/34/3,9/12,3/217
Dx. ICH ar Frontalis sinistra Ur/Cr : 25/0,60
Na/K/Cl : 145/112
dr. Imam Hidayat, SpBS
RAUDAH 4
K4b2 Muhammad Rizky, lk, 22 tahun, Lab 14/12/2018
1194107 Hb/Ht/E/L/T :
POD 4 Dx. EDH ar temporoparietal 11,5/32/3,9/12,2/209
dextra+Unilateral facet dislocation

dr.Imam , SpBS
RAUDAH 5
K6B1 M. Irfan, lk, 17 thn Lab 10/12/2018
POD 6 1184153 Hb/Ht/E/L/T:
14,5/41/5,2/9,6/307
Dx. Defek air skull post kraniotomi Ur/Cr : 12/0,43
Na/K/Cl : 148/4,2/106
dr. Bustami, SpBS

HCU S
B9 Fachrurrazy, lk, 25 thn Lab 13/11/2018
119-09-73 Hb/Ht /L/T : 12,4/36/10,4/363
POD 1 Ur/Cr : 13/0,64
Dx. Tumor Medulla spinalis post Na/K : 140/3,9
Laminectomy microsurgery removal
tumor

dr.Imam , SpBS
 SHAFA
K3B2 Adnan RA, lk, 49 tahun Lab 18/12/18
AD 1 0660722 Hb/Ht/Tr/L : 13,7/40/334/20,8
PT/APTT : 13,2/31,9
dx. Hidrocephalus Ur/Cr : 53/0,66
Na/K/Cl : 122/3,2/78
dr. Imam, Sp.BS
Zamzam 1
K2 Mursyidah , pr 54 th, 1193523 Lab 9/12/2018
POD 9 Dx : ICH ar temporoparietal sinistra Hb/Ht/E/L/T :
14,3/39/4,9/243/16,4
dr. Bustami, SpBS HbsAg negatif
tgl op 9/12/18 Ur/Cr : 2/0,83
Na/K/Cl : 149/3,6/107

MINA 2
K6B2 Nur Azizah, pr, 16 tahun Lab 17/12/18
1194387 Hb/Ht/L/Tr : 6,8/23,19,5/532
AD 1 PT/APTT : 9,8/24,5
dx. Penurunan kesadaran ec susp. Ur/Cr : 49/0,87
SOL dd/ susp. Tumor temporal
sinistra
K6b6 Ruhmi, pr, 47 th -rencana op
1194247 -tunggu icu
AD 4 dx. Meningioma

dr. Imam, SpBS

MINA 1
K1B1 Irwansyah, lk, 27 thn Lab 17/12/18
AD 3 1173212 Hb/Ht/L/Tr : 13,3/38/14,5/253
dx. CKR + edema cerebri Ur/Cr ; 15/0,72

dr. Imam, Sp.BS

K3B2 Abdul Rahman, lk, 71 thn Lab 18/12/18
0843162 Hb/Ht/L/Tr : 11,3/32/11,2/245
POD 1 dx. Normal pressure hidrosefalus

dr. Bustami, SpBS

K7B4 Pirdaus M Ksem, lk, 48th Lab 15/12/18
1194292 Hb/Ht/L/Tr : 17,0/48/19,9/424
Ur?Cr : 39/0,57
Dx. SOL Intracranial Na/K/Cl : 137/4,0/104

dr. Imam Hidayat, SpBS

NICU
Level III By. Rauzatul Jannah Lab 5/12/18
POD 10 1192129 Hb/Ht/E/L/Tr/:
7,6/21/2,6/7,3/176
tgl op 4-12-18 Dx: hidrocepalus non komunikan + Albumin : 2,90
post vp shunt Na/K/Cl: 144/6,2/107

dr. Iskandar, SpBS Lab 3/12/18

Bil.total : 11,73
Bil.direct : 0,41

Level III By. M Hanan Yindi Tgl 5-12-18

Hb/ht/leu/trombo:
dc. Hidrosefalus ec dd hidrancephali 13,9/36/4,4/86
Ur/Cr : 26/1,83
Na/K/Cl : 127/ 3,9/84

dr. Imam Hidayat, Sp.BS Tgl 10-12-18

Ur/cr : 85/1,41
Level IIB By Khairan Romi, lk, tgl lahir 29-11- Lab 10-12-18
2018, 1192824 Ur/Cr : 22/1,2
Na/K/Cl : 134/6,5/98
Dx. Hidrosefalus non communicans +
BBLR Lab 1-12-18
Hb/Ht/E/Tr/L:
dr. Bustami, SpBS 15,4/43/4.2/208/10

Level IIB Muyasir Hamdani, lk, 3 hari Lab 16/12/18

1194313 Hb/Ht/E/L/T :
16,0/47/4,5/10,3/154
Dx. Craniosynostotosis Ur/Cr : 24/0,61
dr. Imam Hidayat, Sp.BS Na/K/Cl: 156/5,0/128
 ARAFAH 1
K5B3 Askal Azkia, pr, 2 bulan Lab 14/12/18
AD 3 1194230 Hb/Ht/L/Tr : 5,8/18,2/12,5/538

dx. APCD 17/12/18

Ur/Cr : 8/0,20
dr. Imam, Sp.BS Na/K/Cl : 137/4,5/113