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No
Bed
Identitas
Abdul Halim
34 tahun
62987
MRS 25/9/13
Lorensius
30 tahun
631677
MRS 7/10/13
Diagnosis
Post release
contractur + skin
graft day 34 th
due to right
chronic femur
ulcer and
contracture of
genu
Electric Burn
Injury 30%
Pemeriksaan Penunjang
Terapi
Lab 5/11/2013
WBC 14,96 RBC 5,01 HGB 12,1
HCT 346 PLT 784 Na 152 K 4,4
Cl 109 Ur/Kr 16/0,3 GOT/GPT
33/15 CT/BT 8/2 GDS 112
Sulaiman
27 tahun
631384
MRS
10/10/2013
Labeda, Sp. BKBD
Electric burn
injury 20% + post
debridement POH
16
Lab 4/11/2013:
CT;800, BT: 300, PT: 9,9,
APTT: 27,3, GDS: 99, Ur: 32,Cr:
0,6, GOT: 28, GPT: 65 Prot.total
6,08 Alb 3,40
RBC: 4,80, WBC: 14,46, HGB:
11,3, HCT: 34,4,
Jasmail
18 tahun
632625
MRS 13/10/13
Electric burn
injury 7%+
mycompartment
sindrom+post
fasciot
Lab 6/11/2013
RBC 3,09 HGB 9,1 HCT 26,3
PLT 305 WBC 10,4
Zeisyah
1 tahun
635764
MRS 5/11/2013
POST
debridement ec
combutio gr.II A
9% due to burn
injury
Lab 5/11/2013
WBC 14,96 RBC 5,01 HGB 12,1
HCT 35,9 PLT 346 SGOT/SGPT
33/15 GDS 112 Ur/Cr16/0,3
Na/K/Cl 152/4,4/109
Rikardus
19 tahun
635465
MRS 2/11/2013
Kompartemen
sindrom due to
electric burn
injury
Lab 10/11/13
WBC 36,28 RBC 3,71 Hb 10,4
HCT 29,6
Lab 8/11/13
WBC 25,83 Hb 8,2 RBC 2,98
HCT 23,4
Cefadroxyl
2x500
Vit c 3x1
Rawat luka +
GV
Rawat
luka+GV
Cotrimoxazole
2x2
Vit c 3x1
Ranitidin 3x1
as.mefenamat
3x1
Ampicilin
3x500
Vit c 3x1
Ranitidin 3x1
Rawat
luka+GV
Rawat
luka+GV
Cefadroxyl
2x500
Ranitin 3x1
Vitc 3x1
Vip albumin
3x2
As.mefenamat
3x1
Cefadroxyl syr
2x1/2 cth
PCT syr 3x3/4
cth
Elkana syr 1x1
cth
Rawat
luka+GV
Rawat luka
Ranitidin/8J
Ketorolac/8J
Bed
409
B
Identitas
Fathurahman
Achmad
23/10/2011
006421
MRS
10/11/2013
Askes
Dr. A. J.
Riewpassa,
Sp.B, Sp.BP
Diagnosis
POH cordektomi
Pemeriksaan Penunjang
LAB 4/11/2013
WBC 6.91 RBC 4.75 HGB 12.5
HCT 34.7 PLT 212 Na/K/Cl
138/4.5/102 CT/BT 700/200
PT/APTT 13.7/33.2 SGOT/SGPT
38.1/20.4 Prot. Total 5.7 Alb 4.3
GDS 105 As. Urat 4.0 Ur 18.5
Terapi
Instruksi post op:
- Aff infus bila
sadar baik
- Cefat 2x1
- Sanmol 3x1
- GV/3 hari
IC
No
Bed
Lt.2
K2B
1
Identitas
Minton Sesean
10/05/1976
635406
MRS
02/11/2013
Umum/tunai
Dr. A. J.
Riewpassa,
Sp.B, Sp.BP
Diagnosis
-
Ulkus region
manus (S)
DM tipe II
Pemeriksaan Penunjang
Sputum BTA 3x (pewarnaan)
6/11/2013
- Pewarnaan BTA 1: Negatif
- Pewarnaan BTA 2: Negatif
- Pewarnaan BTA 3: Negatif
Sputum BTA 1x (pewarnaan)
4/11/2013
Sputum BTA: negative
HbA1c 4/11/2013
HbA1c 9,2
Laboratorium 3/11/13
WBC: 27,82 RBC: 3,55 HGB: 9,9
HCT: 30 PLT: 352 GDP: 222
Ur/Cr: 19/0,6 SGOT/SGPT: 6/6
Prot.total: 6,92 alb: 2,6 kol.total:
97 kol.HDL: 18 kol. LDL: 67
trigliserida:98 as.urat: 4,9
Na/K/Cl: 131/3,5/95 HBsAg:
nonreactive antiHCV: nonreactive
Foto manus sinistra AP/oblik
2/11/2013
Tidak tampak kelainan radiologic
pada foto manus ini
Terapi
GV per hari
Terapi sesuai
TS interna
Tunggu hasil
kultur
Bed
Identitas
Diagnosis
Pemeriksaan Penunjang
K4B
1
Harun
16 tahun
629937
Post amputasi
abses kaki (s) +
skin defect femur
(s) + pro skin
grafting (KJS dari
BTKV)
Terapi
Lontara 2
No
Bed
10
L2
uro
K11
B6
Identitas
Herlinda
P/1-1-1997
RM : 556307
Jamkesmas
Diagnosis
Terapi
POH 18
Debridement
Necroting tissue + pemasangan
vaccum luka
-
Dr.dr.Fonny
Josh, Sp.B-RE
IVFD RL 20 tpm
Meropenem 500 mg/8j/iv
Neurobion amp/24 j
Diet TKTP
Pem. Penunjang
Kultur dan
sensitivitas
29/10/2013
Sensitif :
Meropenem,
levofloxacin,ceftazi
dim,ofloxacin,cipro
floxacin,azternam
Lab 24/10/2013
WBC 12,4 RBC
4,14 HCT 32,1
HGB 10,3 PLT 473
PT/APTT 13,0/34.4
NA/K/CL
134/4,0/100 GDS
70 UR/CR 31/0,5
GOT/GPT 46/51
11
L2
Onk
o
K4B
2
Tahir
L/1-12-1956
RM : 631446
MRS : 8-102013
Jamkesmas
Dr.dr.Fonny
Josh, Sp.B-RE
POH 11
Rekonstruksi
Labia superior
Cefadroxyl 2 x 500
PA 21/10/2013
GV/ 2 hari
13
L2
Orth
oped
i K8
B5
L2
Orth
oped
i K8
B1
Theopilus
L/2-11988/460312
POH 9
Debridement
ulcer gluteus
GV/hari
Lab 2/11/2013
Ceftriaxon 1 g/12j/iv
CT/BT 8/3
PT/APTT 11,5/29,5
GDS 196 UR 21
GOT/GPT 37/41
NA/K/CL
144/3,9/110
Ranitidin amp/8j/iv
MRS :
24/10/2013
JKM
Sado dg.Siala
L/15-51978/635357
-IVFD RL 24 tpm
Lab 2/11/2013
-Ceftriaxone 1g/12j/iv
-Ketorolac 1amp/8j/iv
-Ranitidin 1 amp/8j/iv
-Takar drain/hari
Posisi tidak boleh terlentang
14
15
L2
Orth
oped
i K9
B1
L2
Orth
oped
i K5
B1
A. Dea Anugrah
P/1-11995/634848
MRS : 29-102013
Aldi
L/1-1-2000/
POH 15
Debridement
Skin loss femur
sinistra
Closed Fraktur
Ramus mandibula
(S)
636047
IVFD RL : DS 1:1
Lab 10/11/2013
Ceftriaxone 1 gr/12j/iv
Ranitidin amp/8j/iv
IVFD RL 28 tpm
Lab (7/11/2013)
Ceftriaxon 1 g/12j/iv
Ranitidin amp/8j/iv
CT/BT 700/300
PT/APTT 11,6/29,0
GDS 115 Ur/Cr
20/0,60 GOT/GPT
20/18 Na/K/Cl
142/4,0/112 WBC
10,95 RBC 4,32
HGB 12,1 HCT
34,2 PLT 192
Lontara 3
No
Bed
Identitas
Diagnosis
Penunjang
Terapi
5
17
K1
B1
Kam
ar 2
Bed
6
Nama : Rasidi
RM: 636485
Nama : Nur
Annizah
D/ Fraktur
Depressed os
frontal +
maksilofacial
D/ Labioschistis
Lab 10/11/2013
IVFD RL 28 tpm
Inj Ceftriaxon
1gr/12 jam/IV
Inj Ketorolac 30
mg/8 jam/IV
Inj Ranitidin
50mg/8 jam/ IV
Cito trepanasi
RM: 630519
R/ Rencana operasi
tgl 12/11/2013
Lab 30/09/2013
WBC: 9,71 RBC: 4,65 HGB: 10,5
HCT: 31,7 PLT: 315 CT/BT :
800/300 INR: 0,91 PT: 11,4
kontrol 13,0 APTT: 33,5 kontrol
26,1 Natrium: 138 Kalium: 4,4
Klorida: 106 GDS: 104 Ur/Cr:
8/0,2 SGOT/SGPT: 41/24 Protein
total: 8,1 Albumin: 4,4 HBsAg:
Non Reaktif
18
19
Kam
ar 3
Bed
1
Kam
ar 3
Bed
2
Nama: Ajamiah
RM: 636235
Nama: Hj.
Banong
RM: 636372
D/ POH 1 open
fraktur segmental
mandibula
D/ POH 3 repair
wajah kompleks/
maxillofacial
injury
Lab 08/11/2013
IVFD RL 28 tpm
Inj Ceftriaxon
1gr/12 jam/IV
Inj Ketorolac 30
mg/8 jam/IV
Inj Ranitidin
50mg/8 jam/ IV
Lab 08/11/2013
IVFD RL 28 tpm
Inj Ceftriaxon
1gr/12 jam/IV
Inj Ketorolac 30
mg/8 jam/IV
Inj Ranitidin
50mg/8 jam/ IV
Cernevit 1 vial/
6
20
Kam
ar 3
Bed
3
Nama : Dinda
RM: 591017
D/ POH 8
Chordectomy
GV besok
Pertahankan
benang silk
rekanalisasi
ductus
nasolacrimalis 2
minggu
IVFD RL 28 tpm
Inj Ceftriaxon
1gr/12 jam/IV
Inj Ketorolac 30
mg/8 jam/IV
Inj Ranitidin
50mg/8 jam/ IV
GV hari ini
Rawat luka/ 3
hari
Cefadroxyl
2x500
Asam
mefenamat 3x1
Ranitidin 3x1
GV hari ini
IVFD RL 28 tpm
Inj Ceftriaxon
22
Kam
ar 3
Bed
4
Kam
ar 3
Bed
Nama: Nursia
Tamrin
RM: 632591
Nama: Muh.
Aqsa Marhaban
D/ POH 24 Skin
Graft ec Skin loss
regio scalp
D/ POH 1
Labioplasty
Lab 13/10/2013
WBC: 11,37 RBC: 3,93 HGB:
10,6 HCT: 31,3 PLT: 210 CT/BT :
730/200 INR: 0,9 PT: 11,3
kontrol 10,8 APTT: 28,7 kontrol
24,3 Natrium: 141 Kalium: 4,3
Klorida: 112 GDS: 105 Ur/Cr:
12/0,8 SGOT/SGPT: 32/64
Protein total: 6,3 Albumin: 3,5
Globulin: 2,8
RM: 634282
spesifik
250mg/12
jam/IV
Lab 28/10/2013
-
Paracetamol
syrup 3 x cth
GV/ 3 hari
Tunggu jadwal
operasi
Rencana ORIF
Cefadroxyl syr
2x1
Paracetamol syr
3x1
Vit C 3x1
GV/ 2 hari
Inj Ceftriaxon
1gr/12 jam/IV
Inj Ketorolac 30
mg/8 jam/IV
Inj Ranitidin
50mg/8 jam/ IV
Pneumocephal
Regio Frontal
Cernevit 1 vial/
24 jam/ drips
Mobilisasi mika
miki
Kam
ar 3
Bed
6
Nama:
Nurlindawati
D/ Maxilofacial
injury
RM: 636540
Fraktur
Zygoma (s)
Fraktur
maxilla (s)
24
25
Kam
ar 1
Bed
1
Beda
h
saraf
Kam
ar 5
Bed
1
Beda
h
saraf
Nama: Adri
RM: 627752
D/ POH 14
Debridement
nekrotik tissue ec
skin loss region
frontal
Nama:
Samsuddin
D/ POH 4
Craniectomy
RM: 636204
TCS GCS13
(E3M6V4)
Open
depressed
Fracture R.
Frontal
Lab 11/11/2013
WBC: 10,89 RBC: 4,44
HGB: 10,3 HCT: 31,1 PLT: 245
CT/BT : 800/200 INR: 1,00 PT:
12,5 kontrol 11 APTT: 26,5
kontrol 25,0 Natrium: 140
Kalium: 3,8 Klorida: 113 GDS:
118 Ur/Cr: 21/0,6 SGOT/SGPT:
17/9 Protein total: 6,5 Albumin:
3,9
Lab 22/10/2013
WBC: 11,37 RBC: 4,22 HGB:
11,2 HCT: 32,6 PLT: 580 CT/BT :
700/300 INR: 0,90 PT: 10,6
kontrol 10,5 APTT: 32,5 kontrol
25,7 Natrium: 144 Kalium: 3,3
Klorida: 109 GDS: 95 Ur/Cr:
12/0,4 SGOT/SGPT: 35/15
Lab 07/11/2013
WBC: 14,52 RBC: 3,91 HGB:
11,0 HCT: 31,6 PLT: 236 CT/BT :
600/200 INR: 1,095 PT: 13
kontrol 10,4 APTT: 24,3 kontrol
24,8 Natrium: 140 Kalium: 3,9
Klorida: 113 GDS: 156 Ur/Cr:
56/1,0 SGOT/SGPT: 31/14
Protein total: 6,6 Albumin: 3,4
Fraktur nasal
8
Kam
ar 2
Bed
4
Saraf
Nama: Narliah
RM: 612116
D/ Ulkus
decubitus
Miring kiri +
Miring kanan
Spondylosis thoracolumbalis
GV/ hari
Lab 01/11/2013
GV
Cefadroxyl 2dd1
Aspirasi: pagi,
sore
27
Kam
ar 2
Bed
6
THT
Nama:
Rismawati,
RM: 624228
D/ Post Explorasi
Hemangioma
29.
Kam
ar 3
Bed
6
Mata
Nama:
Dewiyanti
Kam
ar 4
Bed
3
Mata
Nama: Yahya
kurniawan
RM: 634445
RM: 613862
D/
Lab 28/10/2013
Fraktur
mandibula
parashymphisis
(D)
D/
Lab 07/11/2013
Post Op ORIF ec
Fraktur
mandibula
R/Tunggu jadwal
operasi
Thorax PA 07/11/2013
Tidak tampak kelainan radiologic
pada foto thorax
30.
Kam
ar 1
Bed
2
Kulit
Kela
min
Nama: Haliong
D/
Lab 06/11/2013
RM: 635625
Basalioma region
nasal
31.
Kam
ar 2
Bed
5
Kulit
Kela
min
Nama: Peti
susanti
RM: 627123
D/
Ruptur Perineum
Cardiomegaly
Tidak tampak metastasis pada
foto thorax ini
Lab 29/10/2013
WBC: 4,6 RBC: 4,50 HGB: 10,2
HCT: 32,4 PLT: 359 CT/BT: 800/
300 PT: 12,5 kontol 12,1 APTT:
24,6 kontrol 24,9 INR: 1,04
Ur/Cr: 13/0,3 SGOT/SGPT: 33/9
GDS:79 Natrium: 138 Kalium:
10
Bed
Identitas
Diagnosis
32
K8B
1
Rifqi Wahid
10/02/2011
626677
MRS
07/09/2013
Jamkesmas
Dr. Dr. Fonny
Josh, Sp.B,
Sp.BP
Ulkus decubitus
region occipital
Pemeriksaan Penunjang
Laboratorium 7/11/2013
WBC:21,23 RBC: 3,57 HGB: 9,8 HCT: 29,1 PLT: 757 Prot.total: 5
alb: 2,8 Na/K/Cl: 128/4,4/100
Laboratorium 1/11/2013
Ferritine: 1106,86
HbA1c 4/11/2013
HbA1c 9,2
Laboratorium 3/11/13
WBC: 27,82 RBC: 3,55 HGB: 9,9
HCT: 30 PLT: 352 GDP: 222
Ur/Cr: 19/0,6 SGOT/SGPT: 6/6
Prot.total: 6,92 alb: 2,6 kol.total:
97 kol.HDL: 18 kol. LDL: 67
trigliserida:98 as.urat: 4,9
Na/K/Cl: 131/3,5/95 HBsAg:
nonreactive antiHCV: nonreactive
Foto manus sinistra AP/oblik
2/11/2013
Tidak tampak kelainan radiologic
pada foto manus ini
Terapi
GV per hari
Tunggu jadwal
operasi
11
Bed
Identitas
Tanggal
L3
K2B
6
Nur Annizah
12/11/2013
L3K
3B6
Nama: Nurlindawati
Diagnosis
Labioschistis
RM: 630519
RM: 636540
D/ Maxilofacial injury
Fraktur Zygoma (s)
Fraktur maxilla (s)
L3K
3B6
mata
Nama: Dewiyanti
L4K
8B1
Rifqi Wahid
10/02/2011
626677
MRS 07/09/2013
Jamkesmas
Dr. Dr. Fonny Josh, Sp.B, Sp.BP
RM: 634445
Ulkus decubitus region occipital
12