LONTARA 3 BEDAH SARAF KAMAR 5

K5B1Khairil Parawansyah70276225-07-2000

MRS :25-02-2015dr Andi Ihwan, Sp BSS: Nyeri kepalaGangguan bicara pasca traumaO: KU: sedang/sadarGCS 15 (E4M6V5)Pupil isokor/isokor

Regio kepala: edema tidak ada,laserasi tidak adaA:- trauma capitis ringan GCS 15-Fraktur linear os.frontal sinistra-Subgaleal hematom Observasi afasia/gangguan bicarap/ Cefadroxyl 500mg/12 jam/oral Ranitidine 50mg /8jam/intravena Aricept tablet/12 jam/oral elastic verban kepala konsul fisioterapiLab 25-2-2015RBC : 4,50WBC : 14,7HGB : 12,8HCT : 39,1PLT : 315BT/CT : 300/730PT/APTT: 11,2/28,5Ur/Cr : 14/0.70Albumin 3,9SGOT 39SGPT 12Na/k/cl : 146/4,9/112HBs Ag(ICT) Non reactiveAnti HCV Non reactive

K5B2Aurel Fitratul Aufha70322727-06-2009

MRS :01-03-2015Prof. DR.dr. Andi Asadul Islam Sp BS(K)S:nyeri kepala,kejang tidak adaO: KU: Sakit sedang/Gizi cukup/SadarGCS 15 (E4M6V5)Pupil IsokorA: Trauma capitis ringan GCS 15-Epidural Hematom

O2 4 lpm-Infus RL 14 tpm-Ceftriaxone 300 mg/12jam/iv-Ketorolak 10 mg /8jam/iv-Ranitidin 15 mg /8jam/iv-CT control sudah adaLab 1-3-2015RBC : 4,02WBC : 12,5HGB : 10,8HCT : 33PLT : 343BT/CT : 200/630PT/APTT: 10,1/21,6GDS : 85Ur/Cr : 29/0,4Albumin 4,0SGOT : 24SGPT : 11Na/k/cl : 140/4,4/104HBs Ag(ICT) Non reactiveAnti HCV Non reactive

K5B3Suhardi24-3-1966702256

MRS :21-02-2015

Dr Willy Adhimarta Sp BSS : Nyeri di tempat keluarnya urinAir seni merahO : KU : baikGCS : 15 (E4M6V5) Urin bag:Tampak urine merah kemerahan A : TCR Gcs 15 hematuria

Infus Nacl 28 tpm Ceftriaxone 1 gr/12 jam/ intravena Terapi lain sesuai TS bedah urologiLab 23-2-2015RBC : 2,72WBC : 17,6HGB : 8,4HCT : 24,7PLT : 222Lab 25-2-2015RBC : 3,71WBC : 14,4HGB : 10,9HCT : 24,7PLT : 318

Usg abdomen 23-2-2015KesanSuspek hematoma Droneprosis dextrasubcapsular renal dextrasuspek bekuan darah dalam buli buliEfusi pleura minimal dextra

K5B4Naruh69944623-09-1964

MRS :21-02-2015

Dr willy adhimarta Sp BSS: Nyeri berkurangO: KU: Sakit sedang/Gizi cukup/SadarGCS 15 (E4M6V5)Regio scarum : Tampak ulkus decubitus, pus ada, jaringan granulasi adaA: spinal cord injuryUlkus decobitus Elevated liver enzyme

ceftriaxone 1 gr/12 jam/ intravena metronidazole 1 vial/12 jam/ intravena Omeprazole 40 mg/24 jam/intravena Sistenol 500 mg/8 jam/oral Ranitidine 150 mg/12 jam/ oral Bisolvon syr 3x1 cth Terapi lain sesuai TS interna

Lab tgl 3-3-2015RBC : 3,73WBC : 8,5HGB : 12HCT : 32PLT : 450PT/APTT :11,5 /26,4SGOT/SGPT : 39/89Albumin : 3,0

Lab tgl 25-2-2015RBC : 4,34WBC : 7,6HGB : 12,1HCT : 37,1PLT : 275Ur/Cr : 12/0.40SGOT/SGPT : 273/281Na/k/cl : 131/4.1/103

K5B5Radi Mega Irawan70290130-09-1995

MRS :26-02-2015

dr. Andi Ihwan, Sp.BSS: Nyeri kepala berkurang

O:KU: Sakit sedang/ Gizi cukup/sadarGCS 15 (E4M6V5)Pupil isokorAnemis (-), icterus (-)A: -Trauma Capitis Ringan GCS 15-Elevated liver enzim-Close fraktur os zygomatikus sinistraP/ Infus Asering 20 tpm Ceftriaxone 1 gr/12jam/intravena Terapi lain sesuai TS orthopedic dan interna Konsul bedah plastic untuk fraktur os zygomatikusLab 26-2-2015RBC : 4,58WBC : 21,8HGB : 13,6HCT : 40,3PLT : 229BT/CT : 300/700PT/APTT: 10,9/27,2GDS : 151Ur/Cr : 27/1.10Albumin 4,0SGOT : 46SGPT : 101Na/k/cl : 142/5,0/109HBs Ag(ICT) Non reactiveAnti HCV Non reactive

K5B6Muh Alfaris gunawan70124416-11-2014

MRS :25-02-2015

Prof. DR.dr. Andi Asadul Islam Sp BS(K)S: Bengkak pada scrotum,berkurang, fontarel cekungO: sakit sedang, kesadaran baik GCS 15 (E4M5V4)VP-shunt potensi baikFontarel tampak cekungA: Post VP-Shunt H-4 ec Hydrocephallus

Infus Asering 10tpm Ceftriaxone 150mg/12jam/iv Paracetamol 60mg/8 jam/iv Ranitidin 10mg/8jam/ivLab 16-2-2015Wbc 10,6Rbc 3,97Hgb 10,1Plt 571Hct 32Ur/Cr 9/0,13Got/gpt 57/28Na/K/Cl 136/5,8/113