Ward Report

Wednesday, October 17th 2018

A. Patient transferred to other hospital (-)

B. Patient died (2)
1. An. Gibran Elando / Male / 8 months old
Dx. Anorectal Malformation tanpa withoit fistula post colostomy + post PSARP + post
rerouting + anemia + hipoalbuminemia + bronchopneumonia + Down Syndrome
COD : MOF
2. Edi Irawan / Male /60 years old
Dx. Acute severe cholangitis e.e Carcinoma caput pancreas + Anemia + hipoalbuminemia +
hipokalemia + AKI stage V
COD : MOF
C. Patient treated in ICU (8)
1 . Emsi Hadi / Male/20 years old / Day 1
S: (-)
O: A : Cleared
B : Nasal canul O2 3 lpm RR : 20 x/m SpO2 : 100%
C :TD = 107/68mmHg HR : 82 x/m
D : GCS = E4M6V5 = 15 Isochoric pupil, Light reflex +/+
E : Sinus Rhythm
F: Fluid Balance Lab (17-10-18)
I : 1982cc Hb : 14,2
L : 10.700
O : 2100 cc Ht : 42
IWL: -609 cc Tromb : 267.000
Total: - 727 cc/14 hours

A : Crebral abcess post Craniotomy abcess drainage POD 1 + Hidrocephalus post VP shunt
POD 19
 P : IVFD RL gtt XX/mnt
Omeprazole 1x40 mg IV
Ceftriaxon 1 gr/ 12 hour
Paracetamol 1 gr / 8 hour

2. Annisa Mayang Putri / Female / 20 years old / Day 21 (No improvement)

S : (-)
O : A : Tracheostomy
B : PS PEEP 6 FiO2 50% RR: 22 x/m SpO2 : 99 %
C : TD: 115 / 78 mmHg HR : 87 x / m
D : GCS: E4M6VT =10 Tc Isochoric pupil, Light reflex +/+
E : Sinus Rythm
F : Fluid balance: Lab (11-10-18)
Hb : 10.5
I : 1700 cc
L : 15.500
O : 1950 cc Ht : 32
Tromb : 367.000
IWL : 568 cc
Total : - 818 cc / 24 hour

A : SOL of medulla oblongata region

Post CTR POD 31

P: IVFD Tutofusin gtt xx / m

Vancomycin 1 gr/ 12 hour IV
N-acetylcysteine 200 mg/ 8 hour NGT
Vitamin C 1000 mg/12 hour IV
Neurobion 1 tab/24 hour NGT
Amikasin 1gr/ 24 hour IV
Omeprazole 40 mg / 24 hour IV
3. Tarmizi Bin sholeh / Male / 65 years old / Day 5 (No improvement)
S : (-)
O : A : ETT
B : PS PEEP 5 FiO2 40% RR: 18 x/m SpO2 : 99 %
C : TD: 118 / 82 mmHg HR : 80 x / m
D : GCS: DPO pupil reflek, Light reflex +/+
E : Sinus rhythm
F : Fluid Balance 14 – 10- 2108
Hb 11.7
I : 2230cc
L 14.600
O : 2400cc Ht 37
Tr 150.000
IWL : 450 cc
Total : - 620 cc / 24 hour

Frontal region : dry gauze, drain 5cc/24hour

A : ICH Right teporoparietal lobe + left lateral IVH + hidrocephalus post craniotomy
decompression POD 5

P: IVFD Ringerfudin gtt xx / m

Paracetamol 1 grams / 8 hour IV
N-acetylcysteine 200 mg/ 8 hour via NGT
Citicoline 200 mg / 8 hour IV
Omeprazole 40 mg / 24 hour IV
Bisolvon 4 mg / 8 hour IV
Meropenem 1 gr/ 8hour IV
Milos 3mg/hour IV
4. Muryati Bt Atas / Female / 46 Years old/ Day 2 (improvement)
S : (-)
O : A : ETT
B : CPAP PEEP 5 Fi02 40% RR: 20x/m SpO2 : 99%
C : BP:130/75 mmHg HR : 95 x / m
D : GCS: E2M4VT 6T Isochoric pupil, , Light reflex +/+
E :Sinus Rhytm
F : Fluid balance Lab 16-10-2018
I : 2000cc Hb 9,8
O : 2430c Ht 22
IWL : 668 cc L 12.100
Total : - 238 cc / 24 hour Tr 227.000
Cranium region : Dry gauze +

SOL of left tempoparietal region + SOL of occipital region

Post CTR POD 2

P : - IVFD Ringer fundin gtt xx / m

Meropenem 2 gr/12 hour IV
Omeprazole 30mg/24 hour IV
Dexametason 40mg/24 hour IV
Morphin 30mcq/kgbb/hour IV
Manitol 150cc/6 hour
5. Damiatun/ perempuan /Day -3 (Improvement)
S : (-)
O : A : Cleared
B : Nasal Canul 3 lpm RR : 22x/m SpO2 : 100%
C : TD :90/60 mmHg Hr : 115 x/m
D : GCS : E4M6V5 : 15
E : sinus tachycardi
F : Fluid Balance
I : 1950cc
O : 2080cc
IWL S: 540 cc
Total : -670 cc / 24 hour
Cranium region :
I : Dry gauze +
A : SOL of frontal region
post CTR POD 3
P : IVFD tutofusin gtt xx/mnt
Ceftriaxon 2gr/24 hour
Paracetamol 500 mg /8 hour
Lansoprazole 30 mg/24 hour
N asetyl sistein 200mg/8 hour
Fenitoin 100mg /8 hour
6. Zulmi Zalnani / female / 45 years old / Day 8 (Improvement)
S : (-)
O : A : ETT  Cleared
B : NRM O2 12lpm RR: 20 x/m SpO2 : 99 %
C : TD: 135 / 77 mmHg HR : 135 x / m
D : GCS: E4M6V5 15 Isochoric pupil, Light reflex +/+
E : Sinus tachycardi
F : Fluid Balance Lab (14-10-18)
I : 2200 cc Hb : 11,6
L : 12.800
O : 2350 cc Ht : 36
IWL : 465 cc Tromb : 226.000
Total : -615 cc / 24 hour

Cranium region : Dry gauze +

A : SOL of suprasellar region + anemia

Post CTR POD 8

P: IVFD Tutofusin gtt xx / m

Ceftriaxone 2 grams / 24 hour IV
N-acetylcysteine 200 mg/ 8 hour via NGT
Paracetamol 1 g/ 8 hour IV
Manitol 125 cc /8 hour IV
Metylprednisolone 125 mg / 8 hour IV
Citicoline 200 mg / 8 hour IV
Omeprazole 40 mg / 24 hour IV
Bisolvon 4 mg / 8 hour IV
Phenytoin 100 mg / 12 hour IV
7. Samsan bin Yusuf/ Male / 87 years old / Day 6 (No improveent)
S : (-)
O : A : tracheostomy
B : SIMV PEEP 5 FiO2 40% PS RR: 22 x/m SpO2 : 99 %
C : TD: 128 / 75 mmHg HR : 76 x / m
D : GCS: E3M3VT 6T Isochoric pupil, Light reflex +/+
E : Sinus rythm
F : Fluid Balance 13 – 10- 2108
Hb 11,2
I : 1980 cc L 13.600
O : 2500 cc Ht 30
Tr 243.000
IWL : 515 cc
Total : -1035 cc / 24 Hour
Cranim region
A : CVD Hemoragik e.c ICH regio frontal dextra post craniotomy evakuasi POD 6
P: IVFD Ringerfudin gtt xx / m
Ceftriaxon 1gr/8hour IV
Lanzoprazole30 mg/24 hour IV
N-acetylcysteine 200 mg/ 8 hour via NGT
Pracetamol 1 gr/8 hour
8. Ali Imron/ Male / 35years old / Day 5 (no improvement)
S : (-)
O : A : Tracheostomy
B : SIMV PEEP 5 FiO2 40% RR: 22 x/m SpO2 : 99 %
C : TD: 135 / 75 mmHg HR : 76 x / m
D : GCS: E4MxVTc pupil reflek, Light reflex +/+
E : Sinus rhythm
F : Fluid Balance 13 – 10- 2108
Hb 12.7
I : 2120 L 15.2
O : 2430cc Ht 39
Tr 170
IWL : 540 cc
Total : -850 cc / 24 hour

Colli region : rigid cervical collar (+)

A : Spinal cord injury frankle A ec fraktur cervical V post laminoplasty + pneumothorax

sinistra post chest tube sinistra + ftraktur clavicula dextra 1/3tengah tertutup

P: IVFD Ringerfudin gtt xx / m

Inj Amikasin 1gr/8hour
Paracetamol 1gr/8hour
Omeprazole 40 mg/24 hour
Albumin 25%/24 hour
Bisolvon 200mg/8 hour
D. Pasien Dirawat di PICU (1)
1. An. Alesha Adifta/Female/1 years old/Day 1
S : (-)
O : A : Cleared
B : Nasal canul O2 2lpm RR : 30x/m SpO2 99%
C : HR 84 x/menit
D : Hypoactive
E : Fluid Balance 14 – 10- 2108
I : 287 cc Hb 12,3
L 9600
O : 340cc Ht 35
IWL : 40 cc Tr 283.000

Total : -93 cc/17 hour

Thorax region :
I : Dry gauze (+), drain 2cc/17hour
A : PDA post Ligation POD 1

P: IVFD D5 1/2 NS kec 22,5cc/hour

Cefuroxime 90 mg/8 hour (IV)
Paracetamol 100 mg/12 hour
Captopril 3mg/8hour
Furosemide 6mg/8 hour
E. Pasien Dirawat di NICU : (1)
1. By. Ahmad Alfarizi/ lk/Day 3 (No Improvement)
S : (-)
O : A : ETT
B : B CPAP PEEP 7 FiO2 40% RR : 40x/m SpO2 97%
C : HR 158 x/mnt
D : Hipoaktif
E : Fluid Balance
I : 500 cc
O : 105 cc
IWL : 53 cc
Total : 342 cc/24 hour

Abdominal region : I : dry gauze (+), ileostomy (+)

A: Umbilical hernia post laparotomy + post ileostomy POD 3

P: IVFD D10 1/5 NS + Ca. Gluconas 300 mg kec. 15,6 cc/hour

Ampicilin 65 mg x 4mg (IV)
Ceftazidim 125 mg x 3 (IV)
Matronidazole 20 mg x 2 (IV)