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    List Pasien Divisi Thovask Kamis, 18 Agustus 2016 Irina A Atas: No Kamar Identitas Diagnosis Lab Terapi 15/8/2016 1/8/2016

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    Brien Liem
    This document lists patients in the thoracic division including their room number, identity, diagnosis, and recent lab results. For each patient, it provides treatment plans and notes from doctors.

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    List Pasien Divisi Thovask Kamis, 18 Agustus 2016 Irina A Atas: No Kamar Identitas Diagnosis Lab Terapi 15/8/2016 1/8/2016

    Uploaded by

    Brien Liem
    21 views3 pages
    This document lists patients in the thoracic division including their room number, identity, diagnosis, and recent lab results. For each patient, it provides treatment plans and notes from doctors.

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    Original Title

    LIST Thovask 17Agust2016

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    This document lists patients in the thoracic division including their room number, identity, diagnosis, and recent lab results. For each patient, it provides treatment plans and notes from doctors.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    21 views3 pages

    List Pasien Divisi Thovask Kamis, 18 Agustus 2016 Irina A Atas: No Kamar Identitas Diagnosis Lab Terapi 15/8/2016 1/8/2016

    Uploaded by

    Brien Liem
    This document lists patients in the thoracic division including their room number, identity, diagnosis, and recent lab results. For each patient, it provides treatment plans and notes from doctors.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    LIST PASIEN DIVISI THOVASK

    kamis, 18 Agustus 2016


    IRINA A Atas :
    No

    Kamar

    Identitas

    Diagnosis

    Lab
    15/8/2016
    Leu
    12720
    Eri
    3,48
    Hb
    10.0
    Ht
    31.7
    Trom 361
    MCH 28.8
    MCHC 31.6
    MCV 91.1
    Cl
    82.5
    K
    3.63
    Na
    129
    SGOT 18
    SGPT 10
    Ur 12
    Cr 0.7
    Protein total 5.6
    GDS 147
    Alb 2.76
    Globulin 2.84

    1/8/2016
    PT
    Pasien
    detik
    Kontrol
    detik
    INR
    Pasien
    detik
    Kontrol
    APPT
    Pasien
    Kontrol

    12/8/2016
    Leu 5638
    Eri 4.33
    Hb
    10,7
    Ht
    33.9
    Trom 385
    MCH 24,6
    MCHC 31,5
    MCV 78,2

    SGOT 20
    SGPT 19
    Ur
    16
    Cr
    0,7
    GDS 106
    Cl
    99.5
    K
    4,28
    Na
    135
    Alb 2.98

    -Sol RL 20 gtt/m
    -Ceftriaxone 21
    -Ketorolac 31
    -Ranitidine 21
    - rawat Luka
    - Terapi lain sesuai TS ortho

    Trauma tumpul thorax


    susp bronkhiestasis
    susp Tb paru

    08/08/16
    Leu 13980
    Eri 4,70
    Hb 13,7
    Ht 40,8
    Trom 318^
    ur 18
    cr 0,8
    GDS 116

    15/8/16
    Foto thorax:
    - susp infected
    bronchiectasis +
    kista paru
    - fr. costa kanan
    depan

    Efusi pleura sinistra ec


    susp pneumonia
    dd malignancy

    12/08/2016
    Leu
    9405
    Eri
    4,10
    Hb
    12,3
    Ht
    37,4%
    Trom 811^
    MCH 30
    MCHC 32.9
    MCV 91.2
    SGOT 118
    SGPT 156
    Ur
    15
    Cr
    0,8

    Pneumothorax dextra +
    v.ictum thoracoabdominal

    14/08/2016
    Leu
    18200
    Eri
    4.15
    Hb
    12,5
    Ht
    35.5%
    Trom 290^
    MCH 30.1
    MCHC 35.2
    MCV 85.5

    Abrina Adrian
    P/65th/47.51.18
    A6
    1

    MRS
    7/7/206

    Bed 2
    DPJP:
    dr. Adrian Tangkilisan, SpBTKV

    Post thoracotomi
    dekortikasi + malignancy
    biopsy ec tumor
    mediastinum

    Michael Lilipali
    L/27th/47.74.91
    2

    A7
    Bed 6

    MRS
    1/8/2015
    DPJP:
    dr. Adrian Tangkilisan, SpBTKV

    -fr. tibia fibula 1/3


    dista; terbuka
    - rupture a tibialis
    anterior posterior

    Ronald Tumilantouw
    L/47th/41.31.94
    3

    A8
    Bed 4

    MRS
    04/8/2016
    DPJP
    dr. Adrian Tangkilisan, SpBTKV

    Jackson kawengian
    L/ 36th/ 48.02.91
    4

    A8
    bed 3

    MRS
    7/8/16
    DPJP
    dr. Adrian Tangkilisan, SpBTKV

    Manorek Andrano/L/ 22 th/


    48.08.12

    A7 bed 2

    MRS:
    14/8/2016

    Terapi

    DPJP:
    dr. Adrian Tangkilisan, SpBTKV

    12,5
    13,0
    0,99
    1,04 detik
    27,0 detik
    29,9 detik

    11/7/2016
    Pemeriksaan Cairan
    Pleura: EKSUDAT

    -Sol NaCl 21 gtt/mnt


    -Ciprofloxacin drips
    -Ranitidine 21
    -Ketorolac 31
    - vit c 3x1
    - duragesic patch
    -Nebu Combivent 31
    -Vip Albumin 3 x 2 po
    - tunggu hasil PA
    - tunggu hasil foto thorax
    - Terapi lain sesuai TS interna

    Sitologi
    (12/7/2016)
    Tidak ditemukan
    sel ganas

    Uric Acid 3.9


    Cl
    96.8
    K
    5.11
    Na 134
    15/8/16
    foto thorax: massive
    pleural efusion
    sinistra + suspek TB
    paru

    Ur
    15
    Cr
    0,7
    GDS 128
    Cl
    110
    K
    3.6
    Na 138

    Venflon
    Ceftriaxone 2x1 iv
    Ranitidin 2x1 iv
    Ketorolac 3x1 iv
    Duragesic patch
    Nebulizer combivent 3x1
    Tunggu hasil sputum BTA, lab
    Terapi lain sesuai TS interna

    -IVFD NaCl 0,9% 14 gtt/m


    - nebulizer combivent 3x1
    -Ceftriaxone 2x1
    - Ranitidine 2x1
    - Ketorolac 3x1
    -PCT drips k/p
    - tunggu hasil CT scan thorax, BTA
    - tunggu hasil LED

    - ceftriaxone 2x1
    - Ranitidine 2x1
    - Ketorolac 3x1
    - Nebu combivent 3x1
    - NaCl 0.9% 500 cc/12 jam
    - rawat WSD
    - R/ foto rontgen hari ini

    15/08/2016
    Leu
    5430
    Eri
    3.85
    Hb
    10.7
    Ht
    33.1%
    Trom 247
    MCH 27.8
    MCHC 32.3
    MCV 86.0
    OT/PT 25/14
    Gamma GT 42
    Bil tot 0.54
    Bil Dir 0.33

    Madjisat Mangawingi/L/ 58
    th/ 47.61.79

    A10

    MRS:

    DVT tungkai kiri

    DPJP:
    dr. Djony E Tjandra, SpB
    (K) V

    Ur
    40
    Cr
    0.9
    Prot tot 4.51
    Alb 2.09
    Glob 2.42
    Alk fosft 71
    Cl
    100
    K
    3.75
    Na 136
    PT
    @detik 14.1
    @INR 1.16
    APPT 35.8

    - Ekstrenal fiksasi
    - Cek PT/APTT target 2-2.5
    - Heparinisasi:
    Bolus heparin 5000 UI (1cc)
    Maintanace 15000 UI (3cc) dalam
    Nacl dalam 24 jam selama 5 hari.

    Ruauw Durin/P/ 81 th/


    37.86.89

    A6

    MRS:
    16/8-16
    DPJP:

    IRINA A Bawah
    No

    Kamar

    Identitas

    Tumelap Herry/
    /47.88.07/12-191950/L/malalayang
    1

    B7
    bed 1

    MRS
    19-07-16
    DPJP
    Dr. Adrian T, SpB-TKV

    Diagnosis

    Lab
    8/8/2016
    Leu
    12580
    Eri
    4,29
    Hb
    12,7
    Ht
    38,8
    Trom 450
    GDP 163
    SGOT 20
    SGPT 24
    Ur
    28
    Cr
    0,5

    as urat 4,5
    chol 155
    HDL 25
    LDL 103
    Tri 135
    Mg 2,2
    Alb 3,52
    Ca 9.68
    Na 135
    K 4,72
    Cl 94,9

    15/08/16
    Leu 5100
    Eri 3,28
    Hb 9.2
    Ht 27.6
    Trom 250
    MCH 28.0
    MCHC 33.3
    MCV 84.1
    SGOT 30

    Ur 20
    Cr 0.8
    Protein total 6.19
    GDS 99
    Alb 3.63
    Globulin 2.56
    Cl 99.8
    K 3.36
    Na 136

    15/08/2016
    Leu 9700
    Eri 4.74
    Hb 14.7
    Ht 43.4
    Trom 465
    MCH 31
    MCHC 33.9
    MCV 91.6
    SGOT 54
    SGPT 40

    Ur 20
    CR 0.9
    GDS 93
    Alb 4.05
    Uric Acid 6.9
    Na 139
    K 3,98
    Cl 102.1

    Trauma tumpul thoraks


    Fraktur tibia fibula 1/3
    tengah terbuka grade I

    12/08/2016
    Leu 9282
    Eri 3.27
    Hb 9.8
    Ht 29.4
    Trom 308

    MCH 30.1
    MCHC 33.4
    MCV 90
    HbA1c 8.7
    15/8/16
    Alb 2.50

    Empiema sinistra

    10/08/2016
    Leu 5036
    Eri 6.03
    Hb 16.4
    Ht 48.7
    Trom 267
    MCH 27.2
    MCHC 33.7
    MCV 80.8

    SGOT 14
    SGPT 9
    ur 18
    Cr 0,8
    GDS 99
    Alb 4.5
    Cl 98
    K 3,27
    Na 141

    Fr. clavicula dextra et


    sinistra
    fr femur sinistra 1/3
    tengah tertutup
    Contusio paru
    Post pemasangan WSD
    ec hematothorax sinistra

    Muhamad Angga/
    L/21/48.06.02
    2

    B8 Bed 6

    MRS
    11/08/2016
    DPJP
    dr. Djony Tjandra,
    SpB(K)V

    Ridwan Makahontong/
    L/42thn/07.12.50
    3

    B11 bed 2

    MRS
    11/08/2016
    DPJP
    Dr. Adrian T, SpB-TKV

    Vulnus schizum region


    antebrachii sinistra ec
    pecahan kaca
    Ruptur Arteri

    Fraktur costae III


    posterior sinistra +
    Old fracture costa III-IV
    posterior dextra
    LEPAS RAWAT(?)

    Manuel Sangian/L/81
    th/48.60.10
    4

    B9
    bed 8

    MRS:
    3/8/16
    DPJP:
    Dr. Adrian T, SpB-TKV
    Lendeng Hizkia/L/24
    th/47.25.77

    B8 bed 4

    MRS:
    12/8/2016
    DPJP:
    Dr. Adrian T, SpB-TKV

    Terapi

    - RL 20 gtt/m
    -Bisolvon 3 x1
    - Nebulizer combivent 3x1
    - Ketorolac 3x1 k/p
    - ceftriaxone 2x1 -> H7
    - rawt WSD
    - foto thorax AP tegak

    Ceftriaxone inj 2 x1
    Ranitidine 2 x 1
    Ketorolac amp 3 x 1
    Heparin 3cc dal am NaCl
    0.9% 500cc/24 jam
    Warfarin tab 2 mg > po
    20.00
    Rawat luka
    transfusi PRC 1bag

    NaCl 0.9% 14 gtt/m


    Ceftriaxone 2x1
    Ketorolac 3x1
    Ranitidine 2x1
    Konservatif

    Konservatif
    Terrapi lain sesuai TS
    orthopedi dan interna
    Nebulizer combivent 3x1
    sudah ada jawaban konsul
    RM

    R/ Thoracotomy

    - fr costa II - VII
    sinistra post
    - fr. clavicula 1/3 tajam
    tertutup

    15/08/2016
    Leu 19800
    Eri 5.89
    Hb 16.9
    Ht 48.2
    Trom 309
    MCH 28.7
    MCHC 35.1
    MCV 81.8

    SGOT 23
    SGPT 21
    ur 23
    Cr 0.7
    GDS 280
    Cl 104
    K 4.10
    Na 135

    Hematopneumothorax
    sinistra + syok
    hipovolemik
    teresusitasi + vulnus
    laceratum region
    manus sinistra +
    faraktur terbuka digiti
    IV, V manus sinistra

    17/08/2016
    Leu 18600
    Eri 3.37
    Hb 10.6
    Ht 29.3
    Trom 152
    MCH 31.5
    MCHC 36.2
    MCV 86.9

    SGOT 373
    SGPT 298
    ur 27
    Cr 1.2
    GDS 102
    Cl 110
    K 3.5
    Na 138

    Karimang Rio/ L/ 29 th/


    48.09.14
    6

    B8

    MRS:
    15/8/2016
    DPJP:
    Dr. Adrian T, SpB-TKV

    Runtu Yesias/ L/ 27 th/


    48.10.41
    7

    B9 bed 3

    MRS:
    17/8/2016
    DPJP:
    Dr. Adrian T, SpB-TKV

    - duragesic patch
    - bisolvon 3x1
    - R/ AGD
    - CPPT belum ditulis

    PobelaYusdianto/ L/18 th/


    48.10.35
    7

    B9 bed 6

    MRS:
    17/8/2016

    -. Line 1 : IVFD NaCl 0.9%


    -. Line 2: RL
    -. WSD (+)
    -. O2 3 lpm

    Hematothorks sinistra
    + SCI+post wsd

    DPJP:

    LUAR IRINA A
    No

    Kamar

    Identitas

    Diagnosis

    Irina B
    Kamar 3

    Karindra Hendrik
    L/65th/45.48.68

    - Stenosis Vena Central


    - Post AVF BrachioChepalica
    - Ulkus Brachialis Dextra

    MRS

    Lab

    DPJP:
    dr. Djonny Thandra SpB
    (K)V

    Boarding
    A1

    Rani Kawengian

    Irina B
    Kamar 3

    MRS

    Tumor regio hemithorax


    sinistra

    DPJP:
    dr. Adrian T, SpB-TKV

    Ansyela Pohayouw
    P/54th/24.36.08
    4

    Anggrek 2
    Kamar
    110

    32150
    3,62
    9,5
    29,3
    439
    26,1
    32,3
    80,0

    10/8/16
    Leu
    Eri
    Hb
    Ht
    Trombo
    MCH
    MCHC
    MCV

    6900
    2,65
    8,0
    25,5
    149
    30,2
    31,4
    96,2

    11/8/16
    Leu
    Eri
    Hb
    Ht
    Trombo
    MCH
    MCHC
    MCV

    8625
    2,00
    6,5
    18,9
    243
    32,5
    34,5
    94,3

    Ur
    Cr
    Protein Total
    Fosfor
    Mg
    Albumin
    Globulin
    Cl
    K
    Na
    Ca

    104
    8,6
    6,20
    5,2
    2,87
    2,95
    3,25
    88,3
    4,36
    127
    8,42

    -Rawat Luka
    -As. Tranexamat 3x1 iv
    -Vit K 1x1 im
    -Elevasi Tangan 15

    Stenosis vena sentral

    Sumual Susye
    P/66th/23.35.43
    3

    25/7/16
    Leu
    Eri
    Hb
    Ht
    Trombo
    MCH
    MCHC
    MCV

    Terapi

    MRS : 11/8/2016
    DPJP:
    dr. Adrian T, SpB-TKV

    Ur
    Cr
    SGOT
    SGPT
    GDS
    Albumin
    Cl
    K
    Na

    Ur
    Cr
    Asam urat
    GDS

    19
    1,5
    26
    10
    86
    2,85
    101
    3,6
    140

    96
    6,6
    7,0
    107

    IVFD NaCl 0.9% 20 gtt/mnt


    Tramadol 3xa amp IV

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