Ward Report

Wednesday, February 22th 2017

D. Patient move to other hospital: (-)

E. Patient Died : (1)
1. Afian Darma Wijaya /Male /3 years old /Day care 3
Diagnose: Mesojejunal Tumor + Adhesive post explorative Celiotomy + Adhesiolisis
day 3 + relaps of ALCL+ multiple tumor of right kidney + Bilateral Hydronefrosis
grade I + mass in right lower lung + Anemia + Trombositopenia + Hypocalsemia +
Acidosis Respiratory + Hypoalbuminemia
COD: MOF
2. Leoni Ananda/Female/5 years old/ Day care 27
Diagnose: ICH + SOL + fracture linear temporoparietal sinistra post craniotomy
decompression
COD: MOF

F. Patient treated in ICU : (2)

1. Rohaya binti Muhammad/ Female / 65 years old /Day care 3
S:-
O : A : ETT
B : SIMV PS 10 PEEP 5 FiO2 40 % RR : 16 x/m SpO2 : 100 %
C : TD : 122/63 mmHg HR : 103 x/m
D : GCS : DPO Pupil Isocor, Light reflex +/+

Left temporo parietal region: Lab 22-02-2017

Hb : 9,1
I : Dry gauze, Drain 20cc/24 hour Leukosit : 15.300
Ht : 28
Plt : 259.000
Na : 150
Fluid Balance: K : 4,1
Cl : 126
I : 1252 cc
O : 1761 cc
IWL : 252 cc
Total : -767 cc/24 hour

1
 A : ICH Temporoparietal sinistra lobe + IVH + Post Craniotomy day 3

P : - IVFD Ringer Fundin gtt xx/ minute

- Inj Ceftriaxon 1 gr/ 24 hour IV
- Inj Omeprazole 40 mg/24 hour IV
- Inj Morphin 10mcg/kgBW/hour continous
- Precedex 0,2 mcg/kgBW/hour continous
- Manitol 125 mg/6 hour drip
- Amlodipin 10 mg/24 hour NGT
- Valsartan 80mg/24 hour NGT

2. Syahrido Bestari / Male / 13 years old/ Day care 5

S:-
O: A : ETT
B : Ventilator C PEEP 5 FiO2 40%
C : BP : 113/79 mmHg HR: 118 x/m
D : GCS : E4M6VT=10T

Shoulder dextra region: Lab 21-02-2017

I : VAC, efective (+) Hb : 7,6

Leuko : 19.900
Ht : 23
Tromb : 427.000
A: Alb : 2,8
Na : 135
- Limb ischemic extremity superior dextra K : 4,3
- Post disarticulation glenohumeral dextra
pH : 7,484
- Closed Fracture mid 1/3 clavicula dextra, fracture scapula dextra pCO2 : 44,1
pO2 : 98,6
HCO3 : 33,4

Fluid Balance:
I : 1308 cc
O : 1325 cc
IWL : 310 cc
Total : -327 cc/24 hour

P:

2
 - Meropenem 1 gr / 8 hour iv
- Paracetamol 1 gr / 8 hour iv
- Omeprazol 40 mg / 24 hour iv
- Ca Gluconas 2 g 1x order iv
- Metoclorpamide 10 mg 1x iv
- Caxadyn 30cc 1x NGT
- Wound care with modified VAC

G. Patient treated in PICU: (-)

H. Patient treated in NICU: (1)
1. Baby. Salama/Female/30 days old /Day care 24
S:-
O: A : Nasal Pronge
B : BCPAP PEEP 7 FiO2 40% SpO2 : 94%
C : HR : 178 x/m Pupil isocor, Light Reflex +/+
D : Active Temperature : 36,9 C

Abdominal Region:
I : Operation wound dry Lab 21-02-2017

P : lump Hb : 13,1
Leuko : 12.100
P : Timpany Ht : 40
Plt : 37.000
A : Bowel Sound (+) Albumin: 3,4
NGT : (+), production (+) 50 cc, green

Fluid Balance:
I : 735,7 cc
O : 341,5 cc
IWL : 55,2 cc
Total : 339 cc/24 hour

A:
-Intestine Malrotation
-Post Ladds procedure day 21

3
 -Trombocitopenia

P :- IVFD D10 1/5 NS + Ca gluconas 300 mg + KCl 10 cc 20 cc/ hour IV

- Inj. Aminofusin pedatrik 5% 9 cc/hour IV
- Inj. Sibital 10mg /12 jam IV
- Inj. Omeprazole 2 mg/12 hour IV
- Inj. Vancomicyn 100 mg/8 hour IV
- Inj. Fluconazole 40 mg/24 hour IV
- Inj. Metronidazole 60 mg/12 hour IV