KORAN BEDAH WANITA

SABTU, 20 JULI 2013

NO

KMR/
BED

MRS/
JAMINAN

NAMA/
JK/UMUR/
RM

DPJP

1.

Bed 13

16/07/2013
JKM

Ny. Maulany
P/28th/175611

HN

D/ Hemoroid grade IV pada G1P0A0

TD : 90/80
N : 80x/menit
P : 20x/menit
S : 36,5C

2.

Bed 11

19/07/2013
JKM

Ny. Yoke Kastanya

P/45th

JT

D/ Appendisitis Akut
TD : 110/70
N : 80x/menit
P : 20x/menit
S : 36,5C

3.

4.

5.

6.

7.

Kamar 8

Bed 7

Bed 15

TT 17

TT 7

08/07/2013
ASK

19/07/2013
ASK

08/07/2013
ASK

09/07/2013
JKM

12/07/2013
Umum

Ny. Hanijary Levina

P/46/043342

Ny. Wehelmina Mainake

P/58th/176119

Ny. Regina Sirken

P/29

Nn. Tince Takaria

P/27/032485

Ny. Maryam
P/48/175909

AT

AT

AT

AT

HN

DIAGNOSIS

Lab (19/07/2013)
RBC: 3.47,Hb:10.0,HCT: 29,1
D/ Post Laparatomi hari ke IV
TD : 100/60
N : 80x/menit
P : 20x/menit
S : 36,5C
Lab (09/07/2013)
RBC: 4,4 Hb: 9,8 HCT: 30,7 PLT: 373
WBC: 9,5 golda: A
D/ Ulcus Ca Mamma (D)
TD : 110/50
N : 80x/menit
P : 20x/menit
S : 36,5C
Lab (09/07/2013)
RBC: 1.73, Hgb 4.3, Hct 13.4, Mcv 78,
Wbc 22.8
D/ Tumor 1/3 cruris tengah (D)
TD: 100/60
N : 80x/menit
P : 20x/menit
S : 36,5C
Lab (13/07/2013)
HCT: 34,4, PLT: 510 WBC: 18,3
D/ Post Apendektomi hari ke IV
TD : 100/60
N : 80x/menit
P : 20x/menit
S : 36,5C
Lab (05/07/2013)
RBC: 3,95 Hb: 11,3 HCT: 33,1 PLT: 304
WBC 10,1
D/ Tumor Rectum 1/3 tengah
TD : 130/70
N : 80x/menit
P : 20x/menit
S : 36,5C

KET

Ivfd RL 20 tpm
Ceftriaxone 1x1gr/iv
Anti hemoroid Supp 2x1
Paracetamol 3x1
Rendam PK pagi dan
sore
USG
Ivfd RL 20 tpm
Ceftriaxone 1x1gr/iv
Ranitidine 2x1/iv
Ketoorolac 3x30mg/iv

Aff infuse
Rawat jalan
Ganti oral
Cefadroxil 2x500
Asam mefenamat 3x500
Sohobion 2x1 tab

Foto rontgen
Ekg
Ivfd RL 20 tpm
Ceftriaxone 2x1/iv
Ketorolac 3x30mg/iv
Transamin/8 jam/ IV

IVFD RL 20 tpm
Ciprofloxacin 12 jam/ IV
Ketorolac 3 x 30 mg/ IV
Ranitidine 2 x 1 amp/iv
Sohobion drip/iv
Metronidazole /8 jam/iv
Ondancetron 2x1/iv
Ivfd RL 24 tpm
Tramadol 100mg dalam
RL 500ml
Cefadroxil 2 x 1 gr/ IV
Metronidazole 0,5 gr/ 12
jam
Ranitidine 2 x 1 amp/ IV

Aff infuse
Raway jalan
Ciprofloxacin 2x1
Paracetamol 3x1 kp

8.

Kamar 1

13/07/2013
Umum

Ny. Ita Wahyunita

P/48th

AT

9.

Bed 9

08/07/2013
JKD

Ny. Yosina Disera

P/62/175810

AT

10.

Bed 6

15/07/2013
U

Ny. Rumlawang
P/38/043245

AT

11.

Kamar 6

16/07/2013
ASK

Ny. Barbalin Orlapean

P/29th 043556

JT

D/ Post Ulcus Ca Mamma (D), Sepsis,

Metastasis ke Tulang
TD : 80/50
N : 120x/menit
P : 20x/menit
S : 36,5C
Lab (12/07/2013)
Hb 10.2, Wbc 30.000, Eos 21-51,
Trombosit 315.000, SGOT/PT 37/45,
Ureum 25, Creatinin 0,7, Cholesterol
136, Bil T/I/D 0,4/0,7/0,1, Gdp 78
D/ Fraktur tibia fibula (S) grade II
TD : 100/70
N : 80x/menit
P : 20x/menit
S : 36,5C
D/ Post isthmus lubektomi tiroid hari ke
IV
TD : 90/70
N : 80x/menit
P : 20x/menit
S : 36,5C
Lab (08/07/2013)
FT4 0.970, TSH 0.640, SGOT/PT 37/29,
Ureum 26, Creatinin 0.77, GDP 81,
CT/BT 2/4
D/ Post Apendektomi hari ke III
TD : 110/60
N : 80x/menit
P : 20x/menit
S : 36,5C
Lab (08/07/2013)
Ureum 18, Creatinin 0.8, GDP 74,
CT/BT 6/2
D/ Post Excisi tumor hari ke I
TD : 100/60
N : 80x/menit
P : 20x/menit
S : 36,5C
D/ Post excisi tumor hari ke I
TD : 100/70
N : 80x/menit
P : 20x/menit
S : 36,5C

12.

Kamar 2

18/07/2013
ASK

Ny. Theresia Ursula

P/042240

AT

13.

Kamar 3

18/07/2013
ASK

Ny. Marla

AT

14.

Kamar 7

18/07/2013
ASK

Ny. Susana Ubro

P/40th/043450

AT

D/ Post appendektomi hari ke I

TD : 110/70
N : 80x/menit
P : 20x/menit
S : 36,5C

15.

Bed 4

18/07/2013
JKM

Nn. Prety Simboh

P/17th/025839

AT

16.

Bed 16

18/07/2013
JKM

Nn. Feronika Mansoni

P/17th/025839

JT

D/ Post debridement
TD : 120/70
N : 80x/menit
P : 20x/menit
S : 36,5C
D/ Ca Mamma (D) post mastektomi
TD : 110/70
N : 80x/menit

MENINGGAL
01.48 am WIT

Pukul

Cefadroxil 2 x 500 mg
Asam mefenamat 3 x 500
mg
Sohobion 2 x 1 tab
Aff
infuse
karena
bengkak
Ketorolac 3x30mg/iv
Ranitidine 2x1/iv
Ceftriaxone
2gr/24jam/iv
Kalnex 1gr/8 jam/iv

Diet Lunak
Cefadroxil 2x500
Asam mefenamat 3x500
Ranitidine 2x1 tab

Aff infuse
Terapi
ganti
oral
cefadroxil 2x500
As. Mefenaat 3x500
Sohobion 2x1 tab
Aff infuse
Rawat jalan
Terapi
ganti
oral
cefadroxil 2x500
As. Mefenaat 3x500
Sohobion 2x1 tab
Ivfd RL 24tpm
Tramadol 100 mg dalam
RL 500 ml
Cefotaxim 2x1/iv
Metronidazol 0,5gr/12
jam/drips
Aff infuse
Terapi
ganti
oral
cefadroxil 2x500
As. Mefenaat 3x500
Sohobion 2x1 tab
Ivfd RL 20tpm
Ceftriaxone 2x1/iv
Novalgin 3x1/iv

P : 20x/menit
S : 36,5C

Paracetamol infuse
GV pagi dan sore
Konsul dr.saraf