KORAN THORAX TANGGAL 19 DESEMBER 2010

No Ruangan Identitas MRS Keterangan

1 Palem Bw h/ Ny. Rabiah / P / 59 22/11  Post chest tube hr -5 e.c Efusi Pleura (D)
B2 kmr9 thn /10
 Tu. Mediastinum
 GDS:136;GOT/GPT:13/22.
 (15/12/10) Na/K/Cl: 142/3,6/106
 (15/12/10) GDS: 154; Ur: 53; Kr:0,7; GOT:14; GPT:20;
Prot.Total: 7,1, Alb:3,8; Glb: 3,3
 (15/12/10) WBC:17; RBC:3,79; Hb:10,7; HCT:33; PLT:286
 (10/12/10) Ft. Thorax PA: Efusi Pleura
 (22/11/10) Ft. Thorax PA: Tu. Mediastinum D/ +
Atherosklerosis aorta
Drain: Ka= cc
2 Palem Ats / B2 Nn. Desi / P / 21 5/12/  Post chest tube Hr. 12 e.c Pneumothorax
kmr 7 thn 10
 TB paru on treatment
 (05/12/10) GDS:125; GOT/GPT:18/18; Na/K/Cl:130/3,6/110;
Ur/Cr: 20/0,6
 (11/12/10) WBC:6,5; RBC:4,5; Hb:13,3; HCT:40,1; PLT:181
 (06/12/10) AGD: kesan asidosis respiratorik terkompensasi
sempurna
 (06/12/10) Ft. Thorax PA: Pneumothorax bilateral terutama
kanan + KP Duplex Aktif
 (15/12/10) Ft. Thorax PA (kontrol): Pneumothorax (S) + KP
(D) lama aktif dengan bulla apical + Efusi Pleura (D)
Drain: cc, U: B:
3 Lt 1 Ats Dpn/ Ny. Syamsiah/P/40  Post Chest tube hr-5 ec neoplasma ovarium campuran suspek
Kmr 6 thn ganas
(08/12/10) Ft. Thorax: Efusi pleura S + elevasi diafragma
kanan (proses intraabdominal??)
USG Obgyn : Tu. Myxoma
(06/12/10) Na/K/Cl: 124/3,6/91
(09/12/10) WBC:9; RBC:3.7; Hb:10.3; HCT:32,5; PLT:513
Drain: Ki= cc
4 Lt 1 Ats Blk/ Marding/L/ 5/12/ Post AV shunt H-10
Kmr 6 10 CKD stg V e.c. Nefropati Diabetik
CHF NYHA II ec HHF
HT Gr.II on treatment
DM Type 2 Non Obese
(17/12/10) GDP: 207
(05/12/10) Na/K/Cl: 132/3,9/100
(05/12/10) Ur/Cr: 71/3,5; LDL:162
(05/12/10) WBC:4,4; RBC:48,2; HB:12,6; HCT:39,3; PLT:337

5 Pakis / Vip B2 Mansyur/L/21 thn 10/11 Post Thoracotomy hr-31

Kmr 3 /10 Post ekstraksi corpus alienum hr-31
GDP:102;Ur/Cr:33/0,6;GOT/GPT;32/29
WBC:8,7;RBC:3,33;HB:9,3;PLT:240
P.tot: 7,1; Alb:3,5
6 Lt 1 Bwh Blk Tn. Anggun/L/23 13/12 CKD stage V e.c PNC bilateral
Kmr 6 /10 Post AV Shunt hr-3
(06/12/10) Ur/Kr: 190/17; Fe/TIBC: 149/262; CK: 568
(06/12/10) Na/K/Cl: 134/4/102
(06/12/10) WBC:5,6; RBC:2,59; Hb:7; HCT:21; PLT: 127
7 Lt 1 Bwh Blk/ Nurlia ali/P/43 thn 27/11 Diabetic Foot + DM Type 2 Non-Obese
Kmr 5 /10 (17/12/10) GDS:189
(10/12/10) Na/K/Cl:139/3,5/105; Ur/Cr: 24/0,5; Prot.Tot:9,2,
Alb:2,5; Glb:6,7
(10/12/10) WBC:8,93; RBC:3,34; HB:9,7; HCT:30,6; PLT:444

8 Lt 1 Bwh Blk/ Ida/P/43 thn 9/11/ Ulkus Inguinal (D)

Kmr 5 10 DM tipe 2 non obese
(17/12/10) GDS: 97
(09/12/10) WBC:12,16; RBC:3,21; HB:9,2; HCT:307; PLT:658;
UR/KR: 110/1,1
9 Lt 1 Bwh Blk Nurlianti/P/22 thn CKD stage V ec PNC bilateral
Kmr 5 Pro AV-Shunt
(14/12/10) Na/K/Cl: 136/3,5/103
(14/12/10) Ur/Kr: 106/9,9
(14/12/10) WBC:7,11; RBC:3,95; Hb:10,7; HCT:33,4; PLT:196
10 Lt 1 Bwh Blk Nurmania/P/35th 17/12 CKD stage V ec PNC bilateral
Kmr 5 n /10 Pro AV-Shunt
(16/12/10) Na/K/Cl: 137/4,5/104
(16/12/10) Ur/Kr: 99/17,3; As.Urat:5,5; Fe/TIBC: 24/337
(16/12/10) WBC:8,5; RBC:3,35; Hb:9,3; HCT:28,7; PLT:309
11 Lt 1 Bwh Blk Ariyani B/ P / 52 17/12 CKD stage V ec Nefropati DM
k.ISO th /10 Pro AV-Shunt
(17/12/10) GDS: 147
(16/12/10)WBC:8,31; RBC:4,4; Hb:10,1; HCT:30,9; PLT:
341
(16/12/10) Ur/Kr: 147/4,5; Na/K/Cl: 130/3,7/104

12 Lt 1 Bwh Dpn Ismail/L/25 thn CHF NYHA II ec AR Severe

Kmr 2 (kardio) Pro operasi valve heart replacement
(14/12/10) WBC:8,6; RBC: 3,98; Hb:11; HCT:31,8; PLT: 387
(14/12/10) CT:7; BT:2
(14/12/10) Na/K/Cl: 135/3,5/104
(14/12/10) GDP:53, Ur/Kr: 41/1,1; GOT/GPT:28/21; As.Urat:
10,7
(23/11/10) Ft. Thorax PA: Cardiomegaly dengan tanda2
bendungan paru dini
(23/11/10) Echo: CHF AR Severe Susp. Infection Endocarditis
13 Lt 1 Bwh Dpn Theresia 14/12 Ulkus Cruris (D) + DM Type 2 Non Obese
Kmr 1 kls 2 /10 (16/12/10: GDS: 250
(09/12/10) Na/K/Cl: 139/3,8/108
(10/12/10) HbSAg (+); Ur/Kr: 96/4; GOT/GPT: 13/13; Prot.Tot:
5,5; Alb: 1,9
(10/12/10) WBC: 16,36; RBC:3,41; Hb: 9,4: HCT: 28,8; PLT:
323
(13/12/10) Ft. Cruris (D) AP-Lat: soft tissue swelling bagian
proximal
14 Lt 2 Digest Sattu Dg. Nuru 16/18 Post chest tube hari ke-2 e.c efusi pleura (S)
Kamar ISO L / 60 th /10

15 Lt 2Digest / Nurhayati/P/41 30/11 Susp. Tu mediastinum Posterior

Kmr 3 /10 Post biopsi intratorakal (9/12/10)
Tunggu hasil tgl 14/12/10
(15/12/10) HbSAg (+). Na/K/Cl: 133/3,8/103. Alb:2,8
(13/12/10) Hasil PA:Non small cell carcinoma
(15/12/10) WBC:9,7; RBC: 4,01; Hb:9,6; PLT: 590; GDS:84;
 Ur/Cr:15/0,7
16 Lt2 Digest/ Dg Lomo/P/51thn Post Chest tube hr-4 ec Efusi pleura (S)
kmr 3 Soft tissue mass region mammae + axilla (S)
Drain: Ki= cc

17 Lt 2 orto/ kmr 6 Dedy alam/L/24 30/11 Post Amputasi hari-1 e.c Buerger disease dorsum pedis (S)
thn /10 (16/12/10) WBC:21,5; RBC:3,13; Hb:9,4; HCT:29,7; PLT:526
(03/12/10) Arteriografi: Oklusi proksimal a.femoralis superficial
dan a.femoralis profunda dengan kolateral2 pada daerah distal
Foto pedis PAP/OBLQ: osteomyelitis akut pedis S/ dengan gas
gangrene
18 Lt 2 Onko/ Nursiah/P/45 thn 25/10 Post chest tube Hr-18
Kmr 7 /10 Efusi pleura (D)
Ca mamae D CT4BN0M1
(13/12/10) WBC:8,98; RBC :3,38; HB:9,4; PLT:352;
Ur/Kr:15/7; GOT/GPT:21/19; Alb:2,3
Drain: Ka= cc;
19 Lt 2 onko/ Ny. Maryam/P/37 DS/ Struma Nodosa non toksik retrosternal
Kmr 7 thn (09/12/10) CT/BT : 6/2, PT/APTT : 10.6/23.8
(09/12/10) GDS 81, Ur/Cr : 10/0.4, Na/K/Cl : 141/4.2/110,
WBC : 5.29,RBC : 4.45,Hb : 12.9
20 Lt 2 Onko/ Hasma/P/ 35 thn 29/11 Post chest tube Hr. 18 ec Ca.Mammae (D)
Kmr 8 /10 Post pleurodesis tgl 16/12/10 pkl 14.30
(11/12/10) Na/K/Cl: 137/3,9/106
(11/12/10) GDS:116; Ur/Kr:14/0,6; GOT/GPT:34/22
(18/10/10) PA: adenokarsinoma mamma
Drain:Ki= cc
21 Lt 2 Onko/ Isa / P / 56 thn 06/12 Post Chest Tube (D) Hr-3
Kmr 8 /10 Ulkus Ca Mammae Residif
(16/12/10) WBC:8,96; RBC:4,13; Hb:11,1; HCT: 34,9; PLT:
388
(07/12/10) GDS:108; Ur/Kr: 17/0,6; GOT/GPT:68/6,
As.Urat:5,7
(06/12/10) Ft. Thorax AP: soft tissue mass region axilla dan
mamma (D) + Efusi Pleura (D) + Cardiomegaly dengan
Dilatasi Aorta

22 Lt 2 Onko/ Hafsah/P/50 thn 8/11/ Ulkus Ca mamae S stadium 3B

Kmr 6 10 Aff chest tube
WBC:18,89/;RBC:4,2;HB;10,4;PLT:267
GDS:124;GOT/GPT:14/22;Alb:2,2;P.tot:4,3
Drain: Ki= cc;
23 Lt 2 Uro/ Wahyuddin/L/46th 15/12 Post Chest Tube hari ke-8 ec Efusi pleura (D) (5 hari di RSI
Kmr 10 /10 Faisal)
Tu. Mediastinum (D)
(15/12/10) WBC:15; RBC:4,8; Hb:12,9; HCT:42,8; PLT:457;
Na/K/Cl:131/3,9/103
24 Lt 2 Uro/ Asnani/P/37 thn 9/12/ Post AV shunt graft hari ke 3
Kmr 11 10 CKD stg V e.c GNC on HD
(11/12/10) WBC:7,4; HB:10,6; CT/BT:9’/3’;
PT/APTT:13,4/26,6; GDS:85; GOT/GPT:14/10;
UrKr:173/12,4; AntiHCV (+)
25 ICU bed 2 An Rizal/L/14 thn Post chest tube hr-4 ec pneumothorax (D)
EDH temporoparietal (D)
ICH temporal (D)
Drain: Ka= cc;
26 ICU bed 5 Raming dg nawing 12/12 Post chest tube hr-5 ec emfisema subkutis
/10 Drain: Ka= cc;
27 ICU vip 1 Muchlis/L/28 14/12 Trauma Tumpul thoraks+trauma tumpul abdomen+fraktur
tahun /10 costa
Pleura thoraks +post chest tube hr -2
 Drain: Ka= cc;

28 Lt 2 Digest H. dollah/L/70 thn 12/12 Abses hepar

Kmr 11 /10 Emfiema thoracis
29 PCC / Lt 2 kmr Anggraini Burhan/ Ca. Mamma D/ + efusi pleura massive bilateral post chest tube
P / 49 thn hr-7
Drain: Ka= cc; Ki: cc
30 PCC/214 Drs. M. Nasir 14/12 Susp. Tumor Mediastinum
Karim/l/60 tahun /10